Agoraphobia

Agoraphobia is an anxiety disorder characterized by an abnormal, debilitating fear of being caught in a place or situation from which escape might be difficult or embarrassing during a panic attack. It also refers to fear of being trapped in circumstances in which medical help might not be available during such episodes. Like other phobias, agoraphobia involves irrational, involuntary fears of ordinary situations and things.

People with agoraphobia frequently avoid any situations or places in which they might experience these feelings. Examples of such scenarios might include:

• Being outside of the home alone
• Being in a crowd of people, or standing in a line
• Traveling in cars, buses, trains or airplanes
• Being on a bridge
• Being in an elevator

Agoraphobia is closely linked with panic disorder, another type of anxiety disorder in which a person regularly experiences panic attacks – sudden episodes of fear and anxiety that usually last for between 10 and 30 minutes and cause symptoms such as racing heartbeat, heavy sweating, chest discomfort, shortness of breath, nausea and fear of dying. In many cases, panic disorder is actually the cause of agoraphobia. In other cases, people have agoraphobia without the presence of panic disorder, although they usually experience some panic-related symptoms (e.g., excessive sweating or racing heartbeat).

The hallmark of agoraphobia is avoidance. A person with agoraphobia avoids any potentially threatening circumstance that could cause a panic attack or other panic-inducing symptoms. For example, if a panic attack occurred in a shopping mall, the person avoids malls and perhaps other crowded areas as well.

Agoraphobia should be differentiated from several other phobia categories. A specific phobia refers to fear of a certain object or situation (e.g., a person who fears dogs avoids all dogs). Social phobia involves fear of social situations because of embarrassment or humiliation, not because of panic symptoms.

Agoraphobia tends to begin in a person’s 20s. Women are affected more often than men. The condition can substantially hamper a person’s quality of life. Some patients are able to endure certain potentially threatening situations (e.g., traveling) if they are accompanied by another person. Others may not be able to withstand threatening situations under any circumstances. Patients may find it difficult to work, socialize, travel or perform important daily tasks such as grocery shopping. People with agoraphobia may eventually experience much less anxiety by limiting their exposure to potentially threatening situations.

The term “agoraphobia” includes the Greek word “agora,” which referred to the open spaces of the ancient marketplace. Today, it can refer to any place in which anxiety or panic symptoms occurred and the person now tries to avoid.

The cause of agoraphobia remains unclear. However, genetics, biochemical factors and stress are believed to play a role in the development of agoraphobia.

Symptoms of agoraphobia are often both psychological and physical in nature. Patients who have experienced a panic attack or other panic symptoms in the past may fear being trapped in similar situations where escape is difficult or where they may lose control in a public place. Psychological symptoms of agoraphobia can include:

• Feeling agitated or short-tempered
• Remaining homebound for long periods of time
• State of being detached or estranged from others
• Sense of helplessness and feeling dependent on others
• Sense that the body and environment are unreal
• Confused or disordered thoughts

Typically, patients will experience anxiety or panic attacks and the physical symptoms that often accompany them, such as rapid heartbeat, excessive sweating and breathing problems. Other physical symptoms include:

• Abdominal distress
• Chest pain
• Dizziness
• Trembling or twitching
• Lightheadedness
• Nausea and vomiting
• Numbness and tingling
• Skin flushing

People with agoraphobia often become frustrated and ashamed of their behavior. As a result, they are at risk for developing many other related conditions, including depression and substance abuse problems.

Before diagnosing agoraphobia, a physician should perform a complete physical examination and compile a thorough medical history to rule out any potential physical cause. If a mental disorder is suspected, the patient will be referred to a psychiatrist, psychologist or other mental health professional.

Agoraphobia will be diagnosed if the patient has symptoms consistent with agoraphobia that are not caused by another mental condition. Other mental conditions that may present with symptoms similar to those of agoraphobia include:

• Obsessive-compulsive disorder
• Post-traumatic stress disorder
• Separation anxiety disorder
• Social phobia
• Specific phobia

Agoraphobia frequently occurs with another condition called panic disorder. Many patients share at least some of the symptoms of both of these conditions. Patients may be diagnosed as having either panic disorder with agoraphobia or agoraphobia without history of panic disorder.

The criteria used to diagnose these two conditions are virtually identical. However there is one key exception: agoraphobia without history of panic disorder is diagnosed if the patient's fear is focused on the potential for experiencing incapacitating or embarrassing, panic-like symptoms or attacks with limited symptoms. For example, the patient may fear having heart-related symptoms and not being able to get help. This differs from panic disorder with agoraphobia, in which the patient's fear is centered on the possibility of full-blown panic attacks, after experiencing panic attacks. In essence, patients who are diagnosed with agoraphobia without history of panic disorder do not have a history of recurrent panic attacks.

Finally, agoraphobia will not be diagnosed for conditions in which a patient's fears are reasonable given certain medical conditions. For example, a patient who has Crohn's disease (a chronic autoimmune disease) may fear being struck with an episode of diarrhea at an inconvenient time. This fear is normal given the patient's circumstances.

In the majority of cases, a combination of psychotherapy and anti-anxiety and antidepressant medications is the most effective treatment. Cognitive therapy is done to suggest that panic is a misinterpretation of body sensations and that the danger is not as extreme as is perceived. Relaxation training and progressive muscle relaxation can be done, along with respiratory control training. Exposure therapy, where the person is gradually exposed little by little to the dreaded situation, is a useful treatment. Supportive psychotherapy is done as needed. Drug therapy is usually a serotonin-specific reuptake inhibitor (SSRI) with some use of benzodiazepine.Tricyclic antidepressants are occasionally prescribed.