Agoraphobia

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Photo by: Saty Bhat

Definition

Agoraphobia is an anxiety disorder characterized by intense fear related to being in situations from which escape might be difficult or embarrassing (i.e., being on a bus or train), or in which help might not be available in the event of a panic attack or panic symptoms. Panic is defined as extreme and unreasonable fear and anxiety.

According to the handbook used by mental health professionals to diagnose mental disorders, the Diagnostic and Statistical Manual of Mental Disorders , fourth edition, text revision, also known as the DSM-IV-TR , patients with agoraphobia are typically afraid of such symptoms as feeling dizzy, having an attack of diarrhea, fainting, or "going crazy."

The word "agoraphobia" comes from two Greek words that mean "fear" and "marketplace." The anxiety associated with agoraphobia leads to avoidance of situations that involve being outside one's home alone, being in crowds, being on a bridge, or traveling by car or public transportation. Agoraphobia may intensify to the point that it interferes with a person's ability to take a job outside the home or to carry out such ordinary errands and activities as picking up groceries or going out to a movie.

Description

The close association in agoraphobia between fear of being outside one's home and fear of having panic symptoms is reflected in DSM-IV-TR classification of two separate disorders: panic disorder (PD) with agoraphobia, and agoraphobia without PD. PD is essentially characterized by sudden attacks of fear and panic. There may be no known reason for the occurrence of panic attacks; they are frequently triggered by fear-producing events or thoughts, such as driving, or being in an elevator. PD is believed due to an abnormal activation of the body's hormonal system, causing a sudden "fight-or-flight" response.

The chief distinction between PD with agoraphobia and agoraphobia without PD is that patients who are diagnosed with PD with agoraphobia meet all criteria for PD; in agoraphobia without PD, patients are afraid of panic-like symptoms in public places, rather than full-blown panic attacks.

People with agoraphobia appear to suffer from two distinct types of anxiety— panic, and the anticipatory anxiety related to fear of future panic attacks. Patients with agoraphobia are sometimes able to endure being in the situations they fear by "gritting their teeth," or by having a friend or relative accompany them.

In the United States' diagnostic system, the symptoms of agoraphobia can be similar to those of specific phobia and social phobia . In agoraphobia and specific phobia, the focus is fear itself; with social phobia, the person's focus is on how others are perceiving him/her. Patients diagnosed with agoraphobia tend to be more afraid of their own internal physical sensations and similar cues than of the reactions of others per se. In cases of specific phobia, the person fears very specific situations, whereas in agoraphobia, the person generally fears a variety of situations (being outside of the home alone, or traveling on public transportation including a bus, train, or automobile, for example). An example of a patient diagnosed with a specific phobia rather than agoraphobia would be the person whose fear is triggered only by being in a bus, rather than a car or taxi. The fear of the bus is more specific than the agoraphobic's fear of traveling on public transportation in general. The DSM-IVTR remarks that the differential diagnosis of agoraphobia "can be difficult because all of these conditions are characterized by avoidance of specific situations."

Causes and symptoms

Causes

GENETIC. As of 2002, the causes of agoraphobia are complex and not completely understood. It has been known for some years that anxiety disorders tend to run in families. Recent research has confirmed earlier hypotheses that there is a genetic component to agoraphobia, and that it can be separated from susceptibility to PD. In 2001 a team of Yale geneticists reported the discovery of a genetic locus on human chomosome 3 that governs a person's risk of developing agoraphobia. PD was found to be associated with two loci: one on human chromosome 1 and the other on chromosome 11q. The researchers concluded that agoraphobia and PD are common; they are both inheritable anxiety disorders that share some, but not all, of their genetic loci for susceptibility.

INNATE TEMPERAMENT. A number of researchers have pointed to inborn temperament as a broad vulnerability factor in the development of anxiety and mood disorders. In other words, a person's natural disposition or temperament may become a factor in developing a number of mood or anxiety disorders. Some people seem more sensitive throughout their lives to events, but upbringing and life history are also important factors in determining who will develop these disorders. Children who manifest what is known as "behavioral inhibition" in early infancy are at increased risk for developing more than one anxiety disorder in adult life—particularly if the inhibition remains over time. (Behavioral inhibition refers to a group of behaviors that are displayed when the child is confronted with a new situation or unfamiliar people.) These behaviors include moving around, crying, and general irritability, followed by withdrawing, seeking comfort from a familiar person, and stopping what one is doing when one notices the new person or situation. Children of depressed or anxious parents are more likely to develop behavioral inhibition.

PHYSIOLOGICAL REACTIONS TO ILLNESS. Another factor in the development of PD and agoraphobia appears to be a history of respiratory disease. Some researchers have hypothesized that repeated episodes of respiratory disease would predispose a child to PD by making breathing difficult and lowering the threshold for feeling suffocated. It is also possible that respiratory diseases could generate fearful beliefs in the child's mind that would lead him or her to exaggerate the significance of respiratory symptoms.

LIFE EVENTS. About 42% of patients diagnosed with agoraphobia report histories of real or feared separation from their parents or other caretakers in childhood. This statistic has been interpreted to mean that agoraphobia in adults is the aftermath of unresolved childhood separation anxiety. The fact that many patients diagnosed with agoraphobia report that their first episode occurred after the death of a loved one, and the observation that other agoraphobics feel safe in going out as long as someone is with them, have been taken as supportive evidence of the separation anxiety hypothesis.

LEARNED BEHAVIOR. There are also theories about human learning that explain agoraphobia. It is thought that a person's initial experience of panic-like symptoms in a specific situation— for example, being alone in a subway station— may lead the person to associate physical symptoms of panic with all subway stations. Avoiding all subway stations would then reduce the level of the person's discomfort. Unfortunately, the avoidance strengthens the phobia because the person is unlikely to have the opportunity to test whether subway stations actually cause uncomfortable physical sensations. One treatment modality—exposure therapy—is based on the premise that phobias can be "unlearned" by reversing the pattern of avoidance.

SOCIAL FACTORS RELATED TO GENDER. Gender role socialization has been suggested as an explanation for the fact that the majority of patients with agoraphobia are women. One form of this hypothesis maintains that some parents still teach girls to be fearful and timid about venturing out in public. Another version relates agoraphobia to the mother-daughter relationship, maintaining that mothers tend to give daughters mixed messages about becoming separate individuals. As a result, girls grow up with a more fragile sense of self, and may stay within the physical boundaries of their home because they lack a firm sense of their internal psychological boundaries.

Symptoms

The symptoms of an episode of agoraphobia may include any or all of the following:

• trembling
• breaking out in a sweat
• heart palpitations
• paresthesias (tingling or "pins and needles" sensations in the hands or feet)
• nausea
• fatigue
• rapid pulse or breathing rate
• a sense of impending doom

In most cases, the person with agoraphobia feels some relief from the symptoms after he or she has left the precipitating situation or returned home.

Demographics

In general, phobias are the most common mental disorders in the general United States population, affecting about 7% of adults, or 6.4 million Americans. Agoraphobia is one of the most common phobias, affecting between 2.7% and 5.8% of American adults. The onset of symptoms is most likely to occur between age 15 and age 35.The lifetime prevalence of agoraphobia is estimated at 5%–12%. Like most phobias, agoraphobia is two to four times more common in women than in men.

The incidence of agoraphobia appears to be similar across races and ethnic groups in the U.S.

Diagnosis

The differential diagnosis of agoraphobia is described differently in DSM-IV-TR and in ICD-10, the European diagnostic manual. The U.S. diagnostic manual specifies that agoraphobia must be defined in relation to PD, and that the diagnoses of specific phobias and social phobias are the next to consider. The DSM-IV-TR also specifies that the patient's symptoms must not be related to substance abuse; and if they are related to a general medical condition, they must have excessive symptoms usually associated with that condition. For example, a person with Crohn's disease has realistic concerns about an attack of diarrhea in a public place and should not be diagnosed with agoraphobia unless the fear of losing bowel control is clearly exaggerated. The DSMIV-TR does not require a person to experience agoraphobia within a set number of circumstances in order to meet the diagnostic criteria.

In contrast, the European diagnostic manual primarily distinguishes between agoraphobia and delusional or obsessive disorders, and depressive episodes. In addition, ICD-10 specifies that the patient's anxiety must be restricted to or occur primarily within two out of four specific situations: crowds; public places; traveling alone; or traveling away from home. The primary area of agreement between the American and European diagnostic manuals is that both specify avoidance of the feared situation as a diagnostic criterion.

Diagnosis of agoraphobia is usually made by a physician after careful exclusion of other mental disorders and physical conditions or diseases that might be related to the patient's fears. Head injury, pneumonia, and withdrawal from certain medications can produce some of the symptoms of a panic attack. In addition, the physician may ask about caffeine intake as a possible dietary factor. As of 2002, there are no laboratory tests or diagnostic imaging studies that can be used to diagnose agoraphobia.

Furthermore, there are no widely used diagnostic interviews or screening instruments specifically for agoraphobia. One self-report questionnaire, however, is under development by Dutch researchers who recently reported on its validity. The test is called the Agoraphobic Self-Statements Questionnaire, or ASQ, and is intended to evaluate thinking processes in patients with agoraphobia, as distinct from their emotional responses.

Treatments

Treatment of agoraphobia usually consists of medication plus cognitive-behavioral therapy (CBT). The physician may also recommend an alternative form of treatment for the anxiety symptoms associated with agoraphobia. Some patients may be advised to cut down on or give up coffee or tea, as the caffeine in these beverages can be contribute to their panic symptoms.

Medications

Medications that have been used with patients diagnosed with agoraphobia include the benzodiazepine tranquilizers, the MAO inhibitors (MAOIs), tricyclic antidepressants (TCAs), and the selective serotonin uptake inhibitors, or SSRIs. In the past few years, the SSRIs have come to be regarded as the first-choice medication treatment because they have fewer side effects. The benzodiazepines have the disadvantage of increasing the symptoms of agoraphobia when they are withdrawn, as well as interfering with CBT. (Benzodiazepines can decrease mental sharpness, making it difficult for patients taking these medications to focus in therapy sessions.) The MAO inhibitors require patients to follow certain dietary guidelines. For example, they must exclude aged cheeses, red wine, and certain types of beans. TCAs may produce such side effects as blurred vision, constipation, dry mouth, and drowsiness.

Psychotherapy

CBT is regarded as the most effective psychotherapeutic treatment for agoraphobia. The specific CBT approach that seems to work best with agoraphobia is exposure therapy. Exposure therapy is based on undoing the association that the patient originally formed between the panic symptoms and the feared situation. By being repeatedly exposed to the feared location or situation, the patient gradually learns that he or she is not in danger, and the anxiety symptoms fade away. The therapist typically explains the procedure of exposure therapy to the patient and reassures him or her that the exposure can be stopped at any time that his or her limits of toleration have been reached. The patient is then exposed in the course of a number of treatment sessions to the feared situation, usually for a slightly longer period each time. A typical course of exposure therapy takes about 12 weeks.

On the other hand, one group of German researchers reported good results in treating patients with agoraphobia with individual high-density exposure therapy. The patients were exposed to their respective feared situations for an entire day for two–three weeks. One year later, the patients had maintained their improvement.

Exposure treatment for agoraphobia may be combined with cognitive restructuring. This form of cognitive behavioral therapy teaches patients to observe the thoughts that they have in the feared situation, such as, "I'll die if I have to go into that railroad station," and replace these thoughts with positive statements. In this example, the patient with agoraphobia might say to him- or herself, "I'll be just fine when I go in there to buy my ticket."

Although insight-oriented therapies have generally been considered relatively ineffective in treating agoraphobia, a recent trial of brief psychodynamic psychotherapy in patients with PD with agoraphobia indicates that this form of treatment may also be beneficial. Of the 21 patients who participated in the 24-session course of treatment (twice weekly for 12 weeks), 16 experienced remission of their agoraphobia. There were no relapses at six-month follow-up.

Alternative and complementary treatments

Patients diagnosed with agoraphobia have reported that alternative therapies, such as hypnotherapy and music therapy, were helpful in relieving symptoms of anxiety and panic. Ayurvedic medicine, yoga , religious practice, and guided imagery meditation have also been helpful.

Prognosis

The prognosis for untreated agoraphobia is considered poor by most European as well as most American physicians. The DSM-IV-TR remarks that little is known about the course of agoraphobia without PD, but that anecdotal evidence indicates that it may persist for years with patients becoming increasingly impaired. The ICD-10 refers to agoraphobia as "the most incapacitating of the phobic disorders," to the point that some patients become completely housebound. With proper treatment, however, 90% of patients diagnosed with agoraphobia can recover and resume a normal life.

Prevention

As of this writing in 2002, the genetic factors that appear to be implicated in the development of agoraphobia cannot be prevented. On the other hand, recent recognition of the link between anxiety and mood disorders in parents and vulnerability to phobic disorders in their children may help to identify children at risk and to develop appropriate preventive strategies for them.

Resources

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th edition, text revised. Washington, DC: American Psychiatric Association, 2000.

Eichenbaum, Luise, and Susie Orbach. Understanding Women: A Feminist Psychoanalytic Approach. New York: Basic Books, Inc., Publishers, 1983.

Pelletier, Kenneth R., MD. "CAM Therapies for Specific Conditions: Anxiety." In The Best Alternative Medicine , Part II. New York: Simon and Schuster, 2002.

"Phobic Disorders." Section 15, Chapter 187 in The Merck Manual of Diagnosis and Therapy , edited by Mark H. Beers, MD, and Robert Berkow, MD. Whitehouse Station, NJ: Merck Research Laboratories, 2001.

Rowe, Dorothy. Beyond Fear. London, UK: Fontana/Collins, 1987.

World Health Organization (WHO). The ICD-10 Classification of Mental and Behavioural Disorders. Geneva: WHO, 1992.

PERIODICALS

Craske, Michelle G., and others. "Paths to Panic Disorder/Agoraphobia: An Exploratory Analysis from Age 3 to 21 in an Unselected Birth Cohort." Journal of the American Academy of Child and Adolescent Psychiatry 40 (May 2001): 556-563.

Fehm, L., and J. Margraf. "Thought Suppression: Specificity in Agoraphobia Versus Broad Impairment in Social Phobia?" Behavioral Research and Therapy 40 (January 2002): 57-66.

Gelernter, J., K. Bonvicini, G. Page, and others. "Linkage Genome Scan for Loci Predisposing to Panic Disorder or Agoraphobia." American Journal of Medical Genetics 105 (August 2001): 548-557.

Hahlweg, K., W. Fiegenbaum, M. Frank, and others. "Shortand Long-Term Effectiveness of an Empirically Supported Treatment for Agoraphobia." Journal of Consultative Clinical Psychology 69 (June 2001): 375-382.

Kendler, K. S., J. Myers, C. A. Prescott. "The Etiology of Phobias: An Evaluation of the Stress-Diathesis Model." Archives of General Psychiatry 59 (March 2002): 242-248.

Kendler, K. S., and others. "Sex Differences in Genetic and Environmental Risk Factors for Irrational Fears and Phobias." Psychology in Medicine 32 (February 2002): 209-217.

Milrod, B., F. Busch, A. C. Leon, and others. "A Pilot Open Trial of Brief Psychodynamic Psychotherapy for Panic Disorder." Journal of Psychotherapeutic Practice 10 (Fall 2001): 239-245.

"Parents' Disorders Linked to Children's Risk." Mental Health Weekly 10 (January 8, 2001): 29.

van Hout, W. J., P. M. Emmelkamp, P. C. Koopmans, and others. "Assessment of Self-Statements in Agoraphobic Situations: Construction and Psychometric Evaluation of the Agoraphobic Self-Statements Questionnaire (ASQ)." Journal of Anxiety Disorders 15 (May-June 2001): 183-201.

Walling, Anne D. "Management of Agoraphobia." American Family Physician 62 (November 2001): 67.

ORGANIZATIONS

Anxiety Disorders Association of America. 11900 Parklawn Drive, Suite 100, Rockville, MD 20852-2624. (301) 231-9350. <www.adaa.org> .

Ayurvedic and Naturopathic Medical Clinic. 2115 112th Ave NE, Bellevue, WA 98004. (425) 453-8022. <www.ayurvedicscience.com> .

Freedom From Fear. 308 Seaview Avenue, Staten Island, NY 10305 (718) 351-1717. <www.freedomfromfear.com> .

National Mental Health Association. 1021 Prince Street, Alexandria, VA 22314-2971. (800) 969-6642. <www.nmha.org> .

OTHER

National Institute of Mental Health (NIMH). Anxiety Disorders. NIH Publication No. 00-3879 (2000). <www.nimh.nih.gov/anxiety/anxiety.cfm> .

Rebecca J. Frey, Ph.D.