Agoraphobia: definition, causes, symptoms, and treatments
Table of content
- What is agoraphobia?
- What are the causes of agoraphobia?
- What are the symptoms of agoraphobia?
- What are the available treatments for agoraphobia?
- 1. Psychotherapy
- 2. Selective serotonin reuptake inhibitors (SSRIs)
- 3. Anti-anxiety medicine
- How to prevent agoraphobia?
- Is agoraphobia a mental illness?
Agoraphobia is a type of anxiety disorder characterized by intense and overwhelming fear or avoiding situations or places that cause feelings of helplessness, embarrassment, or being trapped. People develop agoraphobic behaviors when they are facing a feared situation or when they expect it. Agoraphobia manifests itself differently from one person to another. People usually have a fear of going outside or develop a fear of crowds and fear of environment.
Causes of agoraphobia are multiple factors such as depression, other phobias such as claustrophobia, other anxiety conditions such as generalized anxiety disorder, sexual or physical abuse, substance abuse, and a family history of agoraphobia.
Symptoms of agoraphobia include intense fear and panic, and physical reactions such as dizziness, fainting, falling, and diarrhea.
Treatments for agoraphobia include a combination of psychotherapy and medications such as selective serotonin reuptake inhibitors (SSRIs) or anti-anxiety medications.
What is agoraphobia?
Agoraphobia is an abrupt surge of intense fear and avoiding places and/or situations that may cause panic and feelings of being helpless, embarrassed, or trapped. The term agoraphobia is derived from the Greek words agora, meaning marketplace, open space, or place of assembly, and phobia meaning fear.
A person with agoraphobia fears an actual or anticipated situation. For instance, they may be afraid of using public transportation, being in crowds, enclosed spaces, or standing in line.
Agoraphobia leads to difficulty feeling safe in any public place, particularly in unfamiliar locations or places where large crowds gather. A person with agoraphobia may feel like they need a family member or a friend to accompany them outside. The fear can be so overwhelming that a person feels they can’t go outside at all.
In the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) by the American Psychiatric Association, agoraphobia is categorized as a type of anxiety disorder. The latest edition of DSM, released in 2013, is particularly interesting because it is the first time agoraphobia appears as a standalone condition. In DSM-4, it was classified as a type of panic disorder. More precisely, DSM-4 indicated that panic disorder could be diagnosed as panic disorder with agoraphobia or panic disorder without agoraphobia. Since agoraphobia has been defined as a standalone condition recently, most of the research on this subject is based on the DSM-4 definition, according to PsychDB.
Agoraphobia was first described in 1871 by a German psychiatrist Karl Friedrich Otto Westphal. He coined the term agoraphobia after observing three patients with severe dread and anxiety upon traveling to certain public places in Berlin, Germany. Even though all of Westphal’s patients were male, it didn’t take long for the term agoraphobia to be applied to women primarily. In 1896, Sigmund Freud published a paper wherein he stated that agoraphobia was a women’s disease. Freud claimed that women with symptoms of agoraphobia were suffering from repressed envy of “public women” or prostitutes. More precisely, they had a repressed desire to engage in sexual intercourse with men they encountered randomly on the streets, according to a paper published by Thomas Lenz, a research scientist at the University of Luxembourg, and Dr. Rachel MagShamhrain from the University College Cork in the journal Society.
The understanding of agoraphobia has been evolving ever since. Today, agoraphobia is described as an irrational or disproportionate fear of situations wherein a person believes escape or access to help would be impossible. Agoraphobia is still misunderstood. A common misconception is that all people with agoraphobia are afraid of leaving their homes. While agoraphobia can manifest itself as fear of going outside entirely, patients may feel discomfort or fear in specific environments such as theaters or restaurants.
Even though agoraphobia contains the word fear or phobia, it is not classified as one of the specific phobias. Johns Hopkins Medicine explains that in specific phobia, the fear centers on harm directly caused by the situation e.g., fear of flying because a person is scared their plane might crash. Agoraphobia, on the other hand, involves fear that centers on whether escape is possible or if help is going to be available in a specific place or situation.
How common is agoraphobia?
An estimated 1.3% of adults in the United States experience agoraphobia at one point or another in their lifetime, according to the National Institute of Mental Health. Past-year prevalence of agoraphobia in U.S. adults was 0.9%, the same report showed. Agoraphobia was slightly more prevalent in women (0.9%) than men (0.8%). Of all U.S. adults with agoraphobia, 40.6% had a serious impairment, 30.7% had a moderate impairment, and 28.7% had mild impairment.
The lifetime prevalence of agoraphobia in U.S. adolescents (13 to 18 years) was 2.4% and all had a serious impairment, according to the abovementioned report. Similar to adults, the prevalence of agoraphobia was higher in female adolescents (3.4%) than in males (1.4%).
Little is known about the prevalence of agoraphobia in children. An older study conducted by J. Biederman et al. from Massachusetts General Hospital and published in the Journal of the American Academy of Child and Adolescent Psychiatry reported that the prevalence of agoraphobia in psychiatrically referred children and adolescents was 15%. The study didn’t specify how many children with agoraphobia account for the total percentage.
According to a paper that Dr. Katja Beesdo and psychologist Susanne Knappe from Technische Universität Dresden in Germany, alongside Dr. Daniel S. Pine from the U.S. National Institutes of Health published in The Psychiatric Clinics of North America, agoraphobia is a low-prevalence mental disorder in childhood and it affects up to 1% of children.
A post by Dr. Kripa Balaram from MetroHealth Medical Center and Dr. Raman Marhawa from Case Western Reserve Un/MetroHealth, on National Library of Medicine, explains the disparity in information regarding the prevalence of agoraphobia stems from the fact it was described as a separate mental illness and received diagnostic criteria only recently. The same article suggests the prevalence of agoraphobia in the general population is around 1.7%.
Section II – The Disorders from Mental Disorders around the World: Facts and Figures from the WHO World Mental Health Surveys a book edited by Dr. Kate M. Scott et al. and published by Cambridge Medicine reported that a systematic review of 13 studies conducted in Europe found a median 12-month prevalence of 1.3% for agoraphobia, but there was high variability in the findings. The prevalence ranged from 0.4% to 3.1%. The high disparity in these studies can be explained by the fact that they focused either on total agoraphobia cases or agoraphobia without a history of panic disorder.
The same book also reported findings from the National Epidemiologic Survey on Alcohol and Related Conditions, a nationally representative study in the U.S., which found a low prevalence of agoraphobia without a history of panic disorder. The 12-month prevalence of agoraphobia without a history of panic disorder was 0.05%, whereas the lifetime prevalence was 0.17%. According to the book, the prevalence of agoraphobia without a history of panic disorder was low in clinical settings, primarily because these patients aren’t recognized or because people with agoraphobia are less likely to seek help due to avoidance behavior.
What are the causes of agoraphobia?
The causes of agoraphobia can be associated with an existing panic disorder, although additional research is required for a more definite answer. Mayo Clinic suggests that biology (including genetics and health conditions), stress, personality, and learning experiences contribute to the development of agoraphobia. The most significant causes of agoraphobia are listed below:
- Other phobias, like social phobia and claustrophobia
- A different form of an anxiety condition, such as generalized anxiety disorder or obsessive-compulsive disorder
- A background of sexual or physical abuse
- A problem with substance abuse
- A history of agoraphobia in the family
Depression, or major depressive disorder, is a mood disorder characterized by persistent feelings of sadness, hopelessness, and loss of interest, which can lead to suicidal thoughts and tendencies. A person with depression isn’t just “feeling blue” and they can’t “snap out of it”. Depression is not a weakness, but a serious mental illness that can significantly affect a person’s quality of life and contribute to the development of other disorders, including anxiety disorders.
It is not clear how depression causes agoraphobia or anxiety in general. Mayo Clinic suggests that anxiety can be a symptom of depression. A paper by Dr. Alan Breier and his team at Yale University School of Medicine published in JAMA Psychiatry suggested that underlying pathological processes are involved in the relationship between depression, agoraphobia, and panic disorder. People with depression often feel anxious and worried, which can be a connection between the two conditions. Another study by Dr. Breier, which was published in the Archives of General Psychiatry revealed that 70% of patients with agoraphobia also had depression with the episodic courses.
Depression is a cause of agoraphobia because it is strongly associated with anxiety states. Depression and anxiety disorders can lead to one another. It can cause intense feelings of worry and fear, which may manifest themselves in the form of anxiety or panic.
2. Other phobias, like social phobia and claustrophobia
A phobia is defined as an exaggerated, inexplicable, and illogical fear of an object or situation. Like agoraphobia, a phobia is a type of anxiety disorder. Dr. Howard E. LeWine, the chief medical editor at Harvard Health Publishing, explains that a person with phobia either attempts to avoid the trigger of their fear or they endure it with significant distress and anxiety. A phobia can limit a person’s daily activities and cause severe depression and anxiety. Having phobias like claustrophobia (fear of confined spaces) and social phobia can contribute to the onset of agoraphobia.
Other phobias cause agoraphobia because they can overlap. For example, a person in a crowded elevator may feel both claustrophobic and agoraphobic because they feel trapped. In that situation, a person may experience a panic attack. Social phobia, the fear of being in social situations where a person is criticized or judged, may cause agoraphobia because a person could feel it is impossible to escape that situation or event.
Other phobias are a cause of agoraphobia because the latter can develop in situations that cause panic attacks. Phobias or exposure to triggers that cause fear can lead to panic attacks. An affected person could consider situations such as being trapped in a confined space or being exposed to criticism during public speaking as impossible to escape from, which could lead to the onset of agoraphobia.
3. A different form of an anxiety condition, such as generalized anxiety disorder or obsessive-compulsive disorder
Anxiety is defined as a feeling of unease, intense worry, or fear that ranges from mild to severe. Anxiety disorder is a term that covers a wide range of mental health conditions including generalized anxiety disorder (GAD), obsessive-compulsive disorder (OCD), panic disorder, separation anxiety disorder, social anxiety disorder, specific phobias, and agoraphobia. Anxiety disorders are often comorbid with one another and other mental disorders, according to a review published in The Lancet by international authors led by Dr. Brenda Wjh Pennix at the Amsterdam University Medical Center. Other anxiety disorders such as GAD and OCD can contribute to the development of agoraphobia.
Other anxiety disorders cause agoraphobia because they involve feelings of intense fear or panic. A person may associate those negative feelings with situations or places where they occurred and start avoiding them. For example, people with GAD may also develop agoraphobia. In a study by Dr. Jennifer L. Francis et al, published in the Primary Care Companion to the Journal of Clinical Psychiatry, 22% out of 150 participants with panic disorder with agoraphobia also had GAD. Keep in mind that most research on agoraphobia referred to the description from DSM-4 when it was known as panic disorder with agoraphobia. The same paper also showed that comorbid GAD at the beginning of the study also predicted recovery from agoraphobia. These findings suggest that treating one anxiety disorder could help manage the comorbid condition.
In a study published in the Comprehensive Psychiatry by Dr. Albina R. Torres et al, 4.9% of 1001 patients with OCD also had agoraphobia. People with OCD have intense, intrusive thoughts or obsessions that are accompanied by compulsive behaviors. Compulsive behavior is the only way for a person with OCD to eliminate their obsessive thoughts. Extreme fear and worry related to obsessive thoughts and behaviors can lead to panic attacks. A person associates panic attacks with the specific situation and may avoid it thinking escape is impossible.
Other anxiety disorders are a cause of agoraphobia because they tend to co-occur with one another. As seen above, anxiety disorders are comorbid with other anxiety disorders and other mental illnesses. Their connection could be due to intense fear and panic.
4. A background of sexual or physical abuse
Background of sexual or physical abuse refers to the history of molestation or abusive behavior (sexual or physical) of one or more persons on another. A history of physical or sexual abuse jeopardizes a person’s mental health. For example, childhood physical abuse is an independent risk factor for psychiatric disorders in adulthood, according to a study by Luisa Sugaya et al, which was published in the Journal of Traumatic Stress. Childhood sexual abuse is also associated with psychiatric abnormalities in adulthood, Dr. Amresh K. Shrivastava et al. reported in their study published in the Industrial Psychiatry Journal. Adults who experience physical or sexual abuse are also more prone to mental health problems. The Office on Women’s Health from the U.S. Department of Health and Human Services reported that women who have gone through trauma or abuse are more susceptible to developing mental health conditions such as depression and anxiety.
A background of sexual or physical abuse causes agoraphobia due to a reaction to the stress induced by an abusive or traumatic situation. History of traumatic events and abuse is associated with agoraphobia through intense feelings of panic. In a post published on Counselling Directory, it is explained that childhood trauma can lead to Post-traumatic stress disorder (PTSD), which can aggravate feelings of general anxiety. Experiencing long-term trauma in childhood makes adverse events in the present seem more intense. A person may feel like these negative events are “last straw” situations, which make the world an unsafe and overwhelming place.
Sexual abuse may cause agoraphobia because it is an attack on a person’s vulnerability. Victims of domestic violence may also develop agoraphobia which is rooted in fear of men. This can happen due to reasons such as helplessness regarding legal outcomes, fear that the perpetrator will get away with it, and insecurity or concern for safety. Victims of abuse find it difficult to rationalize their feelings because they may not seem logical to them, which can contribute to agoraphobia.
When it comes to the role of traumatic experiences in the onset of agoraphobia, it’s useful to mention a research paper that psychiatric nurse Michele T. Laraia and a team of researchers at the Medical University of South Carolina published in the Journal of Anxiety Disorders. Their research focused on the childhood environment of women with agoraphobia. Results showed a history of separation anxiety, conflicted family environment, and emotional, school, or family problems are associated with agoraphobia.
A background of physical and sexual abuse is a cause of agoraphobia because it can cause intense fear and worsens the impact of negative events in present. A woman with a history of domestic abuse may develop a fear of men and thereby avoid situations or places that trigger her anxiety.
5. A problem with substance abuse
Substance abuse is defined as the use of illegal drugs or the use of prescription and over-the-counter (OTC) medications or alcohol in excessive amounts or for purposes other than those for which they were meant to be used. According to the National Institute on Drug Abuse, substance abuse, and addiction can contribute to the development of mental illness. Substance abuse causes changes in brain areas that are also impaired in mental disorders such as anxiety.
Substance abuse causes agoraphobia because people who misuse drugs or alcohol get comfortable in their homes, potentially leading to this type of anxiety disorder. For example, in addition to its initial anxiolytic effects, alcohol use can cause a long-term increase in anxiety and agoraphobia, according to a paper written by Dr. Fatih Canan and Dr. Ahmet Ataoglu from the Department of Psychiatry, Duzce University in Turkey and published in The Primary Care Companion to the Journal of Clinical Psychiatry. Alcohol use and alcohol withdrawal may negatively affect brain chemicals that cause panic and agoraphobia.
History of drug abuse was linked to a significantly higher risk of current panic attacks, agoraphobia, and social phobia, according to a study that Dr. Renee D. Goodwin and Dr. Dan J. Stein from Columbia University in New York published in Psychiatry and Clinical Neurosciences.
The relationship between substance abuse and agoraphobia is bidirectional. Reuters reported findings of the study by Dr. Eric J.L. Griez and his team at Maastricht University in the Netherlands, which found that people with agoraphobia often develop alcohol use disorder and vice versa. Agoraphobia promotes self-medication and excessive alcohol use, but chronic alcohol abuse and withdrawal can cause chemical changes in the brain that induce panic. Alcohol may trigger the onset of panic, the author of the study explained.
A problem with substance abuse is a cause of agoraphobia because it can lead to changes in the brain that pave the way to panic attacks and agoraphobia. Alcohol and drugs work directly on the brain, which is why long-term use can lead to an increased risk of mental illnesses. More research on this subject is necessary.
6. A history of agoraphobia in the family
A history of agoraphobia in the family is a record of this anxiety disorder in a person’s family. Family members share genes, especially direct blood relatives like a person’s parents and siblings. Psychiatric disorders tend to run in families, meaning they have a genetic component. A review that Dr. Sandra M. Meier from Dalhousie University in Canada and Dr. Jürgen Deckert at the University of Würzburg in Germany published in Current Psychiatry Reports showed that anxiety disorders are complex and polygenic. That means multiple genes play a role in their development. In a study from Molecular Psychiatry, Purves et al. found that a common genetic variation involving a gene NTRK2 is involved in anxiety disorders. Family history is an important contributor to the onset of anxiety conditions, including agoraphobia.
The history of agoraphobia in the family causes agoraphobia because parents can pass certain genes and genetic variations to their children. In his paper from Psychiatric Developments, Dr. Raymond R. Crowe, an American educator and psychiatry specialist explained that panic disorder (comprising also agoraphobia for the purpose of his work) is one of the more familial diseases in psychiatry. Dr. Crowe revealed that two-thirds of cases have relatives affected with the same condition. The risk for first-degree relatives to get agoraphobia is three to four times the rate of the general population. In a study from the Journal of Korean Medical Science, authors H.R. Na, E.H. Kang, J.H. Lee, and B.H. Yu of the Department of Psychiatry at Sungkyunkwan University School of Medicine in Seoul, Korea reported that a linkage analysis observed a significant linkage between chromosome 4q and a phenotype comprising agoraphobia, panic disorder, social phobia, and specific phobia. Several candidate genes such as COMT and MAOA have shown links with phobic anxiety and panic disorder.
A history of agoraphobia in the family is the cause of agoraphobia because families can share genes that are associated with this condition. Additionally, anxiety disorders can be learned behaviors. Dr. Charles Sophy, a psychiatrist, explained to SheKnows that children who live in an environment rooted in anxiety tend to develop similar traits. Genetic predisposition reinforces the development of anxiety-related traits.
What are the symptoms of agoraphobia?
Symptoms of agoraphobia are extreme fear and stress, which cause a person to avoid certain places or situations. Signs of agoraphobia are similar to symptoms that people experience during a panic attack. Besides stress, worry, and anxiety, people with agoraphobia experience physical reactions. The most common symptoms of agoraphobia are listed below:
- Falling or diarrhea
Dizziness is the feeling of being lightheaded, weak, woozy, or unsteady. According to Mayo Clinic, dizziness is among the more common reasons adults visit their doctors. Various problems lead to dizziness such as underlying health conditions, motion sickness, certain medications, poor circulation, infection, and anxiety disorders such as agoraphobia.
Agoraphobia causes dizziness because symptoms of the condition can be triggered in areas with large amounts of visual stimuli. When combined with movement, the increases in visual stimuli cause dizziness and nausea, according to the Visual Specialists website. In a case study from the Brazilian Journal of Otorhinolaryngology, authors led by Dr. Joao Daniel Caliman e Gurgel at Hospital Geral de Bonsucesso revealed that patients with panic-related dizziness had higher rates of vertigo and agoraphobic behavior than their counterparts who had dizziness alone.
Dizziness is a symptom of agoraphobia because it is part of the fight or flight response. Fight or flight is a psychological response to a stimulus that our brain and body consider threatening or harmful. Upon perception of a harmful event or a threat, the sympathetic nervous system stimulates the body’s fight or flight response, which usually consists of physiological reactions. The amygdala (integrative center for emotions and emotional behavior) initiates the reaction by triggering the neural response in the hypothalamus, which leads to the release of stress hormones into the bloodstream, according to a paper that Dr. Eunsoo Won of CHA University and Dr. Yong-Ku Kim of Korea University College of Medicine published in the International Journal of Molecular Sciences. When a person is anxious, they can hyperventilate, which changes the balance of blood gases. As a result, dizziness or lightheadedness may occur.
Dizziness, as a symptom of agoraphobia, is identified through lightheadedness, feeling faint, unsteadiness or loss of balance, heavy-headedness, and a false sense of motion or spinning (vertigo). These symptoms occur when a person is feeling anxious in a situation that triggers their anxiety.
Fainting is a brief loss of consciousness caused by a drop in blood flow to the brain. The medical term for fainting is syncope. The episode usually lasts a few seconds up to a few minutes. There are two types of syncope: vasovagal and situational. Vasovagal syncope occurs due to a sudden drop in blood pressure, which reduces blood flow to the brain. It happens in times of emotional distress or when a person is standing for a while so that blood pressure and heart rate inappropriately decrease severely. Situational syncope occurs in a wide range of situations including dehydration, intense emotional stress, pain, fear, hunger, alcohol or drug use, hyperventilation, and anxiety, according to Cleveland Clinic.
Agoraphobia causes fainting because, during exposure to public and crowded places or situations that cause a feeling of being trapped, a person may feel dizzy, nauseous, and even faint. In a study published in the May 2013 issue of Yonsei Medical Journal, authors S.H. Lee et al. revealed that anxiety was associated with frequent episodes of syncope. In patients with recurrent syncope, the anxiety of episode anticipation was increased. Researchers hypothesize that anxiety increases sympathetic tone through the enhancement of catecholamine release (chemicals important for stress response) and direct modulation of the central nervous system (CNS). In turn, it triggers an excessive parasympathetic response linked with bradycardia (slow heart rate) and inappropriate reflex vasodilation (widening of blood vessels).
Fainting is a symptom of agoraphobia because the trigger of symptoms (a crowded or public place) leads to overreacting of part of the nervous system that regulates blood pressure and heart rate. It is part of the fight-or-flight response.
Fainting, as a symptom of agoraphobia, is identified through lightheadedness, blacking out, dizziness, drowsiness, feeling unsteady, headaches, and changes in vision. When facing the trigger of agoraphobia, a person experiences physical reactions that may also include fainting.
3. Falling or diarrhea
A fall is defined as an event that occurs when a person comes to rest inadvertently on the floor or ground or other levels, according to WHO. People fall due to balance problems or muscle weakness, vision loss, or long-term health conditions such as dementia or heart disease. On the flip side, diarrhea is a loose or watery stool that is passed three or more times a day. It can be acute, persistent, or chronic. Causes of diarrhea are bacterial infection, virus, food intolerance, food allergy, or intestinal disease. Both falling and diarrhea can occur as symptoms of anxiety. For example, in a study published in 2016 in Journals of Gerontology, Hallford, et al confirmed that anxiety symptoms are positively associated with falls, especially in older adults. Medical News Today reports that when a person is anxious they may experience diarrhea.
Falling and diarrhea are symptoms of agoraphobia because they are associated with anxiety disorders and the feelings of worry or fear may trigger a chain of physical reactions. Agoraphobia, as a type of anxiety disorder, causes falls because increased fear can lead to stiffening movement and altered gait, postural control, visual stretch strategies, and head movements. These changes can affect balance and increase the risk of falls, according to a post by Dr. Julie A. Honaker, a Director of the Vestibular and Balance Disorder Program at the Cleveland Clinic, in the ASHA Leader.
When it comes to diarrhea, agoraphobia may cause it because the stress on the body affects hormones and chemicals, which can induce negative changes in the gut. Diarrhea may occur as a result of the imbalance of gut microbiota, Medical News Today explained. The state of anxiety can also alter how the brain processes information from the visceral nerves, which are present in the stomach and intestines. An article by Prof. Gerald J. Hotmann et al., published in the October 2016 issue of the journal The Lancet, suggested that an anxiety state may cause the brain to process messages from the stomach as indicating pain or that the movements in the intestine need to speed up.
Falling and diarrhea are symptoms of agoraphobia because the symptoms that people experience can affect balance and impair the microbiome in the gut. These symptoms occur due to the way the body and brain respond to negative stimuli or a situation they perceive as threatening or impossible to escape.
As a symptom of agoraphobia, falling is identified as losing balance after which a person ends up on the ground. Diarrhea is identified as frequent or loose watery stools and may be accompanied by abdominal pain. Falling and diarrhea occur upon exposure to a trigger of agoraphobic behavior or as the body attempts to process the situation.
What can I expect from agoraphobia?
Agoraphobia makes a person fear or avoid places and situations that cause panic or feelings of being helpless, trapped, and embarrassed. A person experiences symptoms of agoraphobia when facing an actual situation such as a crowded place, or when they anticipate it.
People with agoraphobia tend to fear leaving home alone, crowds or waiting in line, enclosed spaces (elevators, movie theaters), open spaces (bridges, parking lots, malls), and public transportation.
Fear or anxiety a person with agoraphobia experiences is out of proportion to the actual danger of the situation. People with this condition tend to feel safer when they are accompanied by friends or family when they’re outside.
Agoraphobia limits daily activities. In the most severe cases, a person with agoraphobia isn’t able to leave their home. A person may be homebound for years unless they get adequate treatment. When left untreated, agoraphobia can lead to complications and other mental illnesses such as depression, substance abuse, and suicidal thoughts and tendencies.
Who is at risk for agoraphobia?
Individuals in their late adolescence or early adulthood, before the age of 35, are more likely to develop agoraphobia. While agoraphobia can begin in childhood, it’s more common in teens or young adults, according to Mayo Clinic. Women are at a higher risk of developing agoraphobia than men.
People with panic disorder or phobias are more susceptible to agoraphobia. The same applies to individuals who respond to panic attacks through avoidance behavior and too much fear. According to Winchester Hospital at Beth Israel Lahey Health, having depression or PTSD makes a person more prone to developing agoraphobia. Being widowed or divorced and having harsh and overprotective parents are considered risk factors for agoraphobia as well.
A history of abuse or major life stress such as being attacked or losing a parent is also a risk factor for agoraphobia. Men and women with anxious or nervous personalities are more prone to agoraphobia.
Having a family member or relative with agoraphobia increases the risk of developing this anxiety disorder.
To sum up, DSM-5 stratifies risk factors for agoraphobia into three categories. The first category is temperamental risk factors (sensitivity to anxiety and disorders of anxiety, neuroticism), while the second category refers to environmental risk factors (negative childhood events). The third category is a genetic or physiological predisposition, according to an article on the website of the National Library of Medicine.
How is agoraphobia diagnosed?
Agoraphobia is diagnosed according to a patient’s symptoms, physical exam, and psychiatric evaluation. Based on the symptoms described, a healthcare provider will suspect agoraphobia is the culprit. However, they will perform a physical exam to rule out the physical causes of the symptoms that a person experiences. Physical exam typically includes blood tests and urine tests, which can also detect a history of drug or alcohol use.
After the physical exam, a patient is referred for a psychiatric evaluation. The psychiatrist asks questions about symptoms and their frequency and duration. The healthcare professional may also ask whether a patient gets stressed out about leaving their house or whether they avoid specific situations and places due to fear. The psychiatrist may also want to know if a patient relies on others to do their errands and shopping.
It’s useful to remember that if a patient is afraid to visit the medical office in person, they may be able to schedule a video or telephone appointment.
A mental health expert uses DSM-5 to check whether a patient meets the diagnostic criteria for agoraphobia. To meet diagnostic criteria, the patient must have a significant, persistent (≥ 6 months) fear or anxiety in at least two out of five situations. These situations include using public transport, being in enclosed spaces, being in open spaces, being outside the home, or standing in crowds and lines.
A person’s fear must include thoughts that escape from the specific situation is impossible or difficult or that they won’t be able to receive help if they have a panic attack or fear. Diagnostic criteria also dictate that all the following requirements should be present for agoraphobia diagnosis: trigger of fear or anxiety is almost always the same, patients require the presence of a companion or actively avoid the situation, fear/anxiety is out of proportion to the actual level of threat, and fear/anxiety and avoidance behavior significantly impairs occupational or social functioning.
A psychiatrist will diagnose agoraphobia only if fear and anxiety can’t be characterized as a different mental disorder such as social anxiety disorder.
What are the available treatments for agoraphobia?
Available treatments for agoraphobia are a combination of therapy and medications. The treatments for agoraphobia are listed below:
- Selective serotonin reuptake inhibitors (SSRIs)
- Anti-anxiety medicine
Psychotherapy, or talk therapy, is a term that refers to a variety of approaches whose main objective is to help a patient identify and change troubling emotions, thoughts, and behaviors. The therapist sets goals and helps a patient learn skills to manage the symptoms they experience.
Psychotherapy helps treat agoraphobia because it teaches patients skills that help them better tolerate anxiety, directly challenge their worries and gradually return to activities or places that a person avoided due to agoraphobia. The most effective type of psychotherapy for the treatment of agoraphobia is, according to Mayo Clinic, cognitive-behavioral therapy (CBT).
Cognitive-behavioral therapy focuses on helping patients identify irrational beliefs in order to replace them with more rational alternatives. Changing thoughts can help change emotions and behaviors. A CBT therapist provides psychoeducation to the patient so they can understand their distorted or irrational beliefs. Patients also learn relaxation and breathing techniques that help them cope with their anxiety.
Psychotherapy is among the best treatments for agoraphobia because it may also include elements of exposure therapy where the therapist helps a patient gradually expose oneself to the situations they fear. Gradual exposure reduces the severity of fear and symptoms of agoraphobia over time, thus making the condition more manageable. Psychotherapy is goal-oriented and focuses on the specific needs of each patient. Patients with more severe symptoms of agoraphobia may need an inpatient or residential program that includes therapy and provides more structure. They may also benefit from an intensive outpatient program (spending half or full day in a clinic or hospital for several weeks) that specializes in the treatment of anxiety disorders. Therapy such as CBT encourages a more positive way of thinking e.g. panic attacks may be unpleasant, but they’re not fatal and they go away. Positive change in thinking pattern also leads to more positive behavior i.e. a patient becomes more willing to confront situations that previously scared them.
Psychotherapy is an effective treatment approach for people with agoraphobia, and a study from Medicine (Baltimore) is a good example. Authors J.A. Lim et al. found that one month of CBT intervention led to significant reductions in symptoms of panic disorder (with and without agoraphobia), anxiety, and depression. In the Indian Journal of Psychological Medicine, clinical psychologist Naeem Aslam of the National Institute of Psychology at Quaid-i-Azam University in Islamabad, Pakistan reported a case study that found that a patient’s agoraphobia significantly improved with cognitive-behavioral therapy.
How long it takes to experience results with psychotherapy depends on each patient and the severity of their condition. Patients may need six to 20 CBT sessions. According to the UK’s NHS, psychotherapy treatment for agoraphobia may include 12 to 15 weekly sessions. The duration of each session is 30 to 60 minutes. Patients may receive homework to practice the skills they learned during the session until the next one.
2. Selective serotonin reuptake inhibitors (SSRIs)
Selective serotonin reuptake inhibitors (SSRIs) are medications that belong to the class of antidepressants. They are the most frequently prescribed antidepressants, but doctors may also prescribe them for the management of other mental illnesses such as anxiety disorders. Selective serotonin reuptake inhibitors are never the sole treatment option for a person with agoraphobia. Doctors combine them with therapy.
Selective serotonin reuptake inhibitors treat agoraphobia by increasing levels of serotonin in the brain. Serotonin is a neurotransmitter that helps regulate mood. Low levels of serotonin play a role in depression, anxiety, and mania, Cleveland Clinic reported. In development, serotonin acts through its receptor to promote the development of the circuitry for normal anxiety-like behaviors. In a person’s adulthood, SSRIs act on the same receptor to promote neurogenesis and reduce anxiety-like behaviors, according to a review that Dr. Joshua A. Gordon and Dr. Rene Hen of the Department of Psychiatry, Center for Neurology and Behavior at Columbia University published in 2004 in the journal Neuromolecular Medicine.
Selective serotonin reuptake inhibitors are among the best treatments for agoraphobia because they can correct a chemical imbalance in the brain and reduce the severity of symptoms such as panic attacks. These medications work well in combination with cognitive-behavioral therapy. A combination of the two can lead to important neurochemical changes in the brain, Uppsala University reported. Patients with agoraphobia may receive prescriptions for SSRIs such as sertraline (Zoloft) or fluoxetine (Prozac).
The effectiveness of SSRIs has been confirmed by scientific research including the review by A. Bakker et al. in the International Clinical Psychopharmacology. The review showed that SSRIs are effective for the treatment of agoraphobia, especially when combined with exposure therapy. Chawla et al. reported in their review from BMJ that SSRIs are associated with high rates of remission and low risk of adverse effects in the treatment of panic disorder with or without agoraphobia. The most frequently studied and effective SSRI were sertraline and escitalopram.
It may take four to eight weeks to experience the full effects of SSRIs. A person with agoraphobia may experience mild side effects as the body adjusts to the medications. These adverse reactions are nausea, low libido, diarrhea or constipation, blurred vision, agitation, and excessive sweating. The duration of the treatment with SSRIs varies from patient to patient, but it can be six to 12 months or longer.
3. Anti-anxiety medicine
Anti-anxiety medicine, or anxiolytic, is a type of medication prescribed for the treatment of anxiety. The most frequently prescribed anti-anxiety medications are benzodiazepines such as clonazepam (Rivotril), lorazepam (Ativan), and alprazolam (Xanax), according to Canadian Center for Addiction and Mental Health (CAMH).
Anti-anxiety medications help treat agoraphobia because they slow down the body’s and brain’s function thus reducing the intensity of symptoms that people experience. That happens because benzodiazepines are a type of sedative medication. Anxiolytic medications target neurotransmitters in the brain to decrease abnormal excitability. More precisely, they may enhance the activity of the neurotransmitter GABA, which makes a person feel calmer.
Anti-anxiety medicine is among the best treatment options for agoraphobia because they work through several mechanisms of action, depending on the specific drug that a doctor prescribes. Like SSRIs, anti-anxiety medications can increase the effectiveness of other treatment approaches for agoraphobia such as psychotherapy, according to Cleveland Clinic.
Anti-anxiety medicine, such as benzodiazepine, is effective in the treatment of agoraphobia. Their efficacy in the treatment of panic disorder results from the control of the excitability of the central nervous system (CNS) by a selective and potent enhancement of GABA-ergic neurotransmission, according to a 2005 study that Dr. Jeffrey Susman and Dr. Brian Klee at the University of Cincinnati published in the Primary Care Companion to the Journal of Clinical Psychiatry.
Benzodiazepines are taken when needed and they work rapidly in 30 to 60 minutes. The effects of benzodiazepines wear off after several hours. It’s important to remember that benzodiazepines are habit-forming, which is why doctors may prescribe them as a short-term treatment for agoraphobia.
How to prevent agoraphobia?
While agoraphobia can’t be completely prevented, symptoms can be alleviated by implementing lifestyle changes, a well-balanced diet, avoiding drugs and alcohol, and learning how to react in triggering situations.
Lifestyle changes help lower the risk of agoraphobia or reduce the intensity of symptoms that patients experience. For instance, regular exercise can alleviate stress and tension while improving mood.
Eating a well-balanced, healthy diet can help maintain weight in a healthy range or support overall health and well-being. Enrich your diet with fruits, vegetables, healthy fats, nuts, and seeds. Avoid or reduce intake of processed, sugar-laden, and other unhealthy foods.
Avoid using drugs or alcohol because they may provide short-term relief, but in the long run, they could make agoraphobia worse. Since caffeine is a stimulant, it may be useful to limit coffee intake.
When in situations that tend to cause agoraphobic behavior, make sure to stay where you are. Try resisting the urge to run to a place of safety. Breathe slowly and deeply to feel calm and peaceful.
Can agoraphobia be prevented?
No, agoraphobia can’t be prevented i.e. there is no sure way to make it happen, according to Mayo Clinic. Early treatment for anxiety or panic disorders can help, Healthline reported. Even though lifestyle changes don’t eliminate agoraphobia, they can reduce everyday anxiety and make it easier for a person to handle stressful situations. With proper treatment, it is possible to reduce the risk of panic attacks and lower the severity of symptoms.
Is agoraphobia a mental illness?
Yes, agoraphobia is a mental illness because it affects the way people think, feel, and behave. The American Psychiatric Association defines mental illness as a health condition that involves changes in emotions, thinking, or behavior (or both combined). Mental illnesses are generally associated with distress and problems in social or occupational functioning. Agoraphobia also affects a person’s quality of life and impairs their functioning at home and in public.
Is agoraphobia an anxiety disorder?
Yes, agoraphobia is a type of anxiety disorder. Anxiety disorders are characterized by feelings of nervousness, tension, impending danger, increased heart rate, hyperventilation, sweating, and panic attacks. These symptoms occur when a person is exposed to the trigger of their anxiety. People with agoraphobia experience physical and psychological reactions when they are exposed to triggers of their fear such as a crowded place or situations that may seem impossible to escape.
What is the difference between agoraphobia and anxiety?
The difference between agoraphobia and anxiety is that agoraphobia is a type of anxiety disorder. Agoraphobia can also occur as a complication of panic disorder, which is also a type of anxiety disorder. In fact, anxiety disorder is an umbrella term that refers to mental health diagnoses characterized by excessive nervousness, fear, worry, and apprehension.
In people with agoraphobia, anxiety occurs due to worry about how to escape the uncomfortable situation or whether it is possible to do so. Separation anxiety disorder is a good example of how anxiety differs from agoraphobia. In separation anxiety disorder, the fear centers on detachment from a parent/caregiver of a significant other or from home, but in agoraphobia, the fear centers on whether escape is possible or if help will be available. It’s also useful to mention PTSD, which is also a type of anxiety disorder, where a person exhibits avoidance behaviors limited to situations that remind them of the trauma they experienced. A person with agoraphobia also exhibits avoidance behaviors in situations that aren’t necessarily related to trauma, according to Johns Hopkins Medicine.
What is the difference between agoraphobia and social anxiety disorder?
The difference between agoraphobia and social anxiety disorder (SAD) is that people with agoraphobia fear losing control or having panic attacks in specific situations or locations, but individuals with SAD worry about being judged or feeling embarrassed in social situations. Agoraphobia and social anxiety disorder are often mistaken for one another or considered to be the same problem. While fear or discomfort in public places or situations is what they have in common, agoraphobia and social anxiety disorder are not the same mental illness.
A person with agoraphobia fears being in situations where escape could be difficult or impossible and they wouldn’t be able to get help if they have a panic attack. On the flip side, a person with SAD fears being in a position where they are being judged, humiliated, or criticized. Patients with agoraphobia experience fear in different situations, not just situations where they could be judged.
While a person with agoraphobia feels safer when a trusted companion is with them, an individual with SAD may feel worse due to potential scrutiny by the companion as well, Very Well Mind explained.
Psych Central explains that both agoraphobia and social anxiety disorder can cause panic attacks. In agoraphobia, the feeling that it’s impossible to escape from a place that causes discomfort may lead to a panic attack, but with SAD people may have a panic attack through exposure to anxiety-provoking social situations.
What is the difference between agoraphobia and panic disorder?
The difference between agoraphobia and panic disorder is that the latter is a mental disorder characterized by frequent and sudden panic attacks and significant worry about future panic attacks or how they could cause harm. Triggers for panic attacks may include stress, substance abuse, pre-existing health conditions, and social events. Agoraphobia may occur as a complication of a panic disorder. According to Cleveland Clinic, about one-third of people with panic disorder develop agoraphobia.
Panic disorder and agoraphobia are two separate conditions that may occur together. A paper by Dr. Jin Shin et al, published in the July 2020 issue of journal Medicine (Baltimore) reported that agoraphobia is frequently accompanied by panic disorder and causes significant suffering. People with both agoraphobia and panic disorder develop symptoms at a younger age than their counterparts who only have panic disorder. Symptoms tend to be more severe in people who have agoraphobia and panic disorder, the same paper revealed.
People with agoraphobia may experience panic attacks due to the fear of not being able to escape the place or situation that makes them feel trapped or uncomfortable. However, the panic disorder doesn’t occur in all patients with agoraphobia. For that reason, DSM-4 differentiated panic disorder with and without agoraphobia. A person with panic disorder can avoid an activity that they fear could cause a panic attack (e.g. watching horror movies), but not fear going to places such as movie theaters. On the flip side, an individual with agoraphobia tends to avoid places that cause discomfort e.g. movie theaters.
The UK’s NHS explains that agoraphobia can be a complication of a panic disorder, but it’s also possible for people with this condition to have no history of panic attacks. In these cases, their fear is associated with issues such as fear of illness, being in an accident, terrorism, or crime.