What Is Agoraphobia? What Causes Agoraphobia?

A person with agoraphobia fears being in places where there is a chance of having a panic attack that people may witness, and getting away rapidly may be difficult. Because of these fears the sufferer will deliberately avoid such places - which may include crowded areas, special events, queues (standing in line), buses and trains, shops and shopping centers, and airplanes.

A person with agoraphobia may find it hard to feel safe in any type of public place, especially where large numbers of people gather. Some people may have it so severely that the only place they feel really safe in is their home, and rarely ever go outside.

Agoraphobia is not the opposite of claustrophobia (fear of closed spaces, such as elevators) - it is not simply a fear of open spaces. Agoraphobia may result in a fear of being outdoors, a kind of open space - but it is not a fear of there being too much openness and no walls, ceilings or boundaries, etc. The fear of going outdoors results from a dread of becoming embarrassed, trapped and helpless somewhere while having a panic attack - this never happens inside one's own home.

According to the National Institute of Mental Health (NIMH), USA, about 3.2 million American adults are living with agoraphobia. The median age of onset of agoraphobia is 20 years.

What are the symptoms of agoraphobia?

Physical symptoms of agoraphobia

Sufferers will usually only experience the symptoms when they find themselves in a situation or environment that causes them anxiety. Physical symptoms are rare because most people with agoraphobia avoid situations that they believe will trigger panic. When symptoms do occur, they may include:

• Accelerated heart beat.
• Rapid and shallow breathing (hyperventilating).
• Feeling hot, flushing.
• Stomach upset.
• Diarrhea.
• Trouble swallowing.
• Breaking out in a sweat.
• Nausea.
• Trembling.
• Dizziness.
• Feeling light headed, as if one were about to faint.
• Ringing in the ears.

Psychological symptoms of agoraphobia

These symptoms are sometimes related to the physical symptoms:

• Fear that people will notice a panic attack, causing humiliation and embarrassment.
• Fear that during a panic attack their heart might stop, or they won't be able to breathe, and may die.
• Fear that the sufferer himself/herself is going crazy.

The following psychological symptoms are also possible:

• Low self-confidence and self-esteem.
• Feeling a loss of control.
• Depression.
• General feeling of dread and anxiety.
• Thinking that without the help of others the sufferer himself/herself would never be able to function or survive.
• Dread of being left alone.

Behavioral symptoms of agoraphobia

• Avoidance - avoiding environments and situations that may trigger anxiety. In some cases this may be mild, where the sufferer avoids going in a crowded train. In extreme cases the person finds it very hard to leave the house.


• Reassurance - the sufferer needs to be reassured by another person. Going out to the shops may only be possible if a friend comes along too. In extreme cases the sufferer finds being alone unbearable.


• Safety behavior - needing to have or to take something in order to confront situations or places that trigger anxiety. Some sufferers have to have an alcoholic drink before going into a crowded place, while others cannot go outside unless they are sure they have their tablets with them.


• Escape - leaving a stressful place or situation straight away and going back home.

What are the causes of agoraphobia?

Experts are not completely sure what the exact causes of agoraphobia are. Most believe that they are a result of physical and/or psychological factors.

• A complication of a panic disorder
  
  Agoraphobia is thought to be a complication of a panic disorder - a disorder characterized by regular episodes of panic attacks (intense fear) which trigger severe physical reactions for no apparent reason. Panic attacks can be extremely frightening - causing people to think they are losing control, or even dying.
  
  Some people may link their panic attacks to one or two situations in which they occurred. By avoiding those places or situations the sufferer believes he/she may be preventing future recurrences of panic attacks. If a situation or place has people - perceived as potential witnesses to a panic attack by the sufferer - they are more likely to avoid it.
  
  Agoraphobia very rarely develops without an accompanying panic disorder. When it does, nobody knows what caused it.


• Some medications and substances
  
  Long-term use of tranquilizers and sleeping medications, such as benzodiazepines, have been linked to agoraphobia. Health care professionals report that when benzodiazepine dependence is treated agoraphobia symptoms eventually improve.


• Difficulties with spatial orientation
  
  Some studies have found a link between agoraphobia and problems with spatial orientation. Most people without agoraphobia can maintain balance by combining data from their vestibular (components in the inner ear) and visual systems, as well as their proprioceptive sense (the sense of the relative position of neighboring parts of one's own body). A higher percentage of people with agoraphobia have weak vestibular function, compared to the rest of the population, and consequently rely more on tactile and visual signals. When visual signals are overwhelming, as may be the case in a crowded place, the sufferer is more likely to become disoriented.


• Some other factors
  
  
  • A history of alcohol abuse.
  • A history of drug abuse.
  • A traumatic childhood experience.
  • A very stressful event, such as bereavement, loss of a job, an explosion, war, or devastating earthquake.
  • A history of mental illness, such as an eating disorder or depression.

How is agoraphobia diagnosed?

A GP (general practitioner, primary care physician) who identifies psychological symptoms of agoraphobia will most likely refer the patient to a psychiatrist - a doctor who specializes in the diagnosis, prevention and treatment of mental illness. The GP may also examine the patient if there are physical symptoms to find out where there are any underlying physical causes.

The psychiatrist will ask the patient about his/her feelings, symptoms and general background. The specialist will also try to find out whether the agoraphobia is being caused by another mental health condition. If this is the case, it must be addressed first before being able to successfully treat the agoraphobia. For example, a person who avoids crowds because he/she has a fear of catching other people's germs most likely has OCD (obsessive-compulsive disorder).

According to the DSM-IV Diagnostic Criteria for Agoraphobia, a patient suffers from agoraphobia if:

• The person is anxious about being in a place or situation where escape or help may be difficult in the event of a panic attack, or panic like symptoms. Examples are being in a crowd or travelling on a bus.


• The person avoids these places (described above).


• The person endures these places (described above) with extreme anxiety.


• The person endures these places (described above) only with the help of a friend or companion.


• There is no other underlying condition that may explain the person's symptoms.

Some experts criticize this classification system because it does not include people with agoraphobia who do not have other symptoms of panic disorder, including patients who have never had a history of panic attacks, or those whose agoraphobia is triggered by other fears not linked to panic attacks. Even so, panic attacks do not necessarily have to be present for a diagnosis of agoraphobia to be confirmed.

What are the treatment options for agoraphobia?

Treatment for agoraphobia usually involves a combination of medication and psychotherapy. In the majority of cases treatment is effective and the patient is either cured or learns to keep it under control.

Medications for agoraphobia

Anti-anxiety drugs and antidepressants are generally prescribed for patients with agoraphobia and panic symptoms. In some cases the patient may have to try out some different medications before hitting on the best one.

• SSRIs (selective serotonin reuptake inhibitors) - these antidepressant drugs include fluoxetine (Prozac, Prozac Weekly), paroxetine (Paxil, Paxil CR) or sertraline (Zoloft).
  
  Side effects may include:
  
  • Headaches
  • Insomnia
  • Nausea
  • Sexual dysfunction


• Tricyclic antidepressants or monoamine oxidase inhibitors - these antidepressant drugs may also be used to treat agoraphobia. However, they tend to have more side effects.


• Anti-anxiety medications (benzodiazepines) - examples are alprazolam (Xanax) and clonazepam (Klonopin). They are used to treat anxiety and can also help control the symptoms of a panic attack. If taken in doses larger than those prescribed, or for too long, they can cause dependence.
  
  Side effects may include:
  
  • Confusion
  • Drowsiness
  • Light-headedness
  • Loss of balance
  • Memory loss

Patients usually start off on small and gradually increasing dosages. At the end of treatment the doctor will probably gradually lower the dosage.

Psychotherapy for agoraphobia

Psychotherapy is treatment by psychological means. Psychotherapy may utilize persuasion, suggestion, reassurance, insight (perceptiveness, self-awareness), and instruction so that the person can see himself/herself and their problems in a more realistic way and wish to overcome and/or cope with them effectively. There are many types of psychotherapy, including cognitive therapy, interpersonal therapy, psychodynamic therapy, and family therapy.

Cognitive behavioral therapy (CBT) - this type of therapy has two parts. The cognitive part focuses on learning more about agoraphobia and panic attacks and how to manage them. The patient learns what the panic attack or panic-like symptom triggers are, and what makes them worse. Coping techniques, such as breathing and relaxation exercises are taught and practiced.

The behavioral part involves altering unhealthy or undesirable behaviors. This may be done through desensitization or exposure therapy, also known as cognitive delivered exposure (CDE). The patient safely confronts the situations or places that cause problems, often in the company of the therapist. With practice and guided exposure the patient learns that what he/she feared might happen does not occur, resulting in a gradual decline of anxiety.

Sometimes the therapist may start sessions off in the patient's home if venturing outside is too difficult. The first few appointment may also take place in a 'safe zone' if getting to the therapist's office is perceived as having too many anxiety triggers. A good agoraphobia therapist should be aware of these problems and have practical options for the patient. Another possibility is to have the first few sessions over the phone.

What are the complications of agoraphobia?

Complications of agoraphobia may occur if the patient does not receive treatment.

An agoraphobia sufferer may eventually have a very restricted lifestyle. In severe cases the person will never leave the house and is dependent on other people. Being housebound usually means the patient's job prospects are severely limited. His/her social life, opportunities for education and learning new skills, walking the dog, running errands, or taking part in various daily activities are affected.

People with untreated agoraphobia have a much higher risk of developing depression, further anxiety disorders, and turning to alcohol or other substances.