AGORAPHOBIA

What is Agoraphobia?

Agoraphobia is a type of specific phobia in the Diagnostic and Statistical Manual (DSM) of mental health disorders. It roughly translates to ‘fear of public spaces, crowds or social situations.’ It is marked under the category of Anxiety Disorders.

The Encyclopedia of Neurological Sciences defines Agoraphobia as “fear of being in situations from which escape might be difficult or in which help may not be available in the event of a full or partial panic attack.”


What does agoraphobia look like?

People who suffer from agoraphobia may experience:

● Severe anxiety in public settings

● Extreme fear of crowds or waiting in line

● Avoidance of enclosed places such as movie theaters, small stores etc.

● Avoidance of open spaces such as parking lots, malls etc.

● Difficulty using public transportation such as a bus, plane or train

● Occasional panic attacks if forced to be in a public or crowded setting


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For those suffering from Agoraphobia, the distress and anxiety caused by these symptoms is so severe and pervasive that it prevents them from leading a normal life and vastly restricts their daily routine and functioning. It may affect how they socialize, their ability to work and even prevent them from engaging in everyday activities such as going to the store or to an appointment or attending meetings.


As in case of most phobias, agoraphobia can lead to severe distress and anxiety when exposed to or confronted with triggers and may even lead to panic attacks in severe cases. These are characterized by difficulty in breathing, cold sweat, rise in body temperature, hyperventilation, shivering, chest pain, increased heartbeat, nausea, dizziness, headache and other sensory motor symptoms. It can lead to helplessness, embarrassment and avoidance of any situation, event or object which may be a possible trigger to the condition.


How is it different from Social Anxiety Disorder?

Social Anxiety Disorder is marked by fear of embarrassment in social situations, fear of apprehension, objection and/or rejection by others. It is more rooted and tied to one’s self-esteem, self-confidence and self-worth. It occurs when an individual internalizes other people’s opinions, thoughts and views about themselves over their own.

On the other hand, agoraphobia has more to do with the fear of harm in public places or crowds, which is greatly disproportionate to the actual risk. The fear is perpetrated by a sense of loss of control, which leads to full-blown anxiety and panic. People suffering from agoraphobia may avoid going out altogether to keep themselves safe from any triggers.


What could be the potential causes for it?

The median age of onset for agoraphobia is 20 years. It usually develops after the individual has had one or two panic attacks in public spaces due to the anxiety and fear surrounding them. Over the years, various physicists and psychologists have accounted temperament to be a leading cause for agoraphobia. Those with high neuroticism are at a greater risk for developing this condition, as well as any other anxiety and depressive disorder.

Many psychodynamic therapists and practitioners believe that lack of sufficient and appropriate caregiving in early childhood set a deep-rooted fear of surroundings in children, causing problems with adjustment to external environment and leading them to develop various adjustment disorders, anxiety disorders, neuroticism and depression in later stages of life. One such psychodynamic theorist Melanie Klein developed Object-Relations Theory, in which individuals get stuck in ‘Paranoid Schizoid position’ in childhood when they do not receive enough safety and security from their caregiver in infancy. This leads them to develop a distrust and fear of the external world.

Other theorists include genetics, pre-existing health conditions, one’s interaction with the environment and learning experiences as the potential leading causes for developing anxiety and agoraphobia. This view maintains that agoraphobic fear is a consequence of learning (i.e., of associating unpleasant anxiety symptoms or traumatic experiences with certain situations). Avoidance of these situations, in turn, maintains this fear. This is explained in the cognitive learning theories as well as the stress diathesis model in etiological studies in psychology.


How common is it? How come I have never heard of it?

According to the DSM-5, agoraphobia is present in approximately 1.7% of the general population. The National Institute of Mental Health estimates lifetime prevalence of agoraphobia at 1.3%, with an annual incidence rate of 0.9%.

It has been consistently reported that agoraphobia is much more likely to occur in women, which gave rise to the hypotheses about gender-related psychological and social factors in the development of agoraphobia. However, as revealed by recent studies and mentioned in DSM-5, yearly prevalence rates have been similar between males (0.8%) and females (0.9%).


Is it treatable? How?

As with most phobias, agoraphobia is completely treatable through psychotherapy.

Selective serotonin reuptake inhibitors (SSRIs) are the primary pharmacotherapeutic agents prescribed for agoraphobia with panic disorder, rather than benzodiazepines and other anxiolytics, which pose a higher risk for the development of dependence and eventually, substance abuse.

Similarly, cognitive behavior therapy (CBT) has the strongest evidence of response and effectiveness among psychotherapeutic treatments.

There are primarily two types of CBT used to treat agoraphobia: cognitive therapy and exposure therapy. Cognitive therapy primarily focuses at recognizing, challenging, and finally counteracting the underlying causative factors of agoraphobia. In exposure therapy, the aim is teaching individuals how to gradually reduce their anxiety level by remaining in the stressful situations/places using techniques such as systematic desensitization, hierarchy, gradual exposure or flooding and response prevention. It is performed along with relaxation exercises, counseling, and self-confidence building for effectiveness and helps the individuals perform activities that they used to avoid previously due to fear or anxiety.

Supplementary psychotherapy or ‘talk therapy’ involves teaching them healthier and more appropriate coping mechanisms other than escapism, which will provide them with better ways of dealing with the immediate anxiety provoked by their triggers.


What are the potential risks?

Individuals diagnosed with Agoraphobia or any anxiety disorder, for that matter, are at risk for further developing disorders such as Obsessive Compulsive Disorder (developing compulsive behaviours due to the obsessive worries experienced in agoraphobia), Panic Disorder (due to frequent occurrence of panic attacks), depressive symptoms and disorders, General Anxiety Disorder (GAD), gastrointestinal problems and substance use disorders for coping. Panic Disorder has the highest comorbidity with agoraphobia.


 

References:

1. UpToDate, Agoraphobia in adults: Epidemiology, clinical manifestations and diagnosis, cursoenarm.net/UPTODATE/contents/mobipreview.htm?3/49/3856/abstract/8

2. Diagnosis and treatment of agoraphobia with panic disorder, https://www.ncbi.nlm.nih.gov/pubmed/17696574

3. Differential familial liability of panic disorder and agoraphobia, https://www.ncbi.nlm.nih.gov/pubmed/18023003

4. Agoraphobia: Causes, Symptoms, Diagnosis & Treatment,

https://www.news-medical.net/health/Agoraphobia-Causes-Symptoms-Diagnosis-Treatment.aspx#3

Cover image credits: Representative photo: iStock / Getty Images Plus)

 

Written by: Akshada Shinde (Psychologist)


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