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Agoraphobia

by Mike on June 22, 2008

What exactly is Agoraphobia?

The term “Agoraphobia” comes from the Greek, literally meaning “fear of the marketplace.” The DSM-IV (1) defines it as an

[a]nxiety about being in places or situations from which escape might be difficult (or embarrassing) or in which help may not be available in the event of having an unexpected or situationally predisposed Panic Attack or panic-like symptoms. 

The DSM-IV’s further criteria are that the situation causing the Panic Attack or panic-like symptoms is avoided. Finally, that “[t]he anxiety or phobic avoidance is not better accounted for by another mental disorder…”

How many people have Agoraphobia?

The National Institute of Mental Health (NIMH) states that about 5 percent of Americans ages 18-54 have Agoraphobic symptoms in any given year. That’s 15,221,312 people exactly as of the time this article was written! And that doesn’t include Americans over the age of 54. Of course, symptoms are not the same as diagnosable Agoraphobia; the NIMH counts diagnosable Agoraphobics at 3.2 million. That’s still a lot of people.

Women are twice as likely to be diagnosed with Agoraphobia as men. Research so far has not provided a single clear explanation for this gender difference. Some speculate that there are social-cultural factors at play, such as women are more likely to seek help than men, and women’s greater willingness to express emotions than men.

Is Agoraphobia related to Panic Attacks?

Agoraphobia is closely related to Panic Attacks, and it’s estimated that about one third of people with Panic Attacks will progress to having Agoraphobia as well. The Richmond, Virginia psychiatrist William D. Kernodle says in his Panic Disorder: The Medical Point of View that Agoraphobia is a “psychological consequence” of panic disorder. (2)

However, Agoraphobia can occur without one having any diagnosable Panic Attacks at all. This condition, oddly enough, is called “Agoraphobia Without a History of Panic Disorder.” The DSM-IV diagnosis criteria are the same as those listed above for Agoraphobia, with the addition of:

  • Criteria have never been met for Panic Disorder. 
  • The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.
  • If an associated general medical condition is present, the fear described in [Panic-associated Agoraphobia] is clearly in excess of that usually associated with the condition.

What are some situations that Agoraphobics might avoid?

The DSM-IV says that Agoraphobia typically involves clusters of situations. In other words, if you have one symptom, you are likely to have others. Generally, Agoraphobics avoid places and situations where they feel trapped, insecure, out of control, and too far from a personal comfort zone. This includes both familiar and unfamiliar settings. Some examples of settings that Agoraphobics might avoid are:

  • Being home alone without a familiar person around
  • Being outside the home while alone
  • Unfamiliar places and situations
  • Crowds
  • Stores and shopping malls
  • Sports arenas
  • Standing in line
  • Driving or being on a bridge
  • Driving or being on a crowded highway
  • Traveling in a bus, train, car, airplane, even for short distances
  • Confined spaces, such as an elevator or a small waiting room
  • Open spaces, like a parking lot
  • Crossing the street
  • Talking on the phone, writing email or communicating with others in general

Some persons with Agoraphobia can tolerate situations like those listed when they are with a familiar, “trusted,” person. For example, one might be able to go to the store with a friend or spouse but not alone.

What are the causes of Agoraphobia?

As mentioned, research has found no reliable single, or even multiple causes of Agoraphobia. No brain factors have been found, such as with Depression. There has been a great deal of unproven speculation about what might cause Agoraphobia. Some of these factors are:

  • Family: Having a family role model with Agoraphobia, parents that are overly critical or controlling
  • Individual Personality: The need for approval, control, and oversensitivity to emotional stimuli
  • Biological: Oversensitivity to hormone changes and physical stimuli, chemical imbalances in the body and brain

Curiously enough, researchers have found that Agoraphobics have physical problems with spatial orientation and balance. (3) They rely more on visual or tactile cues than on those from the ear’s vestibular system. As a result, they become overwhelmed in crowds or disoriented in large open spaces. In addition, it has been found that Agoraphobics do not process audiovisual data as well as “normal” people. (4)

How does Agoraphobia begin?

Agoraphobia begins with a situation where a person either has a Panic Attack or thinks they may have one. Having a panic attack is a horrible ordeal, and people commonly think they are having a heart attack or a similar medical condition. It is both physically and emotionally draining. The person can’t help but think about the Panic Attack and the situation that caused it when it’s all over. In their imagination, they see themselves having an attack in similar situations, and naturally want to avoid those situations.

If after the first Panic Attack there is no diagnosis or treatment and no measures undertaken to prevent another one, it is highly likely that an individual will start avoiding other situations, as well. For example, if someone has a Panic Attack while crossing a bridge, they might come to avoid heavy traffic or even riding in cars, too. 

Avoidance of situations with Panic Attack potential has a way of feeding on itself. First there is one setting to be avoided, then another related one. Without treatment, and sometimes even with it, one’s ability to function will decrease and the ability to take part in the world will get smaller and smaller. Some find that they are eventually confined to their homes, unable to function at all. (This is what happened in my case. See My Story.)

Is everybody’s Agoraphobia the same?

Definitely not. The onset of Agoraphobia, or even whether you develop it at all, is different for every individual. Some people can develop Agoraphobia without ever having a Panic Attacks. Some have many continuing Panic Attacks and still do not develop it. 

Everybody has different clusters of situations they avoid. A person may have one travel-related avoidance, say riding in a car, but be able to ride on trains and airplanes without any trouble. At the same time, this person might also avoid crowds and speaking on the phone.

The same holds true for treatment. Since everybody’s onset particulars and avoidance patterns are different, what works for one may not work for another.

What are the treatments available for Agoraphobia?

There is a silver lining in the cloud! Agoraphobia has one of the highest treatment success rates of any mental illness. And not all treatment solutions require medications. Again, everyone’s best treatment will be different.

There are several “standard” talk therapies that are effective with Agoraphobia. Most of them use some variation of what is called controlled exposure, desensitization, or gradual exposure therapy. Controlled exposure gradually puts the person into the situation that might precipitate a Panic Attack, desensitizing them to it. Behavioral Therapy seeks to modify and gain control over unwanted behavior through controlled exposure. Cognitive Therapy’s goal is to gain control of unproductive, intrusive thought patterns. Cognitive Behavioral Therapy (CBT) combines both behavioral therapy and cognitive therapy. All of these therapies involve a considerable amount of outside work for the patient, as well as work in the therapy session.

There are many non-traditional methods of controlling Agoraphobia, such as meditation, herbal remedies, and diet. Most of these are focused on maintaining control over Anxiety, Panic Attacks, and Agoraphobia over the long term.

The NIMH recommends the combination of medication and Cognitive Behavioral Therapy as the most effective treatment for most people. A good therapist will use the “mix” of therapies that suits you best.

It is important that, whatever treatment your psychiatric professional uses, the emphasis is put upon not only getting better but staying better. Good treatment will give you the tools to combat the situations that cause Panic Attacks not only now, but for the rest of your life.

Above all, if you think you might have Agoraphobia, you must contact a psychological professional now. Agoraphobia does not stand still, but will increase its grip on you over time. The sooner you seek treatment, the easier it is to overcome this imprisoning mental illness.

FOOTNOTES

(1) DSM-IV is the abbreviation for the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders, which is a publication of the American Psychiatric Association. It is a primary American source for mental health professionals that lists categories of mental disorders and the criteria for diagnosing them. It is used by clinicians and researchers, insurance companies, pharmaceutical companies and policy makers. The American Psychiatric Association has more information on the DSM-IV. 

(2) Kernodle, William D. Panic Disorder: The Medical Point of View. Richmond, VA: Cadmus Publishing, 1995. Amazon still has this book.

(3) “Relationship between balance system function and agoraphobic avoidance.” (1995 May). Behavioral Research Therapy 33 (4): 435–9. PMID : 7755529.

(4) “Panic, agoraphobia, and vestibular dysfunction” (1996). American Journal of Psychiatry 153: 503–512. 

Reviewed 12/05/08