People with Agoraphobia suffer from significant fear and anxiety when they encounter any of a variety of public situations. This fear can be extremely restricting; in fact, over a third are unable to leave their homes by themselves due to their illness. As a result, many people with Agoraphobia are unable to work or socialize effectively and will have friends or family run errands for them, such as getting groceries and shopping.
Individuals with Agoraphobia can appear visibly anxious in public places. They will either try to leave or lean on a friend or loved one for emotional support. People fear that they may be stuck in one of these situations and forced to endure the anxiety and embarrassment of a public panic attack. Fear of falling and fear of incontinence are unique to elderly people with agoraphobia, and they also usually fear open spaces and being in lines or crowds. Children with the disorder fear being lost or separated from their caregivers. As a result, the most common situation children fear is being outside of the home by themselves.
Agoraphobia is strongly correlated with panic attacks and Panic Disorder. Although panic attacks are not required for the diagnosis, they are a hallmark of the disorder’s severity. Panic sufferers feel overwhelming waves of doom in addition to somatic symptoms like nausea, dizziness, and chest pain, which frequently bring patients to the emergency room for fear of heart trouble. Agoraphobia is generally chronic and relentless unless met with solid treatment, and increased severity decreases the chances of achieving remission. Even for people who do reach remission, over 50% will experience a relapse at some point.
Causes and Risk Factors
In an average year, 1.7% of Americans aged 13 or older will suffer the diagnosis of Agoraphobia, and women are twice as likely to have the disorder. Although the overall average age of onset is 17 years old, when people with pre-existing Panic Disorder are not included, that average increases to 25-29 years old. In all cases, two thirds of people are diagnosed before age 35.
Compared to the other phobias, Agoraphobia has the strongest genetic component. These genes are the same ones that account for low extraversion (the tendency to be outgoing and sociable) and high neuroticism (the tendency to expect and experience negative and anxious emotions).
Anxiety sensitivity is a personality trait where patients fear experiencing the symptoms of anxiety. This is a critical piece in understanding why people with agoraphobia develop strong avoidance behaviors. In addition to irrational fears about what may happen to them in feared situations (embarrassment, inability to escape), they may experience panic symptoms themselves even though they may not have full symptom panic attacks.
Risk from childhood
Childhood risk factors for Agoraphobia include an overbearing and overprotective, yet emotionally cold, rearing environment. Furthermore, negative life events in childhood such as death of a loved one also increase the risk of Agoraphobia.
Agoraphobia frequently occurs alongside Panic Disorder, with 30-50% of people with Agoraphobia experiencing panic attacks prior to the onset. About half of these people with both Agoraphobia and Panic Disorder also experience a depressive disorder. However, only a third of people with Agoraphobia alone have a depressive disorder. Development of depressive and substance use disorders usually follows the onset of Agoraphobia, most likely as a response to the self-sequestration (refusal to leave home) and, with substances, an attempt to self-medicate.
A new diagnosis
Although in the previous edition of the Diagnostic and Statistical Manual of Mental Disorders, Agoraphobia was only diagnosed in concert with Panic Disorder, it is now a separate diagnosis. When people are in triggering situations, they can have full panic attacks (which may warrant a separate diagnosis of Panic Disorder) or can experience just a few symptoms of panic, like intense fear, shortness of breath, nausea, and feelings of losing control.
People with Agoraphobia have a significant fear of at least two of several different types of situations.
- Public transportation, like buses or subways
- Being in large groups of people, such as standing in a line or just being in a crowd
- Being in wide open spaces, like parks, beaches, or public squares
- Enclosed spaces, such as stores, restaurants, or museums
- Being outside of their homes by themselves.
The fear that is specific to Agoraphobia is that people feel they will be unable to escape from the situation or that no one will be there to help them if they start to have symptoms of panic. They go to great lengths to avoid these situations or struggle through them with the company of someone close. These environments rarely fail to induce these overwhelming fears, which are greatly out of proportion to any real danger. The fear and accompanying avoidance behaviors significantly negatively impact work, social, and domestic life and usually last for at least 6 months. People can have such severe symptoms that they refuse to leave their homes and will only do so when a friend or family member is with them.
Cognitive Behavioral Therapy
Because Agoraphobia has only recently been separated from Panic Disorder, most treatment research applies to the older diagnosis, Panic Disorder with Agoraphobia. This holds true for Cognitive Behavior Therapy (CBT), which is the first line therapy for Agoraphobia. CBT focuses on identifying the anxiety-provoking triggers and understanding that the disorder’s characteristic avoidance behaviors play a key role in perpetuating anxiety. It takes the form of 10-20 weekly 1-hour sessions with additional homework in between. The central element in CBT for Agoraphobia that is crucial in combating avoidance behaviors is exposure.
What is exposure?
Exposure can be to external cues (people seek out and place themselves in triggering environments) or to internal cues (people induce the physical symptoms of anxiety via running in place, intentionally hyperventilating, or spinning to induce dizziness). The first process is most important for Agoraphobia, while the second strategy is especially helpful when panic attacks are present as well. The therapist and the client work together to create a graded list of feared situations that the person then exposes themselves to as part of homework between therapy sessions. People with severe Agoraphobia (such as those who are homebound) may need a therapist to accompany them on their first few exposures outside the home.
As with Panic Disorder, selective serotonin reuptake inhibitors (SSRIs), like Prozac (fluoxetine) and Zoloft (sertraline), are the main medications for Agoraphobia. People with moderate to severe Agoraphobia may experience a more rapid response to treatment with combined SSRI and CBT treatment rather than either alone. Medication can enable people to undergo the exposure experiences that they would not normally be able to tolerate. Anti-anxiety medicine (minor tranquilizers) can be used for limited time periods in severe situations, but they should be avoided if someone has a history of substance use disorders.
The cycle of phobic avoidance not only characterizes the diagnosis but also impedes treatment, especially when panic attacks are not present. In fact, only 27% of people with Agoraphobia but no panic attacks are receiving treatment at any given time. This is less than half as many (61%) as their panic-stricken counterparts who seek treatment of their own accord. This is because the symptoms of panic attacks are so concerning that they are more likely to find treatment.
Treatment itself can be frightening because of the exposure a person will undergo as part of the process, and consistency is crucial to seeing success. This person will need to keep in close communication with their therapist and psychiatrist, and friends and family can help by accompanying patients on some of the initial exposures.
Technology can offer another stepping stone for the homebound, who can meet with their treatment providers via the computer (also called ‘tele-mental health’) if treatment is not locally available.
Alcohol, caffeine, and other drugs can worsen anxiety in the long run, but the person will sometimes try to use substances to self-medicate. If this person is homebound and requesting that friends bring alcohol or other substances to the house, it could likely be the sign of a nascent substance use disorder and is a critical opportunity for intervention.