Agoraphobia

Crowded building

Agoraphobia is the fear of being in large or unknown public places. This phobia is associated with panic attacks and anxiety and often results in an individual's avoiding public situations that might make escape difficult. The most severe case of this condition can confine a person to his or her home, while less severe cases may cause a person to panic when he or she is in an area where there are few or no places to hide or feel protected. While agoraphobic behaviors can seem irrational, a person with agoraphobia has valid fears that often surface in therapy. A person who experiences extreme panic or anxiety at the thought of public situations might consider speaking to a therapist.

What Causes Agoraphobia?

About 1% of the population has agoraphobia. The condition tends to occur more frequently in women than in men, and it usually develops in individuals before age 35, with 20 being the average age of onset. Agoraphobia can be considered a complication of panic attacks, as people who have had panic attacks may become fearful of experiencing an attack in a public location and being unable to escape. A combined fear of embarrassment and being unable to deal with a panic attack in public can lead to agoraphobia.

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Agoraphobia does not always occur with panic, however. The factors that contribute to this condition may vary from person to person, and researchers are not sure what causes it. Some individuals may develop agoraphobia after a traumatic experience or as a side effect of posttraumatic stress.

Symptoms of Agoraphobia

Agoraphobia can affect a person physically, emotionally, and cognitively. Agoraphobia can lead to high blood pressure and a variety of other physical symptoms including abdominal distress that occurs when upset, difficulty breathing, confused and disordered thoughts, nausea, numbness, and tingling. A person experiencing agoraphobia may also become housebound for long periods of time and become increasingly reliant on others. He or she might fear being alone or in public places where escape might be difficult, fear losing control in public, have an intense fear of dying or "going crazy," or feel helpless or unreal. Individuals may change or adapt their daily routine in order to avoid crowds or other situations that cause anxiety, and at least one-third of those with agoraphobia find themselves unable to leave their homes at all.

Therapy for Agoraphobia

Through therapy, people with agoraphobia have the opportunity to talk through the anxieties, thoughts, and feelings that contribute to panic, explore ways to cope with the condition, and develop methods with which to approach situations that agoraphobia may cause them to be unwilling to face, such as using public transportation or going shopping. Through therapy, people with agoraphobia are often able to learn different thought processes and exercises that can lead to the improvement of the condition.

Cognitive behavioral therapy (CBT) is often used to treat agoraphobia, as this type of therapy can be helpful in adapting the thoughts that cause agoraphobia in an individual. Through CBT, an individual may come to learn ways to deal with the symptoms, replace the thoughts that cause him or her to panic, and manage stressful situations. The individual may eventually recognize that it is unlikely that the fears relating to the condition will come true but feel better equipped to deal with them if they do.

Traveling to a therapist's office may pose some challenges for the person with agoraphobia, and therapists who provide home-based therapy or distance therapy may be particularly helpful in this instance. Some therapists may be willing to meet a person in a place where that person feels safe if traveling to the therapist's office is not possible. Supportive family members can often play a helpful role in treatment and can be of general assistance by refraining from accusatory or pushy behavior, such as urging an individual to "conquer" his or her fears or by telling someone, "It's all in your head." Self-care methods such as relaxation, avoiding situations that inspire fear, eating and sleeping well, and exercising might also help a person be better able to cope with agoraphobia.

Diagnostic Criteria for Agoraphobia

Although agoraphobia was classified in previous editions of the Diagnostic and Statistical Manual under panic, the DSM-5 classifies it as its own condition with diagnostic criteria separate from that of panic. To be diagnosed with agoraphobia, an individual must experience significant fear or anxiety toward at least two of the following:

  • Being in an open space.
  • Being in an enclosed public space.
  • Waiting in line or being in a crowd.
  • Being out of home alone.
  • Using public transportation.

An individual diagnosed with agoraphobia will almost always experience fear or anxiety as a result of exposure to one of the above situations; avoid the above situations, facing them only with a companion or if absolutely necessary; experience distress in social situations; and experience a persistent phobia or avoid these situations for six months or longer.

Case Example

  • Agoraphobia resulting from a traumatic experience: Naomi, 26, makes an appointment to speak to a therapist at her mother’s suggestion. She experienced a panic attack seven months ago, shortly after being mugged on the train, and since then she has been unable to take the train and dreads going out in public, experiencing significant anxiety at the thought of being mugged again or of becoming ill in a public place. Because Naomi can no longer commute to work on the train, she gets up two hours earlier each day in order to take her mother to work and borrow her car, and she insists that her mother or best friend accompany her when she must go out. In general, she only ventures out when it is absolutely necessary. In her sessions with the therapist, Naomi opens up about her fears, namely, the terror and panic she experienced while being mugged, and with her therapist, she discusses things that might help her feel more able to go out in public. She decides to attempt the use of public transportation while accompanied by someone, and she is able to take the train to her therapist’s office by the fourth session. Although she experiences some anxiety, the fear is not crippling. Naomi continues to see the therapist, and her anxiety slowly decreases.

References:

  1. Agoraphobia. (2013). In Diagnostic and statistical manual of mental disorders: DSM-5. (5th ed., pp. 217-221). Washington, D.C.: American Psychiatric Association.
  2. Mayo Clinic Staff. (2011, April 21). Agoraphobia. Mayo Clinic. Retrieved from http://www.mayoclinic.com/health/agoraphobia/DS00894/DSECTION=causes.
  3. McIntosh, J. (2014, September 26). What Is Agoraphobia? What Causes Agoraphobia? Retrieved from http://www.medicalnewstoday.com/articles/162169.php#treatment_options.
  4. The numbers count: Mental disorders in America. (n.d.). Retrieved from http://www.nimh.nih.gov/health/publications/the-numbers-count-mental-disorders-in-america/index.shtml.

 

Last updated: 07-13-2015

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