Agoraphobia

Agoraphobia is an anxiety disorder which primarily consists of the fear of certain settings that may present unexpected challenges or demands. These could include parking lots, shoppings malls or restaurants. The social consequences of having a panic attack or losing control in public often becomes an additional source of fear in its own right. As a result, severe sufferers of agoraphobia may become confined to their homes, experiencing difficulty traveling from this "safe place."

Definition

The word "agoraphobia" is an English adoption of the Greek words agora (αγορά) and phobos (φόβος), literally translated as "a fear of the marketplace." This translation is the reason for the common misconception that agoraphobia is a fear of open spaces, and is not clinically accurate.

Agoraphobia describes a condition where the sufferer becomes uneasy in environments that are unfamiliar or where he/she perceives that he or she has little control. Triggers may include crowds, wide open spaces or traveling alone even for short distances. The anxiety is often compounded by a fear of social embarrassment in case of panic attacks or appearing distraught in public.^[1]

People with agoraphobia may experience panic attacks in situations where they feel trapped, insecure, out of control, or too far from their personal comfort zone. In severe cases, an agoraphobic may be confined to his home. ^[2] Some people with agoraphobia are comfortable seeing visitors, but only in a defined space they feel in control of. Such people may live for years without leaving their homes, while happily seeing visitors and working, as long as they can stay within their safety zones. The safety zones can vary, from not being able to leave home, or not being able to make eye contact. If the person leaves his 'safety zone,' he can have an anxiety attack.

Prevalence

The one-year prevalence of agoraphobia is about 5 percent. ^[3] About one third of people with Panic Disorder progress to develop Agoraphobia. ^[4] Agoraphobia occurs about twice as commonly among women as it does in men (Magee et al., 1996^[5]).

Causes and contributing factors

Research has uncovered a linkage between agoraphobia and difficulties with spatial orientation.^{[6] [7]}Normal individuals are able to maintain balance by combining information from their vestibular system, their visual system and their proprioceptive sense. A disproportionate number of agoraphobics have weak vestibular function and consequently rely more on visual or tactile signals. They may become disoriented when visual cues are sparse as in wide open spaces or overwhelming as in crowds. Likewise, they may be confused by sloping or irregular surfaces.^[8] Compared to controls, in virtual reality studies, agoraphobics on average show impaired processing of changing audiovisual data. ^[9]

Diagnosis

Most people who present to mental health specialists develop agoraphobia after the onset of panic disorder (American Psychiatric Association, 1998). Agoraphobia is best understood as an adverse behavioral outcome of repeated panic attacks and the subsequent worry, preoccupation, and avoidance.^[10] Thus, the formal diagnosis of panic disorder with agoraphobia was established. However, for those people in communities or clinical settings who do not meet full criteria for panic disorder, the formal diagnosis of Agoraphobia Without History of Panic Disorder is used (DSM-IV).

Association with panic attacks

Main article: Panic attack

Agoraphobia patients can experience sudden panic attacks when traveling to places where they fear, where help would be difficult to obtain. During a panic attack, adrenaline is released in large amounts for several minutes causing the classical "fight or flight" condition. The attack typically has an abrupt onset, building to maximum intensity within 10 to 15 minutes, and rarely lasts longer than 30 minutes. ^[11] These symptoms include palpitations, sweating, trembling, and shortness of breath. Many patients report a fear of dying, or losing control of emotions or behavior. ^[11]

Treatments

Agoraphobia can be successfully treated in many cases through a very gradual process of graduated exposure therapy combined with cognitive therapy and sometimes anti-anxiety or antidepressant medications. Treatment options for agoraphobia and panic disorder are similar.

Exposure treatment can provide lasting relief to the majority of patients with panic disorder and agoraphobia. Disappearance of residual and subclinical agoraphobic avoidance, and not simply of panic attacks, should be the aim of exposure therapy. ^[12]

Anti-anxiety medications include benzodiazepines such as alprazolam. Anti-depressant medications which are used to treat anxiety disorders are mainly in the SSRI (selective serotonin reuptake inhibitor) class such as sertraline, paroxetine and fluoxetine. Hypnosis is a possible alternative treatment. ^{[citation needed]}

Alternate theories

Attachment theory

Main article: Attachment Theory

Some scholars (e.g., Liotti 1996,^[13] Bowlby 1998^[14]) have explained agoraphobia as an attachment deficit, i.e., the temporary loss of the ability to tolerate spatial separations from a secure base.

Spatial theory

In the social sciences there is a perceived clinical bias (e.g., Davidson 2003^[15]) in agoraphobia research. Branches of the social sciences, especially geography, have increasingly become interested in what may be thought of as a spatial phenomenon.

Agoraphobics

• Jesus Navas, Spanish Footballer
• Philip K. Dick, American science fiction writer
• Emily Dickinson, American Poet
• Kim Basinger, American actress
• Roy Castle, British TV presenter
• Ronald Jones (musician), American musician, guitarist for Flaming Lips
• Elfriede Jelinek, Nobel laureate for Literature, 2004
• Paula Deen, American cook, restaurateur, writer, and TV personality, (after her parents died, recovered, while working at a bank was robbed at gun point, the disorder came back, but recovered again.)
• Rose McGowan, American actress
• Ben Weasel, American musician, frontman of Screeching Weasel
• Edvard Munch, Norwegian Symbolist painter, printmaker, and an important forerunner of Expressionistic art.
• Alessandro Manzoni, Italian novelist and poet
• Peter Robinson, British musician known simply as Marilyn.^[16]
• Edna Turnblad, a fictional character created by John Waters who refuses to leave her apartment.
• Robert Reynolds, a fictional character in the Marvel Universe
• Mason Harris, a fictional character in the internet sitcom Life From The Inside.

See also

• Agoraphobia Without History of Panic Disorder

References

1. ^ http://psychcentral.com/disorders/sx29.htm
2. ^ "Treatment of Panic Disorder", NIH Consens Statement 9 (2): 1-24, Sep 25-27, 1991, <http://consensus.nih.gov/1991/1991PanicDisorder085html.htm>
3. ^ (2006) Anxiety Disorders. NIH Publication No. 06-3879. 
4. ^ Robins, LN & Regier, DN, eds. (1991), Psychiatric Disorders in America: the Epidemiologic Catchment Area Study, New York, NY: The Free Press
5. ^ Magee, W. J., Eaton, W. W. , Wittchen, H. U., McGonagle, K. A., & Kessler, R. C. (1996). Agoraphobia, simple phobia, and social phobia in the National Comorbidity Survey, Archives of General Psychiatry, 53, 159–168.
6. ^ (1995 May) "Relationship between balance system function and agoraphobic avoidance.". Behav Res Ther. 33 (4): 435-9. PMID: 7755529. 
7. ^ (1996) "Panic, agoraphobia, and vestibular dysfunction". Am J Psychiatry 153: 503-512. 
8. ^ (1997 May-Jun) "Surface dependence: a balance control strategy in panic disorder with agoraphobia". Psychosom Med. 59 (3): 323-30. PMID: 9178344. 
9. ^ (2006 Oct) "High sensitivity to multisensory conflicts in agoraphobia exhibited by virtual reality.". Eur Psychiatry 21 (7): 501-8. PMID: 17055951. 
10. ^ Barlow, D. H. (1988). Anxiety and its disorders: The nature and treatment of anxiety and panic. Guilford Press. 
11. ^ ^{a b} David Satcher etal. (1999). "Chapter 4.2", Mental Health: A Report of the Surgeon General. 
12. ^ "Long-term outcome of panic disorder with agoraphobia treated by exposure". Psychological Medicine 31: 891-898. Cambridge University Press. 
13. ^ G. Liotti, (1996). Insecure attachment and agoraphobia, in: C. Murray-Parkes, J. Stevenson-Hinde, & P. Marris (Eds.). Attachment Across the Life Cycle.
14. ^ J. Bowlby, (1998). Attachment and Loss (Vol. 2: Separation).
15. ^ J. Davidson, (2003). Phobic Geographies
16. ^ Whatever Happened to the Gender Benders?, Channel 4 documentary, United Kingdom.

Footnotes

This article incorporates text from the National Institute of Mental Health, which is in the public domain.

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