Agoraphobia

Agoraphobia is an anxiety disorder precipitated by the fear of having a panic attack in a setting from which there is no easy means of escape. As a result, sufferers of agoraphobia may avoid public and/or unfamiliar places. In severe cases, the sufferer may become confined to their home, experiencing difficulty traveling from this "safe place."

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Definition

The word "agoraphobia" is an English adaptation of the Greek words agora (αγορά) and phobos (φόβος), and literally translates to "a fear of the marketplace."

Agoraphobia is a condition where the sufferer becomes anxious in environments that are unfamiliar or where he or she perceives that they have little control. Triggers for this anxiety may include crowds, wide open spaces or traveling, even short distances. This anxiety is often compounded by a fear of social embarrassment, as the agoraphobic fears the onset of a panic attack and appearing distraught in public.^[1]

Agoraphobics 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 or her home. ^[2] Many people with agoraphobia are comfortable seeing visitors in a defined space that they feel in control of. Such people may live for years without leaving their homes, while happily seeing visitors in and working from their personal safety zones. If the agoraphobic leaves his or her safety zone, they may experience a panic attack.

Prevalence

The one-year prevalence of agoraphobia in the United States is about 5 percent. ^[3] According to the National Institute of Mental Health, approximately 3.2 million Americans ages 18-54 have agoraphobia at any given time. About one third of people with Panic Disorder progress to develop Agoraphobia. ^[4]

Gender Differences

Agoraphobia occurs about twice as commonly among women as it does in men (Magee et al., 1996^[5]). The gender difference may be attributable to social-cultural factors that encourage, or permit, the greater expression of avoidant coping strategies by women. Other theories include the ideas that women are more likely to seek help and therefore be diagnosed, that men are more likely to abuse alcohol as a reaction to anxiety and be diagnosed as an alcoholic, and that traditional female sex roles prescribe women to react to anxiety by engaging in dependent and helpless behaviors. ^[6] Research results have not yet produced a single clear explanation as to the gender difference in agoraphobia.

Causes and Contributing Factors

There is no one single cause associated with agoraphobia. Instead, there are a number of factors that contribute to the development of agoraphobia. These factors include:

• Family Factors:
  • Having an anxious parent role model.
  • Being abused as a child.
  • Having an overly critical parent.

• Personality Factors:
  • High need for approval.
  • High need control.
  • Oversensitivity to emotional stimuli.

• Biological Factors:
  • Oversensitivity to hormone changes.
  • Oversensitivity to physical stimuli.
  • High amounts of sodium lactate in the bloodstream.^[7]

Additionally, research has uncovered a linkage between agoraphobia and difficulties with spatial orientation.^{[8] [9]}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.^[10] Compared to controls, in virtual reality studies, agoraphobics on average show impaired processing of changing audiovisual data. ^[11]

Alternate Theories

Attachment Theory

Main article: Attachment Theory

Some scholars (e.g., Liotti 1996,^[12] Bowlby 1998^[13]) 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^[14]) in agoraphobia research. Branches of the social sciences, especially geography, have increasingly become interested in what may be thought of as a spatial phenomenon.

Feminist Theory

Feminist scholars have applied feminist theory in an attempt to construct agoraphobia and other anxiety disorders as gendered issues. One such theory explains agoraphobia as a fear of the hysterical woman, meaning a fear of being perceived by others as overly feminine and out of control.^[15]

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 subsequent anxiety and preoccupation with these attacks that leads to an avoidance of situations where a panic attack could occur.^[16] In rare cases where agoraphobics do not meet the criteria used to diagnose Panic Disorder, the formal diagnosis of Agoraphobia Without History of Panic Disorder is used.

DSM-IV-TR Diagnostic Criteria

A) anxiety 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. Agoraphobic fears typically involve characteristic clusters of situations that include being outside the home alone; being in a crowd, or standing in a line; being on a bridge; and traveling in a bus, train, or automobile.

B) The situations are avoided (e.g., travel is restricted) or else are endured with marked distress or with anxiety about having a Panic Attack or panic-like symptoms, or require the presence of a companion.

C) The anxiety or phobic avoidance is not better accounted for by another mental disorder, such as Social Phobia (e.g., avoidance limited to social situations because of fear of embarrassment), Specific Phobia (e.g., avoidance limited to a single situation like elevators), Obsessive-Compulsive Disorder (e.g., avoidance of dirt in someone with an obsession about contamination), Posttraumatic Stress Disorder (e.g., avoidance of stimuli associated with a severe stressor), or Separation Anxiety Disorder (e.g., avoidance of leaving home or relatives).^[17]

Association with Panic Attacks

Main article: Panic attack

Agoraphobia patients can experience sudden panic attacks when traveling to places where they fear they are out of control, help would be difficult to obtain, or they could be embarrassed. During a panic attack, epinephrine is released in large amounts, triggering the body's natural fight-or-flight response. A panic attack typically has an abrupt onset, building to maximum intensity within 10 to 15 minutes, and rarely lasts longer than 30 minutes. ^[18] Symptoms of a panic attack include palpitations, a rapid heartbeat, sweating, trembling, dizziness, tightness in the throat and shortness of breath. Many patients report a fear of dying or of losing control of emotions and/or behavior. ^[18]

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.

Cognitive Behavioral Treatments

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. ^[19] Similarly, Systematic desensitization may also be used.

Cognitive restructuring has also proved useful in treating agoraphobia. This treatment uses thought replacing with the goal of replacing one's irrational, counter-factual beliefs with more accurate and beneficial ones.

Relaxation techniques are often useful skills for the agoraphobic to develop, as they can be used to stop or prevent symptoms of anxiety and panic.

Psychopharmaceutical Treatments

Anti-depressant medications used are most commonly used to treat anxiety disorders are mainly in the SSRI (selective serotonin reuptake inhibitor) class and include sertraline, paroxetine and fluoxetine. Benzodiazepine tranquilizers, MAO inhibitors and tricyclic antidepressants are also commonly prescribed for treatment of agoraphobia.

Alternative Treatments

Eye movement desensitization and reprogramming (EMDR), a form of information processing therapy initially found helpful in treating trauma survivors, has been proven successful in treatment of agoraphobia. ^[20]

Alternative treatments of agoraphobia include hypnotherapy, guided imagery meditation, music therapy, yoga, religious practice and ayurvedic medicine.

Additionally, many people with anxiety disorders benefit from joining a self-help or support group and sharing their problems and achievements with others. Stress management techniques and meditation can help people with anxiety disorders calm themselves and may enhance the effects of therapy. There is preliminary evidence that aerobic exercise may have a calming effect. Since caffeine, certain illicit drugs, and even some over-the-counter cold medications can aggravate the symptoms of anxiety disorders, they should be avoided.

Notable Agoraphobics

• Woody Allen, American film director, actor, and writer.
• Kim Basinger, American actress.
• Roy Castle, British TV presenter.
• Paula Deen, American cook, restaurateur, writer, and TV personality. (Developed after her parents died. She recovered, but while working at a bank was robbed at gun point and the disorder returned. She recovered again.)
• Philip K. Dick, American science fiction writer.
• Emily Dickinson, American poet.
• David Draiman, American musician. Lead singer of Disturbed, an American rock band.
• Daryl Hannah, American actress.^[21]
• Elfriede Jelinek, Nobel laureate for Literature, 2004.
• Ronald Jones (musician), American musician, guitarist for Flaming Lips.
• Alessandro Manzoni, Italian novelist and poet.
• Rose McGowan, American actress.
• Edvard Munch, Norwegian Symbolist painter, printmaker, and an important forerunner of Expressionistic art.
• Jesus Navas, Spanish footballer.
• Chris Patton, American voice actor.
• Peter Robinson, British musician known simply as Marilyn.^[22]
• Jason Statham, British Actor.
• Ryan C. Stith, American fiction writer and film director.
• Ben Weasel, American musician, frontman of Screeching Weasel.

Agoraphobics in Fiction

• Helen Hudson, a fictional character played by Sigourney Weaver in the 1995 film Copycat
• Harper Amaty Pitt, a fictional character in Tony Kushner's play Angels in America
• Robert Reynolds, a fictional character in the Marvel Universe
• Ambrose Monk, brother of Adrian Monk in USA Networks Monk. He left his house only twice in ten years.

See also

• Agoraphobia Without History of Panic Disorder

References

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3. ^ (2006) Anxiety Disorders. NIH Publication No. 06-3879. 
4. ^ Robins, LN & Regier, DN, eds. (1991), , 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. ^ Agoraphobia Research Center. Is agoraphobia more common in men or women?. Retrieved on 2007-11-15.
7. ^ Agoraphobia Resource Center, , . Retrieved on 2007-11-15
8. ^ (1995 May) "Relationship between balance system function and agoraphobic avoidance.". Behav Res Ther. 33 (4): 435-9. PMID: 7755529.
9. ^ (1996) "Panic, agoraphobia, and vestibular dysfunction". Am J Psychiatry 153: 503-512.
10. ^ (1997 May-Jun) "Surface dependence: a balance control strategy in panic disorder with agoraphobia". Psychosom Med. 59 (3): 323-30. PMID: 9178344.
11. ^ (2006 Oct) "High sensitivity to multisensory conflicts in agoraphobia exhibited by virtual reality.". Eur Psychiatry 21 (7): 501-8. PMID: 17055951.
12. ^ G. Liotti, (1996). Insecure attachment and agoraphobia, in: C. Murray-Parkes, J. Stevenson-Hinde, & P. Marris (Eds.). Attachment Across the Life Cycle.
13. ^ J. Bowlby, (1998). Attachment and Loss (Vol. 2: Separation).
14. ^ J. Davidson, (2003). Phobic Geographies
15. ^ (2001) "La Donna e Mobile: Constructing the irrational woman". Gener, Place and Culture 8 (1): 37-54.
16. ^ Barlow, D. H. (1988). Anxiety and its disorders: The nature and treatment of anxiety and panic. Guilford Press. 
17. ^ (2000) Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DVM-IV-TR). 
18. ^ ^{a b} David Satcher etal. (1999). "Chapter 4.2", Mental Health: A Report of the Surgeon General. 
19. ^ "Long-term outcome of panic disorder with agoraphobia treated by exposure". Psychological Medicine 31: 891-898. Cambridge University Press.
20. ^ (2000) "EMDR for Panic Disorder With Agoraphobia : Comparison With Waiting List and Credible Attention-Placebo Control Conditions". Journal of Consulting & Clinical Psychology 68 (6): 947-957.
21. ^ Biography for Daryl Hannah. Internet Movie Database. Retrieved 28 November 2007.
22. ^ Whatever Happened to the Gender Benders?, Channel 4 documentary, United Kingdom.