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Agoraphobia is an anxiety disorder that centers on fear of open spaces or social situations with many people present. A person with agoraphobia is anxious when he or she is away from home, staying in large crowds or being in places with many people present. It is common with  panic disorder, and agoraphobia is often closely linked to fear of panic attacks away from home.

Photo: by Roberto Nickson on Unsplash



 

Useful to know about agoraphobia

In the ICD-10 diagnostic manual, agoraphobia is described as follows:

Phobias that include fear of leaving home, going shopping, visiting crowds and public places, or traveling alone by train, bus or plane. Panic attacks are a frequent phenomenon in both current and past episodes.

Depressive symptoms and obsessive-compulsive disorder, as well as social phobias, are also commonly present as subsidiary traits.





Avoidance of the phobic situation is often prominent, and some patients with agoraphobia rarely experience anxiety because they are able to avoid the phobic situations. 

Although agoraphobia can manifest itself in different ways, fear of leaving home is a common theme. Many people are afraid to be alone, especially when they have to go out. The fear of having a panic attack in such situations is at the heart of this phobia.

 

Fear of panic attacks contribute to agoraphobia

Most people with agoraphobia also have panic disorder, and the problems usually begin with the person experiencing an abrupt and frightening panic attack. Typical characteristics are:





 

  1. anxiety about being "caught" in certain places where there is little opportunity for escape and assistance
  2. fear that one in this place will panic
  3. fear that this will again develop in a catastrophic direction, by becoming seriously ill, fainting or exposed to humiliating experiences

Anxiety can come gradually and limit the opportunities to move safely outside the home. Often, the problems with a nagging anxiety attack begin in a store or on a bus, before the anxiety spreads to other situations. 

 

Myths about agoraphobia

In an informative post on the blog Anxiety Sisters, the authors outline four myths about agoraphobia. They are: 

 

  1. Myth 1: Agoraphobia is the fear of leaving home.

    No, although at face value it may seem correct that agoraphobia is fear of leaving home, the condition is much more complex than this. The blog Anxiety Sisters write about this:

    Actually, agoraphobia is the fear of being trapped or not being able to access help in a public place. [A]goraphobia is the fear of having a panic attack in a public place and not being able to get help or get to a “safe zone.” It’s not about being afraid to leave the house—it’s the fear of dealing with our phobias, panic, or physical illness when we do. 

  2. Myth 2: Agoraphobics never leave home.

    No, that might not be true either. Anxiety Sisters write:

    In all but the most severe cases, people with agoraphobia do leave home—as long as they are in a safe zone where they feel relatively comfortable.

    For example a safe zone might be more inclusive that merely ones own home. One might for example be able to go anywhere in their own town, but may find it be too fearful to venture further away. 

  3. Myth 3: People with agoraphobia are loners.

    No, this is not a prerequisite of this disorder, and the social life of an agoraphobin in the real-world might or might not be limited to only a few close relationships. Anxiety Sisters write:

    Many people with agoraphobia dislike being alone and are quite dependent on friends or family members, especially when venturing out of their safe zones. In fact, agoraphobics often have trouble going places alone because they are scared that, if something happens to them, nobody will be there to help them. When agoraphobics withdraw from loved ones, it may be because they feel that they are a “burden” to family and friends, which can cause profound loneliness and bouts of isolation.

    Thus, social withdrawal is not necessarily a part of agoraphobia.

  4. Myth 4: You must have panic disorder or many irrational fears in order to develop agoraphobia.

    No, even though panic disorders are common in agoraphobics, this is also is a false prerequisite for the diagnosis. Anxiety Sisters write:

    Many people with agoraphobia do have panic disorder and/or phobias, such as driving. However, this is not the case for everyone. Some older folks may worry about doing something embarrassing in public (e.g., becoming incontinent or falling down) which is neither irrational nor panic-inducing. Children can get agoraphobia as well. When a child is extremely fearful about getting lost, [s]he may try to avoid big or crowded places.

 

Common comorbidities in agoraphobia

As already noted, many individuals with agoraphobia also have other anxiety disorders.

MD Elizabeth Winter highlights that the following comorbid mental illnesses are common in agoraphobia (listed from most common to least common):

 

  1. Panic disorder
  2. Specific phobia 
  3. Social anxiety disorder
  4. Generalized anxiety disorder
  5. Substance use disorder

 

Agoraphobia: a peculiar mental disorder

In a publication by Pam and colleagues (1994), that may not represent the most recent advances in research, it is highlighted that "agoraphobia is in the interface between anxiety and personality disorders." Specifically, they write: 

Although agoraphobia includes distinct symptoms of avoidant and dependent personality disorder, it is currently classified as a form of "anxiety disorder." Such categorization seems to imply that uncontrolled panic attacks sometimes generate subsequent avoidant and dependent traits, leading afflicted persons to virtually seclude themselves in the home.

The authors propose an alternate view, suggesting that in many cases the etiology of the disorder can be attributed to a predisposing antecedent character structure.

Thus, this paper is specifically pointing to traits of avoidance and dependence in individuals with agoraphobia, which is more commonly found in avoidant and dependent personality disorders, respectively. 

 

Treatment of agoraphobia

Cognitive behavioral therapy (CBT) is supported by numerous meta-analyses as an efficacious treatment for panic disorder with or without agoraphobia. Read more here:

 

  1. Gould, R. A., Ott, M. W., & Pollack, M. H. (1995). A meta-analysis of treatment outcome for panic disorderClinical Psychology Review15(8), 819-844.
  2. Mitte, K. (2005). A meta-analysis of the efficacy of psycho-and pharmacotherapy in panic disorder with and without agoraphobiaJournal of affective disorders88(1), 27-45.
  3. Sánchez-Meca, J., Rosa-Alcázar, A. I., Marín-Martínez, F., & Gómez-Conesa, A. (2010). Psychological treatment of panic disorder with or without agoraphobia: a meta-analysisClinical psychology review30(1), 37-50

 

Also, an evaluation by the Cochrane institute concluded: 

There is no high‐quality, unequivocal evidence to support one psychological therapy over the others for the treatment of panic disorder with or without agoraphobia in adults. However, the results show that CBT ‐ the most extensively studied among the included psychological therapies

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