Agoraphobia is a psychiatric illness in which individuals are anxious about being in situations where escape may be difficult or embarrassing. Nervousness may also occur if someone is not available to help in case a panic attack or panic-like symptoms occur.
Due to these apprehensions, individuals with agoraphobia begin to avoid situations, or experience intense anxiety or fear having a panic attack or panic-like symptom attack while in them, or require a companion to accompany them. Individuals with agoraphobia typically avoid being alone either at home or otherwise. Other typical situations that are avoided are places that are difficult to leave abruptly like public transportation, tunnels, theaters, restaurants, and the like.
To understand agoraphobia, the notion of panic must first be elucidated since it is a key component in diagnosis. Panic attacks are episodes of intense anxiety in which at least four of the following thirteen symptoms peak very quickly: increased heart rate, sweating, shakiness, shortness of breath, choking feelings, chest pain, abdominal distress, dizziness, feelings of unreality or detachment from self, fear of losing control or dying, tingling, chills, or hot flushes.
Panic-like symptoms are fewer in number than is required for a full-fledged panic attack, but can also include other incapacitating symptoms (e.g., severe headache). Panic attacks or panic-like symptoms can be either unexpected or situationally predisposed. The former occur unpredictably whereas the latter can be in response to some stimulus, but at other times attacks do not occur with that stimulus at all (e.g., an attack may occur after entering a mall but at other times this may not happen).
A diagnosis of panic disorder with agoraphobia is given when agoraphobia occurs along with unexpected full-fledged panic attacks with a month of concern about one of the following: fears of another attack, or the implications of the attack, or a marked change in behavior associated with the attacks. On the other hand, a diagnosis of agoraphobia without history of panic disorder is made when agoraphobia symptoms are related to fears of developing the panic-like symptoms without a history of full-fledged panic attacks.
There is considerable controversy about the incidence of agoraphobia without a history of panic attack. The unitary model postulates that panic and agoraphobia are variations of the same underlying disorder whereas the dualistic model postulates that they are discrete disorders. Although an epidemiologic study reported a 68% ate of agoraphobia without panic attacks or disorder, it is rarely seen in clinical settings. Another study found that agoraphobia without panic occurred in 7.8% of study participants as opposed to agoraphobia with panic n 0.8% of a young sample (ages 14–24). Others report that the occurrence of agoraphobia without panic disorder is rare as most individuals (95%) have past or present panic disorder. Differences in the results obtained are blamed on flawed study methodology.
Agoraphobia generally develops between the ages of 18 and 35. The exact cause is unknown; however, it is thought to be a combination of biology, gender, and environment. Panic disorder with agoraphobia is three times as likely to occur in women than men. Community samples of individuals with panic disorder indicate that from one half to one third also have agoraphobia. It is estimated that clinical samples (individuals being treated for psychiatric disorders) have even higher rates of agoraphobia.
Agoraphobia usually occurs within the first year of frequent panic attacks and can continue even though panic attacks may remit. Most individuals with limited symptom attacks have experienced full-fledged panic attacks at some point. Panic attacks, as opposed to limited symptom attacks, are associated with greater impairment. In some cases a decrease in agoraphobia follows a decrease in panic symptoms. Cases of agoraphobia without a history of panic seem to have a more difficult course and outcome. Individuals who experience more severe agoraphobia tend to experience other anxiety disorders as well. The course of agoraphobia varies. Some individuals experience a waxing and waning course, while others will have periods of brief improvement or remission.
Treatment of agoraphobia targets the panic symptoms with antipanic medications such as tricyclics, benzodiazepines, serotonin reuptake inhibitors, and monoamine oxidase inhibitors. Psychotherapy using cognitive-behavioral therapy (CBT) focuses on changing the dysfunctional beliefs and behaviors associated with the interpretation of panic symptoms and the agoraphobic avoidance. Exposure-based therapies seem to be most effective for agoraphobic avoidance. A 70% improvement in agoraphobia symptoms has been documented when the treatment used was in vivo exposure. Depending on the assessment of symptoms and their severity, either medication or psychotherapy is used, or a combination of both.