Agoraphobia is a fairly well-defined cluster of phobias embracing fears of leaving home, entering shops, crowds and public places, or travelling alone in trains, buses or planes. Panic disorder is a frequent feature of both present and past episodes. Depressive and obsessional symptoms and social phobias are also commonly present as subsidiary features. Avoidance of the phobic situation is often prominent, and some agoraphobics experience little anxiety because they are able to avoid their phobic situations.
An individual diagnosed with agoraphobia needs to meet all of the following criteria:
Marked fear or anxiety about two (or more) of the following five situatiions:
Using public transportatiion (e.g., automobiles, buses, trains, ships, planes).
Being in open spaces (e.g., parking lots, marketplaces, bridges).
Being in enclosed places (e.g., shops, theaters, cinemas).
Standing in line or being in a crowd.
Being outside of the home alone.
The individual fears or avoids these situations because of thoughts that escape might be difficult or help might not be available in the event of developing panic-like symptoms or other incapacitating or embarrassing symptoms (e.g., fear of falling in the elderly; fear of incontinence).
The agoraphobic situations are actively avoided, require the presence of a companion, or are endured with intense fear or anxiety.
The fear or anxiety is out of proportion to the actual danger posed by the agoraphobic situations and to the sociocultural context.
The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
If another medical condition (e.g., inflammatory bowel disease, Parkinson's disease) is present, the fear, anxiety, or avoidance is clearly excessive.
The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder - for example, the symptoms are not confined to specific phobia, situational type; do no involve only social situations (as in social anxiety disorder); and are not related exclusively to obsessions (as in obsessive-compulsive disorder), perceived defects or flaws in physical appearance (as in body dysmorphic disorder), reminders of traumatic events (as in posttraumatic stress disorder), or fear of separation (asin separatioin anxiety disorder).
Note: Agoraphobia is diagnosed irrespective of the presence of panic disorder. If an individual's presentation meets criteria for panic disorder and agoraphobia, both diagnoses should be assigned.
Approximately 3.2 million , or about 2.2%, of adults in the US between the ages of 18 and 54, suffer from agoraphobia.
There is very little research on the treatment of agoraphobia without panic disorder. Research on the treatment of agoraphobia with panic disorder has found that cognitive behavioral therapy (CBT) [given by a therapist or by a computer], SSRI antidepressants, and clonazepam (an antianxiety medication) are all equally effective.
Research has shown tricyclic antidepressants (like imipramine) and Eye Movement Desensitization and Reprocessing (EMDR) are ineffective in the treatment of agoraphobia. Vitamins and dietary supplements are also ineffective for this disorder.
Which Behavioral Dimensions Are Involved?
The ancient Greek civilization lasted for 1,300 years (8th century BC to 6th century AD). The ancient Greek philosophers taught that the 5 pillars of their civilization were: wisdom, courage, helping others, self-control, and justice. Psychiatry named the opposite of each of these 5 ancient themes as being a major dimension of psychopathology (i.e., irrationality, negative emotion, detachment, disinhibition, and antagonism). (Psychology named these same factors the "Big 5 dimensions of personality": "intellect", "neuroticism", "extraversion", "conscientiousness", and "agreeableness")
Agoraphobia: Negative Emotion
Wisdom vs Irrationality: N/A Courage vs Negative Emotion:
Phobic fears of leaving home, entering shops, crowds and public places, or travelling alone in trains, buses or planes
Panic disorder, depressive and obsessional symptoms and social phobias are also commonly present
Helping Others vs Detachment:
Social withdrawal or housebound due to avoidance of the phobic situations
Self-control vs Disinhibition:N/A Justice vs Antagonism:N/A
Fear and its avoidance are the core features of all anxiety disorders. Agoraphobia can be thought of as "generalized phobic disorder" in which individuals develop many phobias that cause significant distress or disability. More than one-third of individuals with agoraphobia are homebound and unable to work; thus they are dependent on others to provide for their basic needs.
As in panic disorder, many individuals with agoraphobia also develop major depressive disorder. Often these individuals may inappropriately self-medicate their anxiety with alcohol or sedatives, and thus may develop addiction as a consequence. Commonly, these individuals also suffer from other anxiety disorders (e.g., specific phobias, panic disorder, social anxiety disorder) and post-traumatic stress disorder.
Associated Laboratory Findings
No laboratory test has been found to be diagnostic of this disorder.
The 1-year prevalence rate in adolescents and adults is 1.7%, but this drops to 0.4% after age 65. Agoraphobia is rare in childhood, but its incidence peaks in late adolescence and early adulthood. Women are twice as likely as men to develop agoraphobia.
Agoraphobia and panic disorder are closely associated. The majority of individuals with panic disorder have signs of agoraphobia before the onset of panic disorder. Likewise, 30% or more of individuals with agoraphobia have panic disorder before the onset of their agoraphobia. Onset of agoraphobia is before age 35 in two-thirds of individuals. The mean age of onset is 17 years. The course of agoraphobia is chronic and persistent. Complete recovery is rare (10%), unless treated.
Twin studies indicate a strong genetic contribution to the development of agoraphobia; its heritability is 61%.