Agoraphobia refers to an anxiety disorder characterized by intense fear or concerns about being in situations such as the following1,2:
- Open spaces like concerts, parking lots, etc.
- Standing in a crowd or queue
- Being outside one’s home by oneself
- Enclosed areas such as theatres, cinemas, etc.
- Travelling through public transportation. For example, buses, train, etc.
An individual with agoraphobia fears that they may not be able to find an escape from or help in such situations in the event of a panic attack. Apart from the fear of developing panic like symptoms, an individual may also be concerned about exhibiting some other embarrassing or apparently crippling symptoms. Associated autonomic and physical symptoms include palpitations, trembling, dry mouth, breathing difficulties, nausea etc. Cognitively distressing thoughts of dying, losing control, feeling lightheaded, etc are also part of the clinical picture
Due to such concerns one begins to actively avoid such situations. This avoidance can be behavioral (such as changing routines, arranging alternate means of travel or getting work done) or cognitive (example, beginning to count from 1 to 50 while engaged in an agoraphobic setting to distract one’s anxious thoughts). In cases where being in one of such settings can’t be avoided, one may insist on being accompanied by someone they trust or otherwise endure such an event with great discomfort.
The intensity of discomfort or anxiety felt in agoraphobic situations is out of proportion to the context in which it occurs. The level of fear or anxiety one undergoes in such a condition may vary according to the proximity to the feared situation. Individuals may also suffer anticipatory anxiety imagining the context of a feared situation. Given the active avoidance, agoraphobia can cause significant impairment in everyday functioning. More than a third of individuals suffering from agoraphobia are unable to work outside their homes.
Mean age of onset is 17 years. The condition often remains consistent over the lifespan. Neurotic or negative disposition, low threshold for anxiety, stressful childhood events and heritability are some risk factors associated with the onset of agoraphobia.
Assessment and Diagnosis
Assessing and diagnosing symptoms of agoraphobia requires considerable clinical judgment. Thus, trained professional such as psychiatrists or clinical psychologists are consulted for a reliable diagnosis and management. Apart from a thorough clinical history, assessing agoraphobic symptoms also requires medical examinations to rule out medical issues such as thyroid conditions, vestibular issues, effects of certain substances etc. Formal diagnosis is based on criteria set by the International Classification of Diseases-10 Classification of Mental and Behavioural Disorders (10th Revision) and/or the Diagnostic and Statistical Manual of Mental Disorders (5th ed., DSM-5., American Psychiatric Association, 2013). Self report measures are also applied to bolster the diagnostic process.
Cognitive Behavioral Therapy (CBT): Cognitive behavioral therapy is often applied in the treatment and management of agoraphobia. CBT has strong evidence based techniques for addressing clinical symptoms of agoraphobia. The key tecniques applied are as follows:
- Cognitive Therapy: The primary aim of this therapeutic alliance is to make an individual aware of maladaptive thinking patterns that have developed over time and govern their response to agoraphobic situations. Cognitive misappraisals related to bodily sensations are successfully addressed in this therapy3.
- Exposure therapy3: Exposure to feared situations in real life scenarios is called in-vivo exposure and has been found to be an effective treatment method for agoraphobia. It is conducted in a graduated manner by progressing from the least to the most anxiety provoking situation. On more advanced levels, in vivo exposure also addresses safety behaviors like calling for help, looking for exit signs, etc. Interoceptive exposure on the other hand focuses on deliberate inducing of physical symptoms for a set period of time. During each instance misappraisals about sensations are addressed. Both forms of exposure are used in combination as well.
Pharmacological Treatment: Psychiatric management of agoraphobia often involves prescribed medications which address the discomfort caused by anxiety symptoms. Thus, selective serotonin reuptake inhibitors and serotonin norepinephrine reuptake inhibitors are the first line of treatment. Benzodiazepines are also prescribed in some cases.
In addition to the treatment schedules described above important self help techniques are also considered in tandem with symptom relief. These include joining self help groups, creative visualization for challenging negative thought patterns, improving focus on stress relieving activities, etc.
1.American Psychiatric Association. (2013). Anxiety disorders. In Diagnostic and statistical manual of mental disorder (5th ed.). Washington, DC: Author.
2.World Health Organization (1993). Neurotic, stress related and somatoform disorders. In International classification of diseases-Classification of mental and behavioural disorders (5th ed.). Geneva: Author
3.Grant, M. & Barlow, D.H. (2008). Panic disorder and agoraphobia. In Barlow, D.H. (Ed.). Clinical handbook of psychological disorders-A step by step treatment manual (pp. 1-64). New York;NY:Guilford Press.