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Definition: AGORAPHOBIA from Dictionary of Psychopathology

Fear of open spaces. The natural deterioration of functioning in such a person can be illustrated by a progression in which the person at first cannot leave the building to go to work, then cannot leave the apartment itself, then cannot leave the bedroom, and, finally, drawing the circumference and parameter of life to an even more confined space, cannot leave the bed.

Summary Article: Agoraphobia
from Cultural Sociology of Mental Illness: An A-to-Z Guide

Agoraphobia is an anxiety disorder that is often associated with panic disorder and can be characterized by panic symptoms, anxiety regarding circumstances where escape seems difficult, and intense fear of places. Agoraphobia symptoms can develop with or without history of panic disorder. The presence of recurring panic attacks and concern regarding future panic attacks are features of agoraphobia with panic disorder. In agoraphobia without history of panic disorder, the individual's fear is focused on debilitating symptoms that mimic panic and can be embarrassing (e.g., public incontinence). Approximately 95 percent of individuals with agoraphobia also have an accompanying panic disorder diagnosis. Occasionally, differential diagnostic questions can arise between agoraphobia and social phobia. In social phobia, a fear of negative evaluation from others is present, whereas fear of situations associated with panic or difficulty escaping is present with agoraphobia. Diagnostic criteria for agoraphobia take into account the complex relationship between biological, cultural, and psychological processes and how they affect experiences of panic and fear. Elimination of other contributing factors, such as the effects of a substance or other underlying medical conditions, is necessary for an accurate agoraphobia diagnosis. The Diagnostic and Statistical Manual of Mental Disorders (DSM) describes agoraphobia and notes a variety of factors such as individual traits, cultural context, gender features, and other associated disorders that can influence the diagnosis.

Globally, the lifetime prevalence of agoraphobia is approximately 12 percent. Over half of these individuals seek treatment at some point in their lives, and these treatment seekers indicate that agoraphobia affects them over long periods of time. Agoraphobia primarily develops during adolescence and has become more prevalent in recent decades. Many of the diagnostic criteria in the DSM have only appeared within the last 30 years, suggesting that either the frequency of the disorder has increased in recent generations or that identification of the disorder has improved. Cultural socialization influences the level of functional impairment caused by agoraphobic symptomology. The degree to which symptoms related to agoraphobia are a hindrance to one's life may be related to factors such as physical location. Cultures in which survival does not require interaction with others on a regular basis are associated with less functional impairment than cultures that require more interpersonal interaction. In Western cultures, agoraphobia can be debilitating because social and interpersonal skills are the primary traits that allow the acquisition of resources.

Definitions and Characteristics

As described by the DSM, agoraphobia is an anxiety-related disorder characterized by anxiety surrounding environments where the sufferer feels helpless, trapped, and unable to escape. Some of the criteria for a diagnosis of agoraphobia include feeling detached or dependent on others, fear of being alone, disconnection from a surrounding environment, and several panic attack–related symptoms such as shortness of breath, chest pain, numbness, and trembling. Individuals often go to extremes to avoid uncontrollable social and environmental situations in which they believe panic attacks will be triggered. Excessive fear in the absence of actual danger is the primary pathology of the disorder, and it can be compounded by the sufferer's fear of being socially humiliated in public by showing distress. Often, when individuals with agoraphobia are distanced from surroundings where they feel safe, their fear and anxiety increase. Traveling, places where there are crowds, or open spaces where it can be perceived that help is unavailable, and the sufferer's feelings of helplessness are generally how anxiety and panic attacks are generated in those with panic–related agoraphobia.

Individuals with agoraphobia experience powerful responses that are often described as involving three systems: cognitive, psychophysiological, and behavioral. The cognitive system evokes apprehension and feelings of fear. These feelings can significantly impair functioning and create anxiety. Self-defeating thinking can also impair functioning for a sufferer, unsettling them and negatively affecting their self-esteem. A prolonged state of arousal greatly affects the psychophysiological system, activating the sympathetic nervous system that can lead to increased heart rate and blood pressure, muscle tension, and feeling faint.

There are several medical problems that can be mistaken for panic disorder that must be ruled out to effectively treat agoraphobia. Agoraphobia often results in persistent, maladaptive, and excessive behavioral responses; thus, agoraphobia typically has the greatest effect on the behavioral system. Sufferers tend to isolate themselves and avoid certain situations. This avoidance generally makes the disorder worse over time. Nausea, sweating, and feelings of paralysis are other physical symptoms that may be present with agoraphobia.

Variations in Culture

There is currently widespread use of the term agoraphobia. First termed “agoraphobic syndrome” by Carl F. O. Westphal in 1871, the disorder has also been described as anxiety hysteria, street fear, locomotor anxiety, anxiety syndrome, phobic anxious state, phobic-anxiety-depersonalization syndrome, and nonspecific insecurity fears. Currently, the German term platzangst and French terms peur des escapes and horreur du vide share general meanings with the English term agoraphobia, and though their meanings may be similar, they are not representative of all cultural contexts and meanings. A fundamental problem in generalizability arises when comparing agoraphobia among different cultures, while still taking into account the differences in socially governed behavior. Modern researchers theorize that specific stimuli are typically linked with agoraphobia symptomology. Across cultures, there are similar symptoms, experiences, and behaviors that are associated with agoraphobia.

Women are nearly four times more likely to be diagnosed with agoraphobia than men. This gender difference could be because of several biological and behavioral factors, such as hormones, socialization, and other learned behaviors. It is important to consider cultural perspectives on female involvement in community life and separate that from agoraphobia. Women are also more likely than men to seek professional help, which may distort statistical reporting that agoraphobia is a female-dominant disorder. Men with agoraphobic symptomology who seek treatment are more likely than women who seek treatment to be diagnosed with a comorbid substance use disorder because men are more likely than women to use alcohol as a way to cope with their agoraphobia symptoms.

Etiology, Epidemiology, and Treatment

The cause of agoraphobia is unknown, but there are several theories about the contributing factors. One theory explains that agoraphobia is a learned behavior in which an individual may originally experience agoraphobic symptoms with a specific situation, and then associate further symptoms with situations similar to the first. Other research suggests that agoraphobia is associated with insecure or avoidant attachment, where individuals fear leaving spaces in which they feel secure, or have previously been separated from individuals to whom they were attached, such as parents during childhood. Individuals with a history of respiratory disease report higher rates of agoraphobia. Difficulty breathing and feeling suffocated may be contributing factors in associating fear with physiological symptoms. Researchers have also theorized that temperament can factor into the development of agoraphobia. Those with a higher emotional sensitivity are at greater risk to develop agoraphobia, and children of parents with the same sensitivity are more likely to experience agoraphobic symptoms.

From a biological perspective, people diagnosed with agoraphobia often have difficulties with spatial orientation because of deficits in the vestibular and visual systems. If these two systems are weak, sensory signals can cause disorientation when cues are sparse (no stimuli) or overwhelming (abundance of stimuli). Some brain scan studies show that individuals with agoraphobia have delayed processing speed with continually changing audiovisual data, suggesting that they process information too slowly to keep up with other response systems. There is evidence that agoraphobia is associated with genetic factors, but most understand it to be triggered by events, history, trauma, and irrational thinking. The genetic studies that provide this link suggest that there are two loci in DNA that govern an individual's risk for developing agoraphobia.

There are several treatments that are largely effective in the treatment of agoraphobia. There is an abundance of evidence supporting the efficacy of cognitive behavioral therapy (CBT) in the treatment of agoraphobia. Pharmacological treatments start with nonaddictive drugs such as antidepressants (selective serotonin reuptake inhibitors and serotonin norepinephrine reuptake inhibitors) to modify neurotransmitter levels. If antidepressants are ineffective on their own, augmentation with other drugs such as benzodiazepines (only temporary use, to be eliminated after the initial regimen), buspirone, pregabalin, or adrenergic blockades may also be considered. CBT, specifically exposure therapy, relaxation/meditation, recognition and replacement of panic thoughts, and support groups, in combination with antidepressant medications, have been empirically validated as effective treatments for agoraphobia.

See Also: Cognitive Behavioral Therapy Panic Disorder Serotonin Reuptake Inhibitors

Further Readings
  • Hinton, D. E.; B. J. Good. Culture and Panic Disorders. Stanford University Press Palo Alto CA, 2009.
  • Linden, D. The Biology of Psychological Disorders. St. Martin's Press New York, 2012.
  • Tsuang, M. T.; M. Tohen; P. B. Jones. Textbook in Psychiatric Epidemiology. 3rd ed. John Wiley & Sons Hoboken NJ, 2011. doi:10.1002/9780470976739.
  • Shannon Bierma
    Ryan Shorey
    Hope Brasfield
    Gregory L. Stuart
    University of Tennessee, Knoxville
    © 2014 SAGE Publications, Inc

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