Agoraphobia
Agoraphobia[1] is a mental and behavioral disorder,[5] specifically an anxiety disorder characterized by symptoms of anxiety in situations where the person perceives their environment to be unsafe with no easy way to escape.[1] These situations can include public transit, shopping centers, crowds and queues, or simply being outside their home on their own.[1] Being in these situations may result in a panic attack.[2] Those affected will go to great lengths to avoid these situations.[1] In severe cases, people may become completely unable to leave their homes.[2]
Not to be confused with Acrophobia.Agoraphobia is believed to be due to a combination of genetic and environmental factors.[1] The condition often runs in families, and stressful or traumatic events such as the death of a parent or being attacked may be a trigger.[1] In the DSM-5, agoraphobia is classified as a phobia along with specific phobias and social phobia.[1][3] Other conditions that can produce similar symptoms include separation anxiety, post-traumatic stress disorder, and major depressive disorder.[1] The diagnosis of agoraphobia has been shown to be comorbid with depression, substance abuse, and suicide ideation.[6][7] Without treatment, it is uncommon for agoraphobia to resolve.[1] Treatment is typically with a type of counselling called cognitive behavioral therapy (CBT).[3][8] CBT results in resolution for about half of people.[4] In some instances, those with a diagnosis of agoraphobia have reported taking benzodiazepines and antipsychotics.[6] Agoraphobia affects about 1.7% of adults.[1] Women are affected about twice as often as men.[1] The condition is rare in children, often begins in adolescence or early adulthood, and becomes less common in old age.[1]
Etymology[edit]
The term agoraphobia was coined in German in 1871 by pioneering German psychologist Karl Friedrich Otto Westphal (1833–1890), in his article "Die Agoraphobie, eine neuropathische Erscheinung." Archiv für Psychiatrie und Nervenkrankheiten, Berlin, 1871–72; 3: 138–161. It is derived from Greek ἀγορά (agorā́), meaning 'place of assembly' or 'market-place' and -φοβία (-phobía), meaning 'fear'.[9][10]
Treatments[edit]
Therapy[edit]
Systematic desensitization can provide lasting relief to the majority of patients with panic disorder and agoraphobia. The disappearance of residual and sub-clinical agoraphobic avoidance, and not simply of panic attacks, should be the aim of exposure therapy.[41] Many patients can deal with exposure easier if they are in the company of a friend on whom they can rely.[42][43] In this approach, it is suggested that people being treated remain in the situation that provokes anxiety until the symptoms anxiety have subsided because if they leave the situation, the phobic response will not decrease and it may even rise.[43]
A related exposure treatment is in vivo exposure, a cognitive behavioral therapy method, that gradually exposes patients to the feared situations or objects.[44] This treatment was largely effective with an effect size from d = 0.78 to d = 1.34, and these effects were shown to increase over time, proving that the treatment had long-term efficacy (up to 12 months after treatment).[44]
Psychological interventions in combination with pharmaceutical treatments were overall more effective than treatments simply involving either CBT or pharmaceuticals.[44] Further research showed there was no significant effect between using group CBT versus individual CBT.[44]
Cognitive restructuring has also proved useful in treating agoraphobia. This treatment involves coaching a participant through a dianoetic discussion, with the intent of replacing irrational, counterproductive beliefs with more factual and beneficial ones.
Relaxation techniques are often useful skills for the agoraphobic to develop, as they can be used to stop or prevent symptoms of anxiety and panic.[45]
Videoconferencing psychotherapy (VCP) is an emerging modality used to treat various disorders in a remote method.[46] Similar to traditional face-to-face interventions, VCP can be used to administer CBT.[47]
Virtual reality computer stimulated therapy has been suggested to help people with psychosis and agoraphobia manage their avoidance of outside environments. In the therapy, the user wears a headset and a virtual character provides psychological advice and guides them as they explore simulated environments (such as a cafe or a busy street).[48]
Medications[edit]
Antidepressant medications most commonly used to treat anxiety disorders are mainly selective serotonin reuptake inhibitors. Benzodiazepines, monoamine oxidase inhibitor, and tricyclic antidepressants are also sometimes prescribed for treatment of agoraphobia.[49] Antidepressants are important because some have anxiolytic effects.[43] Antidepressants should be used in conjunction with exposure as a form of self-help or with cognitive behaviour therapy.[43] A combination of medication and cognitive behaviour therapy is sometimes the most effective treatment for agoraphobia.[43]
Benzodiazepines and other anxiolytic medications such as alprazolam and clonazepam are used to treat anxiety and can also help control the symptoms of a panic attack.
Alternative medicine[edit]
Eye movement desensitization and reprocessing (EMDR) has been studied as a possible treatment for agoraphobia, with poor results.[50] As such, EMDR is only recommended in cases where cognitive-behavioral approaches have proven ineffective or in cases where agoraphobia has developed following trauma.[51]
Many people with anxiety disorders benefit from joining a self-help or support group (telephone conference-call support groups or online support groups being of particular help for completely housebound individuals). Sharing problems and achievements with others, as well as sharing various self-help tools, are common activities in these groups. In particular, stress management techniques and various kinds of meditation practices and visualization techniques can help people with anxiety disorders calm themselves and may enhance the effects of therapy, as can service to others, which can distract from the self-absorption that tends to go with anxiety problems. Also, preliminary evidence suggests aerobic exercise may have a calming effect. Since caffeine, certain illicit drugs, and even some over-the-counter cold medications can aggravate the symptoms of anxiety disorders, they should be avoided.[52]
Epidemiology[edit]
Agoraphobia occurs about twice as commonly among women as it does in men. It can develop at any age but is much more common in adolescence and early adulthood and occurs more often in people of above average intelligence.[53]
Panic disorder with or without agoraphobia affects roughly 5.1% of Americans,[44] and about 1/3 of this population with panic disorder have co-morbid agoraphobia. It is uncommon to have agoraphobia without panic attacks, with only 0.17% of people with agoraphobia not presenting panic disorders as well.[44]