Agoraphobia

# Overview
Agoraphobia is an anxiety disorder characterized by intense terror and anxiety over any place or situation from which one might not easily be able to escape. This often leads sufferers to avoid leaving their homes, using public transportation or air travel, or being in crowded spaces. The average age of onset of agoraphobia is 20 years. Agoraphobia is closely associated with panic disorder; the two are commonly comorbid. Patients with agoraphobia often exhibit depressive symptoms, as well as social or specific phobias, which can make the disorder difficult to diagnose. Patients with severe agoraphobia may become confined to their homes. The word "agoraphobia" is an English adoption of the Greek words agora () and phobos (), literally translated as "a fear of the marketplace."  This etymology is the reason for the common misconception that agoraphobia is a fear of open spaces.

# Historical Perspective
- In 1871, Agoraphobia was first described by Karl Friedrich Otto Westphal, a German psychiatrist.
- Westphal coined the term after observing three of his patients, who exhibited severe anxiety and dread upon traveling to certain public areas of Berlin, in the city where he worked.

# Classification
- The DSM-V, released in 2013, classifies agoraphobia as a phobia.
- The ICD-10 places agoraphobia under the subcategory of "Phobic anxiety disorders," which falls under the category of "Neurotic, stress-related and somatoform disorders."
- Within the former subcategory, agoraphobia is grouped together with:
Social phobias
Specific/isolated phobias
Other phobic anxiety disorders
Phobic anxiety disorder, unspecified
- Social phobias
- Specific/isolated phobias
- Other phobic anxiety disorders
- Phobic anxiety disorder, unspecified
- Though some experts have argued that agoraphobia can reasonably be thought of as a severe consequence of panic disorder, a comparison of the multivariate comorbidity patterns of agoraphobia and panic disorder supports the independent classification of these disorders.

# Pathophysiology

## Relationship to Balance Disorders
- Agoraphobia may be related to defects in balance. Researchers who noticed a similarity between the situations commonly avoided by sufferers of agoraphobia and the types of environments that trigger disorientation in people with balance disorders administered a battery of audiovestibular tests, coupled with moving platform posturography, to 36 subjects with agoraphobic symptoms and 20 normal, healthy controls.
Over 60% of the former group were destabilized by these disorienting conditions, compared to a mere 10% of the control group.
Postural instability was found to be highly related to agoraphobic avoidance  (r = 0.63, P < 0.01), event after the researchers controlled for symptoms, anxiety, and agoraphobic cognitions.
- Over 60% of the former group were destabilized by these disorienting conditions, compared to a mere 10% of the control group.
- Postural instability was found to be highly related to agoraphobic avoidance  (r = 0.63, P < 0.01), event after the researchers controlled for symptoms, anxiety, and agoraphobic cognitions.

## Attachment Theory
- Some scholars (e.g., Liotti  1996, Bowlby 1998) have explained agoraphobia as an attachment deficit, i.e., the temporary loss of the ability to tolerate spatial separations from a secure base.

## Spatial Theory
- In the social sciences, there is a perceived clinical bias (e.g., Davidson 2003) in agoraphobia research. Branches of the social sciences, especially geography, have increasingly become interested in what may be thought of as a spatial phenomenon.

## Associated Conditions
- Commonly comorbid conditions include:
Panic disorder
SAD
Specific phobia
- Panic disorder
- SAD
- Specific phobia

# Differential Diagnosis
- Agoraphobia must be differentiated from other disorders with similar symptomology, including:
Acute stress disorder
Major depressive disorder
Other medical conditions
Parkinson's disease
Multiple sclerosis
Panic disorder without agoraphobia
Post traumatic stress disorder
Separation anxiety disorder
Social anxiety disorder (social phobia)
Specific phobia, situational type
- Acute stress disorder
- Major depressive disorder
- Other medical conditions
Parkinson's disease
Multiple sclerosis
- Parkinson's disease
- Multiple sclerosis
- Panic disorder without agoraphobia
- Post traumatic stress disorder
- Separation anxiety disorder
- Social anxiety disorder (social phobia)
- Specific phobia, situational type

# Epidemiology and Demographics

## Prevalence
- The prevalence of agoraphobia is 1,700 per 100,000 (1.7%) of the overall population.

## Age
- Among children, ages 13 to 18, there is a lifetime prevalence of 2,400 per 100,000 (2.4%) for agoraphobia.
- Among adults in the United States, agoraphobia has a 12-month prevalence of  800 per 100,000 (0.8%). 40.6% of these cases are classified as "severe."

## Gender
- No gender disparity in the incidence of agoraphobia has been widely established.
- Some studies have suggested that panic disorder patients with agoraphobia are more likely to be female than patients who have panic disorder but not agoraphobia. Female patients were also found to have a higher prevalence of comorbidities.

## Race
- No racial predilection has been established for agoraphobia.

# Risk Factors
- The exact cause of agoraphobia is unknown. In some instances, someone who has a panic attack may begin to exhibit signs of agoraphobia out of fear that another panic attack will occur.
- Risk factors for agoraphobia include:
Anxiety sensitivity
Behavioral inhibition
Genetic predisposition
Neurotic disposition (neuroticism)
Negative events in childhood
Separation/divorce of parents
Death of parent
Bullying
Stressful or traumatic events (e.g., being attacked or mugged)
- Anxiety sensitivity
- Behavioral inhibition
- Genetic predisposition
- Neurotic disposition (neuroticism)
- Negative events in childhood
Separation/divorce of parents
Death of parent
Bullying
- Separation/divorce of parents
- Death of parent
- Bullying
- Stressful or traumatic events (e.g., being attacked or mugged)

# Natural History, Complications, and Prognosis

## Natural History
- People with agoraphobia may experience panic attacks in situations in which they feel trapped, insecure, out of control, or too far from their personal comfort zone. In severe cases, an agoraphobic person may be completely confined to his or her home.
Some people with agoraphobia are comfortable seeing visitors, but only in a defined space in which they feel in control.
Such people may live for years without leaving their homes, while happily seeing visitors and working, as long as they can stay within their safety zones.
If someone suffering from agoraphobia leaves his or her "safety zone," an anxiety attack may occur.
Agoraphobia patients can experience sudden panic attacks when traveling to places where they fear, where help would be difficult to obtain. During a panic attack, adrenaline is released in large amounts for several minutes causing the classical "fight or flight" condition.
The attack typically has an abrupt onset, building to maximum intensity within 10 to 15 minutes, and rarely lasts longer than 30 minutes. 
These symptoms include palpitations, sweating, trembling, and shortness of breath. Many patients report a fear of dying, or losing control of emotions or behavior. 
- Some people with agoraphobia are comfortable seeing visitors, but only in a defined space in which they feel in control.
Such people may live for years without leaving their homes, while happily seeing visitors and working, as long as they can stay within their safety zones.
If someone suffering from agoraphobia leaves his or her "safety zone," an anxiety attack may occur.
- Such people may live for years without leaving their homes, while happily seeing visitors and working, as long as they can stay within their safety zones.
- If someone suffering from agoraphobia leaves his or her "safety zone," an anxiety attack may occur.
- Agoraphobia patients can experience sudden panic attacks when traveling to places where they fear, where help would be difficult to obtain. During a panic attack, adrenaline is released in large amounts for several minutes causing the classical "fight or flight" condition.
The attack typically has an abrupt onset, building to maximum intensity within 10 to 15 minutes, and rarely lasts longer than 30 minutes. 
These symptoms include palpitations, sweating, trembling, and shortness of breath. Many patients report a fear of dying, or losing control of emotions or behavior. 
- The attack typically has an abrupt onset, building to maximum intensity within 10 to 15 minutes, and rarely lasts longer than 30 minutes. 
- These symptoms include palpitations, sweating, trembling, and shortness of breath. Many patients report a fear of dying, or losing control of emotions or behavior. 

## Complications
- Complications associated with agoraphobia may encompass physical, behavioral, or lifestyle changes.
The avoidance behaviors associated with agoraphobia are established correlates of treatment discontinuation.
Individuals with agoraphobia are more likely to show signs of decreased assertiveness, perhaps because their illness cultivates feelings of helplessness and insecurity.
The avoidance of places or structures in which panic attacks have occurred may limit a patients job prospects or proximity to desirable facilities or services.
- The avoidance behaviors associated with agoraphobia are established correlates of treatment discontinuation.
- Individuals with agoraphobia are more likely to show signs of decreased assertiveness, perhaps because their illness cultivates feelings of helplessness and insecurity.
- The avoidance of places or structures in which panic attacks have occurred may limit a patients job prospects or proximity to desirable facilities or services.

## Prognosis
- The prognosis of agoraphobia depends upon the severity of the disease.
- The prognosis is generally good with early medical intervention; if left untreated, the disorder may become more difficult for healthcare providers to effectively manage.

# Diagnosis

## Diagnostic Criteria

### DSM-V Diagnostic Criteria for Agoraphobia
The fifth version of the DSM, released in 2013, sets forth the following as diagnostic criteria for agoraphobia:

## History and Symptoms
Symptoms of agoraphobia may include the following:
- Fear of crowds, bridges, and/or being outside alone
- Fear of losing control of oneself in a public place
- Feeling dependent upon others
- Feeling helpless
- Feeling that ones body or surroundings are not real
- Being easily agitated or angered
- Staying in ones house for long periods of time
- Self-medication with drugs or alcohol
- Inability to function at work or other inherently social settings
- Depression or suicidal ideation
If agoraphobic patients find themselves in a situation that triggers their anxiety, symptoms may include the following:
- Powerful sensations of panic and distress
- Tachycardia
- Chest pain or discomfort
- Choking
- Dizziness or syncope
- Dyspnea
- Sweating
- Tremors

## Physical Examination
- Healthcare providers will examine a patient who is exhibiting signs of agoraphobia for a history of panic disorders.
- The clinician will also get a description of the relevant symptoms and behaviors of the patient and, if possible, from any family members or friends who might have knowledge of relevant behaviors.

# Treatment

## Medical Therapy
- The mainstay of therapy for agoraphobia is a combination of CBT, talk therapy, and medicine. Certain drugs that are regularly used to treat depression, such as SSRIs and SNRIs, may also be helpful in the treatment of agoraphobia.
Treatment delivery factors, particularly therapist adherence, are important indicators of the potential for successful CBT.
Studies have shown that therapist-directed CBT has a more significant impact on agoraphobic psychopathology in the short-term than do SSRIs/SNRIs.
At a physicians discretion, sedatives or hypnotics may also be prescribed. A physician may advise an agoraphobic patient to take such drugs when the symptoms of agoraphobia are particularly severe or as a preventive measure, when one expects to be exposed to a triggering situation.
- Treatment delivery factors, particularly therapist adherence, are important indicators of the potential for successful CBT.
- Studies have shown that therapist-directed CBT has a more significant impact on agoraphobic psychopathology in the short-term than do SSRIs/SNRIs.
- At a physicians discretion, sedatives or hypnotics may also be prescribed. A physician may advise an agoraphobic patient to take such drugs when the symptoms of agoraphobia are particularly severe or as a preventive measure, when one expects to be exposed to a triggering situation.

## Surgery
- Surgical intervention is not recommended for the management of agoraphobia.

## Primary Prevention
- There is no established method for the primary prevention of agoraphobia.

## Secondary Prevention
- Maintenance of a healthy lifestyle may be helpful in the secondary prevention of agoraphobia. This includes:
Eating a balanced diet
Exercising regularly
Getting a sufficient amount of sleep
- Eating a balanced diet
- Exercising regularly
- Getting a sufficient amount of sleep