Self-help Articles

by Marc D. Feldman, M.D.

Agoraphobia is one of the most common and most debilitating types of anxiety disorders. It often involves the fear of being in situations in which embarrassing—if not incapacitating—where feelings of panic might suddenly strike, out of the blue, and without escape.

The problem has been around for centuries, as proven by the derivation of the term. Agoraphobia is originally a Greek word, and is most often translated to "fear of the marketplace".

Agoraphobia: Fear of the "Marketplace"

Quite understandably, sufferers of panic attacks start avoiding places that have previously been the site of an anxiety attack. Then they can systematically start avoiding other places that remind the of the original site, and eventually avoid many places.

The problem get compounded, however, because avoidance generalizes to similar places and then extends to other places. For example, if the original trigger for an anxiety attack happened at a beach, that beach, then all beaches might be avoided.

Then all things that remind the person of beaches might be avoided, such as sporting good stores, department stores selling swimsuits, then all stores. Known as generalization, this process can get extreme. Some people avoid all places and just stay at home.

In severe situations, they might not even want to go out to their mailbox or back yard. Their home becomes their one "safe place". As you can imagine, this places a heavy burden on family and friends, who sometimes are relied upon for even the most basic of exchanged with the outside world.

What are The Symptoms of Panic?

It might help to understand the common symptoms of panic. It is usually unexpected, sudden and often intense anxiety that can last for about 30 minutes, but can be as short as 15 seconds.

Despite the colossal impact specific or social phobias can have on an individual's life (see the articles on Specific Phobia and Social Phobia), agoraphobia can be the most disabling of all the phobic disorders. Agoraphobia, in contrast to specific phobia, strikes in a large number of situations. And unlike social phobia, the fear can develop even when the person is alone. For example, being alone outside the home is intolerable for some people with agoraphobia.

Patients may refuse to go out without a trusted friend or family member, and—in the most extreme cases—an agoraphobic person will refuse to leave home, even with help. Imprisoned by the force field of their own minds, these people evolve into hermits confined to their only safe haven.

Most often, agoraphobic patients experience panic attacks as well. During a panic attack, mind and body seem to conspire in a ruthless assault. Any one or combination of these symptoms can occur without warning:

• massive autonomic system arousal, including:
  • rapid heartbeat (palpitations),
  • chest pain,
  • difficulty breathing, usually manifested in shortness of breath
  • hyperventilation or choking
  • feelings of unreality
  • hot or cold flashes
  • faintness
  • trembling
  • profuse sweating
  • hand and finger numbness
• fear of dying, going crazy, losing control
• racing thoughts and
• abdominal distress

Panic attacks, which hit "out of the blue" and dissipate just as spontaneously, are routinely described by patients as the worst experience of their lives.

Determining the Cause

In many cases, agoraphobia descends after a stressful event. Also, studies suggest that the disorder is more common in families in which other members suffer from an anxiety disorder or from alcohol abuse.

Some researchers suspect that agoraphobic patients process information differently from others. This quality makes them overattentive to potential threats in the environment, and so they anticipate being fearful even in relatively benign situations.

Perhaps the unpredictability of the panic attacks they have had in the past—and their interpretation of these as calamitous experiences—"trains" them to be chronically fearful. If so, this finding would help explain why 40% of patients cannot identify any specific events or situations that contributed to their agoraphobia.

These patients, like many with social phobia, may have had basic personality characteristics such as avoidance, timidity, and over-dependence that predisposed them to developing agoraphobia.

Treatment: Containing the Fear

Psychiatric care usually dramatically reduces the symptoms of agoraphobia. The particular approach taken depends initially on whether panic attacks complicate the agoraphobia. If panic attacks are present and persistent, they often can be remedied with medications, especially antidepressants.

Anti-anxiety medications such as benzodiazepines appear to be effective as well, but can be highly addictive. Withdrawal symptoms can be severe, and can last for months in some patients. It is to most people's advantage to Be sure discuss the risks and benefits with your doctor carefully, and try other approaches first.

A number of non-medication interventions are often used —alone or in combination with one another. When combining medication and psychotherapy, the idea is to use the medication to quickly alleviate the most distressing symptoms, and give the person enough time to find someone to help them learn skills to change their anxiety-producing behaviors and thoughts.

Behavior therapy for panic and agoraphobia is often very effective. It can sometimes involve actually evoking the troubling symptoms, in a planned, careful and controlled way. The therapist can then directly observe and help the patient to learn techniques to combat the symptoms.

Most often, though, behavior therapy incorporates the measures described in the article, "'Fear Itself': Specific Phobia," such as graded exposure, breathing exercises, and systematic desensitization.

Supplemented by cognitive therapy to block the "automatic thoughts" that lead the patient first to misinterpret any strong emotion as "anxiety" and then to equate "anxiety" with "doom," the agoraphobic person discovers that feelings of panic, though unpleasant to be sure, are not a death sentence.

Traditional psychotherapy has its place in some cases. A traditional psychotherapist can be engaged to help the motivated patient identify forgotten sources of horrific anxiety.

Supplementing the individual psychotherapy with a support group can compound the benefits. Finally, family therapy may be important. Families of patients with agoraphobia may have had to suspend their own lives to accommodate their loved one's disorder. Sometimes, this suspension lasts too long or otherwise becomes unduly brudensome for family (or friends). A un-moderated willingness to over-sacrifice can sometimes lead to over-dependence by the patient.

At such times, support and education for family members and significant others are indispensable to freeing everyone from a burdened existence, including the patient. These issues get complicated very quickly, and the help of an objective third party is often the quickest and most reliable solution for everyone involved. Family therapists are trained in identifying the most helpful roles and teaching new skills to maintain healthier relationships for everyone involved, including the primary patient.

References:

Feldman MD, Feldman JM. Stranger Than Fiction: When Our Minds Betray Us. Washington, DC, American Psychiatric Press, Inc., 1998

Furukawa TA, Watanabe N, Churchill R. Combined psychotherapy plus
antidepressants for panic disorder with or without agoraphobia. Cochrane
Database Syst Rev 2007; 24:CD004364

Perugi G, Frare F, Toni C. Diagnosis and treatment of agoraphobia with
panic disorder. CNS Drugs 2007; 21:741-764

About the Author:

Marc D. Feldman, M.D. is the author of "Playing Sick? Untangling the Web of Munchausen Syndrome, Munchausen by Proxy, Malingering, and Factitious Disorder" (2004) and co-author of "Stranger Than Fiction: When Our Minds Betray Us" (1998).