Agoraphobia – A Guide

A Guide to Agoraphobia a term that is used to describe a number of related phobias (irrational fears) that are connected to situations such as:

• leaving home
• entering shops
• being in crowds or public places
• travelling alone on buses, trains or plane

Introduction

Agoraphobia can often lead to a change in behaviour where a person with the condition will avoid situations that may cause them anxiety. They may start only leaving the house with a friend or partner, or ordering groceries online rather than going to the supermarket. This change in behaviour is known as avoidance. Avoiding normal activities can lead to an individual’s life becoming restricted.

Agoraphobia and panic disorder

Many people with agoraphobia also have panic disorder and a history of panic attacks. In these cases, agoraphobia often develops as a result of a previous panic attack.

The person may worry about being in an environment or situation where escaping or getting help would be impossible or embarrassing if they were to have a panic attack. They may also think that having a panic attack will be life-threatening. For example, they think they stop breathing or their heart will beat too fast and they will have a heart attack.

Agoraphobia without panic disorder

It was once believed that all cases of agoraphobia were related to panic disorders and panic attacks. However, research carried out in the last two decades has shown that almost half of people with agoraphobia have no previous history of panic disorders or panic attacks.

In such circumstances, agoraphobia may be caused by different phobias, such as a fear of crime, terrorism, illness or accident. However, people who have agoraphobia without panic disorder are often motivated by the same fears as those with panic disorder, such as experiencing their first panic attack if they are in a situation or environment that provokes anxiety.

How common is agoraphobia?

Mind, the mental health charity, estimates that in the UK there are around 10 million people with a phobia. As many as half of all people with a phobia may have agoraphobia.

However, there may be many more people with phobias (including agoraphobia) due to the fact that some people do not feel comfortable talking about their condition, and therefore many cases may go unreported.

Agoraphobia is twice as common in women as men, and the condition usually starts between the ages of18 and 35.

It is estimated that agoraphobia without panic disorder affects around 4% of women and 2% of men during any 12-month period.

Symptoms of agoraphobia

The severity of agoraphobia can vary significantly between different people with the condition. For example, someone with severe agoraphobia may be unable to leave the house, whereas someone who has mild agoraphobia may be able to travel short distances without experiencing problems.

The symptoms of agoraphobia can be broadly classified into three types:

• physical
• psychological
• behavioural

These are explained in more detail below.

Physical symptoms

The physical symptoms of agoraphobia usually only occur when you find yourself in a situation or environment that causes anxiety. However, many people with agoraphobia rarely experience any physical symptoms because they deliberately avoid situations that make them anxious.

The physical symptoms of agoraphobia can be similar to those of a panic attack and may include:

• rapid heart beat
• rapid breathing (hyperventilating)
• feeling hot and sweaty
• nausea (feeling sick)
• upset stomach
• chest pain
• difficulty swallowing (dysphagia)
• diarrhoea
• trembling
• dizziness
• ringing in the ears (tinnitus)
• feeling faint

Psychological symptoms

The psychological symptoms of agoraphobia are feelings or thoughts that are sometimes, but not always, related to the physical symptoms.

Psychological symptoms may include fear that:

• A panic attack will make you look stupid or embarrassed in front of other people.
• A panic attack will be life-threatening. For example, you may be worried that your heart will stop or that you will be unable to breathe.
• You would be unable to escape from a place or situation if you were to have a panic attack.
• You are losing your sanity.
• You may lose control in public.
• You may tremble and blush in front of people.
• You may be stared at.

There are also a number of psychological symptoms that are associated with agoraphobia that are not necessarily related to panic attacks. They include:

• feelings of low self-esteem
• feeling depressed
• feeling that you would be unable to function, or survive, without the help of others
• a fear of being left alone in your house (monophobia)
• a general feeling of anxiety or dread

Behavioural symptoms

Some of the symptoms of agoraphobia are related to behaviour. They include:

• obsessive and depressive behaviour
• avoiding any situation that could lead to any of the physical and psychological reactions mentioned above
• not being able to leave the house for long periods of time (housebound)
• tolerating a situation but with considerable fear and anxiety
• needing to be with someone you trust when going anywhere
• avoiding being far away from home
• avoiding physical activity due to a fear that it will lead to a panic attack
• avoiding driving

When to seek medical advice

You should visit your GP if:

• Your symptoms become so severe that you feel that you may need medication.
• Your symptoms begin to interfere with your personal, social or professional life.
• You are depressed and/or feel suicidal.

Also seek medical advice if you have any of the following:

• chest pain
• shortness of breath
• headaches
• dizziness
• fainting spells
• unexplained weakness
• the sensation that your heart is beating irregularly (palpitations)

Causes of agoraphobia

The exact cause of agoraphobia is unknown. However, researchers believe that the condition may be related to one or more of the following:

• psychological factors
• genes
• panic disorder
• spatial awareness problems (an inability to comprehend how the body is positioned in relation to other objects within a certain space)

Genes

A number of studies have been carried outthat suggest that certain genetic mutations may increase a person’s likelihood of developing panic disorders, such as agoraphobia. A genetic mutation occurs when the normal instructions that are carried in certain genes become scrambled (mixed up).

A number of specific genetic mutations have been linked to panic disorders, such as a mutation in a type of cell called a lymphoblast. Panic disorders are also known to run in families. However, exactly how these genetic mutations contribute to panic disorders is uncertain and further studies are needed to investigate the relationship between genes and anxiety disorders.

Psychological factors

Psychological factors that may trigger agoraphobia include:

• A traumatic childhood experience, such as the death of a parent.
• Experiencing a stressful event, such as bereavement or job loss.
• A previous history of mental illnesses, such as depression, anorexia or bulimia.
• A previous history of drug or alcohol misuse.
• Being in an unhappy relationship, or in a relationship where the partner isvery controlling.

However, for some cases of agoraphobia there are no obvious contributory psychological factors.

Panic disorder

Some experts believe that agoraphobia may be a complication of panic disorder (an anxiety disorder that involves panic attacks and moments of intense fear).

Agoraphobia may develop as a result of associating panic attacks with certain places or situations where the attacks occurred, and then avoiding those places or situations.

When someone develops panic disorder, agoraphobia often develops within the first year. However, agoraphobia can sometimes occur without panic disorder.

Spatial awareness

A number of links have been found between agoraphobia and spatial awareness. Some people with agoraphobia have a weakened system of balance and space, which causes an imbalance and a need to rely heavily on visual signals. This can result in someone with agoraphobia feeling overwhelmed and disorientated in crowded places.

Diagnosing agoraphobia

If you are experiencing psychological symptoms of agoraphobia, such as fearing that a panic attack will make you look stupid or embarrassed in front of others, your GP may refer you to a psychiatrist (a mental health specialist).

However, if you are experiencing physical symptoms, such as a rapid heart beat, shortness of breath and feeling sick, your GP may examine you to seeif there is an underlying physical cause.

Referral to a psychiatrist

If you are referred to a psychiatrist, they will ask you some questions about your symptoms, your feelings and your general background. They will want to determine whether your agoraphobia is being caused by another mental health condition. If it is, it will need to be addressed first in order to successfully treat the symptoms of agoraphobia.

For example,some patients have obsessive compulsive disorder (OCD), which is a long-term mental health condition where a person has obsessive thoughts and compulsive behaviour, such as cleaning all the time. People with OCD may avoid crowds, not because they have agoraphobia but because they are afraid of catching other people’s germs.

Alternatively, someone with a social phobia may avoid leaving the house because they are afraid that they will embarrass themselves in a social situation.

DSM-IV diagnostic criteria for agoraphobia

The main criteria used to diagnose agoraphobia is the DSM-IV diagnostic criteria for agoraphobia. Under this criteria, a person is thought to have agoraphobia if:

• They are anxious about being in a place or situation, such as being in a crowd or riding on a bus, where escape or help may be difficult in the event of a panic attack or panic-like symptoms.
• They avoid the situations described above, or endure them with extreme anxiety, or with the help of a companion.
• There is no other underlying condition, such as OCD, that may explain their symptoms.

Some psychiatrists and psychologists think that this criteria is too narrow to comprehensively define agoraphobia. They feel that it does not take into account the people with agoraphobia who do not have other symptoms of panic disorder, such as those who have never had a history of panic attacks, and those whose agoraphobia is motivated by fears that are not associated with panic attacks.

However, panic attacks and panic disorder do not have to be present in order to confirm a diagnosis of agoraphobia and treatment for the condition remains largely the same, no matter which diagnostic tool is used.

Treating agoraphobia

Agoraphobia is sometimes treated in connection with panic disorder. If someone has agoraphobia for a year, it may continue for many years unless it is treated. The two main types of treatment for agoraphobia are:

• psychological therapy
• medication

Before starting any form of treatment for agoraphobia, your GP or psychiatrist (mental health specialist) will discuss all of the options with you. They will outline the advantages of each type of treatment with you, and they will also make you aware of any possible risks or side effects.

Different treatments will suit different people, so you may need to try a few before finding one that suits you. The treatment that is recommended for you will depend on the severity of your condition, you general health and your personal preferences.

The various psychological and medicinal treatments for agoraphobia are discussed in more detail below.

Psychological therapy

Psychological therapy has proven long-term benefits, and is the recommended form of treatment for people withpanic disorder (with or without agoraphobia). If you have psychological therapy for panic disorder, it will usually be in the form of cognitive behavioural therapy.

Cognitive behavioural therapy (CBT)

CBT is thought to be one of the most effective forms of treatment for panic disorder with or without agoraphobia. CBT is a type of psychotherapy that is based on the principle that the way you feel is partly dependent on the way you think about things. CBT teaches you to behave in ways that challenge negative thoughts.

Your therapist will also be able to teach you ways of changing your behaviour, which should make it easier for you to deal with future panic attacks. For example, they may be able to show you breathing techniques that you can use to help keep you calm during the stress of a panic attack.

The National Institute for Health and Clinical Excellence (NICE) recommends 7–14 hours of CBT to be completed within a period of four months. Your treatment will usually involve having a weekly one-to-two hour session.

See Cognitive behavioural therapy for more information about this form of treatment.

Exposure therapy

Exposure therapy is another type of psychotherapy that is sometimes used to treat agoraphobia. It involves being gradually exposed to the object or situation that is feared, and using relaxation techniques to help reduce anxiety.

Support groups

Charity organisations such as Anxiety UK  can provide useful information and advice about how to manage your agoraphobia effectively. They are also able to put you in touch with other people who have similar experiences of the condition.

Medication

Medication is sometimes used in combination with CBT to help treat the symptoms of agoraphobia. Medicines that may be used to treat agoraphobia include:

• antidepressants
• selective serotonin re uptake inhibitors (SSRIs)
• tricyclic antidepressants
• beta-blockers

Antidepressants

Antidepressants are often associated with depression, but they can also be used to treat other psychological conditions.

Antidepressants can take between two to four weeks before they become effective. Therefore, if you are prescribed antidepressants, you should continue to take them even if you feel that they are not working.Only stop taking prescribed medication if your GP specifically advises you to do so.

Selective serotonin reuptake inhibitors (SSRIs)

Selective serotonin re uptake inhibitors (SSRIs) are a type of antidepressant that work by increasing the level of a chemical in your brain called serotonin.

SSRIs are the most commonly prescribed form of antidepressant for treating phobias. They are usually started at a low dose before gradually being increased as your body begins to adjust to the medicine.

Common side effects of SSRIs include:

• nausea
• headaches
• low sex drive
• blurred vision
• diarrhoea or constipation
• dizziness
• dry mouth
• loss of appetite
• sweating
• feeling agitated
• insomnia (being unable to sleep)
• abdominal (stomach) pain

When you first start to take SSRIs, your feelings of panic and anxiety may seem to get worse. Inmost cases this is only temporary and you will usually find that your symptoms start to return to normal levels within a few days of taking the medicine.

However, you should speak to your GP if you feel that your symptoms have got worse and that they are not showing signs of returning to normal levels after a few days.Contact your GP if you experience side effects after taking SSRIs that become troublesome and do not ease.

After you start to take a SSRI, visit your GP after two, four, six and 12 weeks so that they can check your progress and whether you are responding to the medicine. Not everyone responds well to antidepressant medicines, so it is important that your progress is carefully monitored.

If your GP feels that it is necessary, you may require regular blood tests or blood pressure checks when taking antidepressant medication. If after 12 weeks of taking the medication you do not show any signs of improvement, your GP may prescribe an alternative SSRI to see whether it is more effective.

Tricyclic antidepressants

If SSRIs do not improve your symptoms after a 12-week course, or if they are not suitable for you, your GP may prescribe a different type of antidepressant for you.

Tricyclic antidepressants work in a similar way to SSRIs. They regulate the levels of certain chemicals in your brain (noradrenaline and serotonin), which has a positive effect on your feelings and mood.

The two tricyclic antidepressants that are often prescribed are:

• imipramine
• clomipramine

Tricyclic antidepressants are not addictive.

SSRIs are usually prescribed before tricyclic antidepressants because they have fewer side effects. However, common side effects of tricyclic antidepressants include:

• constipation
• difficulty urinating
• blurred vision
• dry mouth
• weight gain or weight loss
• drowsiness
• sweating
• light headedness
• skin rash

The side effects should ease after 7–10 days as your body begins to get used to the medication. However, contact your GP if they are troubling you.

Beta-blockers

Beta-blockers are a type of medication that can control symptoms of anxiety, such as sweating and trembling.

Beta-blockers work by slowing down your heart rate and the force of your heart. This reduces the pressure at which the blood is pumped out of your heart and around your body.

Common side effects of beta-blockers include:

• weakness
• dizziness
• cold hands
• fatigue

Beta-blockers are not usually recommended for people with asthma or diabetes because they may make the symptoms of these conditions worse.

Beta-blockers can also interact with other medicines, causing possible adverse side effects. Therefore, check with your GP or pharmacist before taking other medicines in combination with beta-blockers.

It is important that you do not stop taking beta-blockers without consulting your GP. Stopping this medication suddenly will lead to side effects, such as a rise in blood pressure or an angina attack.

Self help

There is some self-help advice that may help to relieve the panic symptoms often associated with agoraphobia. For example:

• creative visualisation–this technique involves thinking about a relaxing place while you are having a panic attack. This helps torelieve your symptoms and to encourage more positive thoughts about yourself and others.
• relaxation– practising relaxation and breathing techniques can help relieve your symptoms during a panic attack. Some people find that complementary therapies, such as massage and aromatherapy, help them to relax.
• exercise– regular aerobic exercise can help to relieve stress and tension. During exercise, your mood can also be improved by your brain releasing a chemical called serotonin.