Agoraphobia

The dictionary defines agoraphobia as “extreme or irrational fear of open or public places” (Oxford Dictionary of English, 2005). However the psychiatric definition of agoraphobia depends on which of the two major diagnostic classification systems that you use. For simplicity, the two systems are simply specified with the acronyms ICD-10 and DSM-IV. A fuller description of the two systems and definitions is provided in Appendix A.

ICD-10 definition of Agoraphobia and some important features

The ICD-10 defines agoraphobia as “A fairly well-defined cluster of phobias embracing fears of leaving home, entering shops, crowds and public places, or travelling alone in trains, buses or planes." and hence treats agoraphobia in a way similar to other phobias such as social phobia or specific phobias.

The fear experienced by the agoraphobic in such places can vary from mild to severe. This usually includes one or more of physical symptoms characteristic of anxiety such : increased heart rate or heart palpitations, hyperventilation, trembling, sweating, dry mouth, or a sinking feeling in the pit of the stomach.

These symptoms may be so severe as to receive the label of “panic attack”. In fact, the ICD-10 specifically mentions that “Panic disorder is a frequent feature of both present and past episodes.” but it does not formally link agoraphobia to Panic Disorder as does the DSM-IV.

The fear experienced by the agoraphobic can lead to them avoiding the feared places completely and in severe cases, especially in women, the agoraphobic can become “house bound”. From clinical experience it seems that, in contrast, male agoraphobics tend to become alcoholic.

The ICD-10 also notes that “Depressive and obsessional symptoms and social phobias are also commonly present as subsidiary features (of agoraphobia). “

DSM-IV definition of Agoraphobia and characteristic symptoms

According to the Diagnostic and Statistical Manual (1994, DSM-IV) of the American Psychiatric Society, agoraphobia is not a psychiatric disorder in itself, but is the “anxiety about, or avoidance of, places or situations from which escape might be difficult (or embarrassing) or in which help may not be available in the event of having a panic attack or panic-like symptoms".

However there is a psychiatric disorder called "Agoraphobia Without History of Panic Disorder" which is characterized by:

  • The presence of agoraphobia related to fear of developing panic-like symptoms for example dizziness, difficulty breathing, heart palpitations.
  • There has never been a diagnosable panic disorder

Prevalence

The largest and most accurate study to date that provides information on lifetime prevalence is the large-scale epidemiological study by Kessler et al. It is to be noted that this study conducted in the US used the DSM-IV criteria for Agoraphobia Without History of Panic Disorder and found a lifetime prevalence of just 1.4% making it the least prevalent of all the anxiety disorders.

Treatments for Agoraphobia

Because of the tendency of the person with agoraphobia to avoid feared situations, this condition can severely limit simple domestic tasks such as going to the supermarket, one's social life and more critically one’s career.

Hence it is important for the person with agoraphobia to obtain treatment. Fortunately as with the other phobic disorders, there are a variety of effective treatment approaches:

  • Cognitive behavioural therapy (CBT, Berle et al 2008;Vogele et al 2010). The psychotherapist helps determine if there are any maladaptive beliefs that contribute to the mental processes that lead to the anxiety and withdrawal and or avoidance of the feared situation (Berle et al 2008).

    The first step in this cognitive process is to keep a diary of thoughts around the feared situation. This will serve as a basis for cognitive restructuring which is done in collaboration with the therapist. The CBT will also contain a behavioural component in which the client is desensitized by approaching the feared situation in a very gentle graded way.

    Another aspect of CBT is teaching of emotional self-regulation skills. For example, the client can learn deep breathing as a relaxation skill and apply it during the graded exposure as soon as any anxiety arises. It is obvious that the CBT approach requires active participation and collaboration.
  • Pharmacological treatment. Antidepressant medications have been used to help alleviate the anxiety symptoms of agoraphobia (Perugi, G., Frare, F., & Toni, C.,2007). Minor tranquilizers such as diazepam are used but have the strong potential for addiction if used over long periods or abused.
  • Virtual reality therapy. As with the other phobias, there is increasing use of virtual reality exposure instead of actual reality for the treatment of agoraphobia (Lorenzo González et 2011). The virtual reality exposure has many advantages including easier access and greater control over intensity and duration and quality.

Appendix A

The world’s two main diagnostic systems are the International Classification of Disease (ICD-10, WHO, 1993) and the Diagnostic and Statistical Manual of Mental Disorders, 4th Ed. (DSM-IV 1994).

Unfortunately, with respect to agoraphobia, use of these two diagnostic classification systems led to “two discrepant diagnostic criteria sets worldwide, and use of different criteria in different diagnostic interviews” (Wittchen et al 2010).

The main source of these discrepancies is the DSM-IV rigorously linking agoraphobia to panic disorder, which research shows is indeed a frequent feature of both present and past episodes of agoraphobia.

However, it is not a necessary feature and Wittchen et al end their comprehensive and thoughtful review of the literature on agoraphobia with the statement: “We come to the conclusion that AG (agoraphobia) should be conceptualized as an independent disorder with more specific criteria rather than a subordinate, residual form of PD (Panic Disorder) as currently stipulated in DSM-IV-TR. Among other issues, this conclusion was based on psychometric evaluations of the construct, epidemiological investigations which show that AG can exist independently of panic disorder, and the impact of agoraphobic avoidance upon clinical course and outcome.”


References

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders. (4th ed., text rev.) Washington, DC: Author.

Berle , D. Starcevic , V. Hannan , A. Milicevic , D. Lamplugh , C. Fenech , P. (2008). Cognitive factors in panic disorder, agoraphobic avoidance, and agoraphobia. Behaviour Research and Therapy, 46, 282-291.

Kessler, Ronald C., Berglund, Patricia, Demler, Olga, Jin, Robert, Merikangas, K. R., Walters, Ellen E., (2005). Lifetime Prevalence and Age-of-Onset Distributions of DSM-IV Disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, Vol. 62(6), 593-602.

Oxford Dictionary of English (2nd ed. revised). (2005). Oxford, UK: Oxford University Press.

Lorenzo González, M., Castro, W. P., Pitti González, C. T., Bethencourt Pérez, J. M., de la Fuente Portero, J. A., & Marco, R. G. (2011). Efficacy of virtual reality exposure therapy combined with two pharmacotherapies in the treatment of agoraphobia. International Journal of Clinical and Health Psychology, 11(2), 189-203.

Perugi, G., Frare, F., & Toni, C. (2007). Diagnosis and treatment of agoraphobia with panic disorder. CNS Drugs, 21(9), 741-764.

Wittchen, H.-U., Gloster, A. T.,Beesdo-Baum, K., Fava, G. A., & Craske, M. G. (2010). Agoraphobia : A review of the diagnostic classificatory position and criteria. Depression and Anxiety, 27(2), 113-133.

Vögele, C., Ehlers, A., Meyer, A.H., Frank, M., Hahlweg, K., Margraf, J. (2010) Cognitive mediation of clinical improvement after intensive exposure therapy of agoraphobia and social phobia. Depression and Anxiety, Vol 27(3), 294-301.

WHO. (1993). The ICD-10 Classification of Mental and Behavioural Disorders: Diagnostic Criteria for Research. Geneva, Switzerland: World Health Organization; 1993.


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