Agoraphobia

Elizabeth Winter, M.D.

DEFINITION

  • Irrational or disproportionate fear of a range of situations in which a person believes escape or access to help may be impossible, very difficult, or very embarrassing if he or she develops panic-like symptoms or some other incapacitating loss of control (e.g. vomiting, falling, seizure)[1]

EPIDEMIOLOGY

  • Lifetime prevalence in the general US population is about 2%[2].
    • The prevalence is higher (10.4%) in adults over 65 years old[3].
  • Twice as likely to occur in women than in men[4]
  • Average age of onset is between 25 and 30[5].
  • Over their lifetime, 87% of people with agoraphobia will meet criteria for another mental illness[5].
  • Risk factors include:[7]
    • History of physical or sexual abuse
    • Behavioral inhibition; high neuroticism and low extraversion
    • Parental over protection, separation from or death of a parent
    • In adults over 65 years old, poor performance on tests of visuospatial memory

DIAGNOSIS

Clinical Presentation

  • Fear may be present in a variety of situations including being in enclosed or wide open spaces, using public transportation, being in a crowd, or simply being alone away from home.
  • Patients tend to actively avoid (or require the presence of a trusted companion in) the situations that trigger their fear.
  • Children may articulate the fear of getting lost, feeling alone without anyone to help, or a persistent fear of leaving the home "in case something bad happens."
  • Older adults often cite the fear of falling or the possibility of a severe medical event like a heart attack or stroke as justification for avoidance.
  • Avoidance in adults can become severe enough to cause drastic impairment.
    • Avoidance of public transportation or driving can result in job loss.
    • Avoidance of shopping areas, including grocery stores, can result in nutritional deficiencies unless the individual specifically engages home delivery or the aid of another individual.
    • Progressive restriction of activity can eventually render a person housebound.

Differential Diagnosis

  • Specific phobia, situational type: In specific phobia, the fear centers on harm directly caused by the situation (e.g., a plane crashing); in agoraphobia, the fear centers on whether escape is possible or if help will be available in the situation.
  • Social anxiety disorder: In social anxiety disorder, the fear centers on the potential judgment by other people; in agoraphobia, the fear centers on a range of situations that generate anxiety or avoidance, not just situations in which an individual could be evaluated by others.
  • Panic pisorder: Agoraphobia should not be diagnosed if all criteria for panic disorder are met unless the avoidance behaviors associated with panic attacks extend to two more situations.
  • Separation anxiety disorder: In separation anxiety disorder, the fear centers on detachment specifically from a parent or significant other or from the home; in agoraphobia, the fear centers on whether escape is possible or if help will be available in a wide range of situations that are not limited to involvement with significant others or the home.
  • Post-traumatic stress disorder: In posttraumatic stress disorder, the avoidance behaviors are limited to situations that remind the individual of the trauma experienced; in agoraphobia, the avoidance behavior includes a range of situations unrelated to a trauma.
  • Major depressive disorder: Individuals with severe depression may become very isolated and not leave the home. These are related to decreased energy, poor self-esteem, irritability or apathy; in agoraphobia, the avoidance behavior is a result of fearing whether escape is possible or help will be available in a situation if the individual develops panic symptoms or a loss of control.

TREATMENT

Pharmacotherapy

  • There are no studies that directly address the effect of medication on agoraphobia in the absence of panic disorder. Consequently, the effect of medication on agoraphobia associated with panic disorder may be confounded by the reduction of panic symptoms.[8]
  • Paroxetine, sertraline, citalopram, escitalopram, and clomipramine appear more effective than placebo, while the effects of fluvoxamine, fluoxetine, and imipramine may be more limited[8][9].
  • D-Cycloserine (DCS) has been suggested as an adjuvant for psychotherapy, but no robust studies have found DCS to be significantly effective for agoraphobia in panic disorder.[10]

Psychotherapy

  • In vivo exposure involves having the individual enter the feared situation in real life.
    • Flooding: one-time exposure in the worst-possible scenario until the individual relaxes spontaneously
    • Graduated exposure: graduated levels of exposure to the feared situation based on a hierarchy of the least fear-provoking situation to the greatest fear-provoking situation
    • A large body of evidence supports in-vivo exposure treatment in agoraphobia. Clinical gains are maintained at 2-year follow up.[11]
  • Imaginal exposure involves patients’ actively imagining the feared situation because the situation can’t be recreated feasibly. This is performed in a hierarchical fashion similar to in-vivo graduated exposure. Several studies demonstrate no difference in efficacy between imaginal and in-vivo exposure in the treatment of agoraphobia.[12]
  • Interoceptive exposure involves confrontation with feared bodily sensations like shortness of breath or heart palpitations. This is a useful adjunct to in-vivo exposure if panic-like symptoms are too severe, even in the lowest-ranking situation on the hierarchy.
  • Virtual reality uses sensory- (e.g. visual-) immersion devices to simulate feared situations like flying.
  • Cognitive therapy (CBT) addresses irrational or distorted thoughts associated with feared stimuli. These maladaptive automatic thoughts are modified to more reasonable and realistic thoughts. One study suggested cognitive therapy and in-vivo exposure have similar efficacy in the treatment of agoraphobia[13], but the majority of the literature favors in-vivo exposure.
    • CBTmay exert an effect partially through improving avoidant and anxious attachment styles. [14]

WHEN TO REFER

  • Refer to psychotherapy when the avoidance behavior is causing functional impairment in social or occupational spheres.

COMMENTS

  • Severe agoraphobia can lead to an individual becoming housebound and fully dependent on other people for personal care. Screen for symptoms of depression or other anxiety disorders, and for substance use disorder - including inappropriate use of prescribed medications (a common maladaptive coping strategy).
  • Older adults are less likely to have insight into the excessive nature of their fears because they view them as being normal, age-related complaints. It is important to screen for agoraphobia, however, because untreated illness is associated with an increased rate of fatal coronary artery disease and sudden cardiac death.[3]

References

  1. Bienvenu OJ, Wuyek LA, Stein MB. Anxiety disorders diagnosis: some history and controversies. Curr Top Behav Neurosci. 2010;2:3-19.  [PMID:21309103]
  2. Kessler RC, Ruscio AM, Shear K, et al. Epidemiology of anxiety disorders. Curr Top Behav Neurosci. 2010;2:21-35.  [PMID:21309104]
  3. Ritchie K, Norton J, Mann A, et al. Late-onset agoraphobia: general population incidence and evidence for a clinical subtype. Am J Psychiatry. 2013;170(7):790-8.  [PMID:23820832]
  4. McLean CP, Asnaani A, Litz BT, et al. Gender differences in anxiety disorders: prevalence, course of illness, comorbidity and burden of illness. J Psychiatr Res. 2011;45(8):1027-35.  [PMID:21439576]
  5. Michael T, Zetsche U, and Margraf J. Epidemiology of Anxiety Disorders. Epidemiology and Psychopharmacology 136:142, 2007.
  6. Goodwin RD, Stein DJ. Anxiety disorders and drug dependence: evidence on sequence and specificity among adults. Psychiatry Clin Neurosci. 2013;67(3):167-73.  [PMID:23581868]
  7. Wittchen HU, Gloster AT, Beesdo-Baum K, et al. Agoraphobia: a review of the diagnostic classificatory position and criteria. Depress Anxiety. 2010;27(2):113-33.  [PMID:20143426]
  8. Perugi G, Frare F, Toni C. Diagnosis and treatment of agoraphobia with panic disorder. CNS Drugs. 2007;21(9):741-64.  [PMID:17696574]
  9. Perna G, Daccò S, Menotti R, et al. Antianxiety medications for the treatment of complex agoraphobia: pharmacological interventions for a behavioral condition. Neuropsychiatr Dis Treat. 2011;7:621-37.  [PMID:22090798]
  10. Hofmeijer-Sevink MK, Duits P, Rijkeboer MM, et al. No Effects of D-Cycloserine Enhancement in Exposure With Response Prevention Therapy in Panic Disorder With Agoraphobia: A Double-Blind, Randomized Controlled Trial. J Clin Psychopharmacol. 2017.  [PMID:28820746]
  11. Gloster AT, Hauke C, Höfler M, et al. Long-term stability of cognitive behavioral therapy effects for panic disorder with agoraphobia: A two-year follow-up study. Behav Res Ther. 2013;51(12):830-839.  [PMID:24184430]
  12. James JE, Hampton BA, Larsen SA. The relative efficacy of imaginal and in vivo desensitization in the treatment of agoraphobia. J Behav Ther Exp Psychiatry. 1983;14(3):203-7.  [PMID:6139389]
  13. Bouchard S, Gauthier J, Laberge B, et al. Exposure versus cognitive restructuring in the treatment of panic disorder with agoraphobia. Behav Res Ther. 1996;34(3):213-24.  [PMID:8881091]
  14. Zalaznik D, Weiss M, Huppert JD. Improvement in adult anxious and avoidant attachment during cognitive behavioral therapy for panic disorder. Psychother Res. 2017.  [PMID:28826378]
  15. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing
  16. Meyerbroeker K, Morina N, Kerkhof GA, et al. Virtual reality exposure therapy does not provide any additional value in agoraphobic patients: a randomized controlled trial. Psychother Psychosom. 2013;82(3):170-6.  [PMID:23548832]
Last updated: November 1, 2017