By Dr Raghuram Y.S. MD (Ay) & Dr Manasa, B.A.M.S
Agoraphobia is a type of anxiety disorder that causes people to avoid places and situations that cause them to feel scared, embarrassed or panicked. The fear may be about an actual situation or anticipated situation. The fear may be about being in open or closed spaces, being in crowd, standing in line / queue or using public transportation.
You would feel that there is no way to get help if the anxiety gets severe. Most people develop this situation after having undergone one or more panic attacks. They worry about having another similar attack. These people would not feel safe in public places, especially in crowded places. They would prefer going to public places along with a close friend or relative. They may even feel difficult leaving home and going outside. Psychotherapy and medications would help in relieving the symptoms of agoraphobia.
Symptoms of panic attack such as nausea and rapid heartbeat may be experienced in severe situations of stress. The condition sometimes is so severe that people avoid doing daily activities such as going to a shop or bank. They tend to stay inside the house for most of the days.
This condition can be disabling if severe symptoms are present. These people may often realize that their fear is irrational but they are helpless and can’t do anything to overcome their fears. This would obviously disturb their personal relationships and performance at school or work place.
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Table of Contents
According to estimates made by NIMH (National Institute of Mental Health), about 0.8% of American adults have agoraphobia. Among these at least 40% cases are considered to be severe. About 1-2% of adults in the US have been diagnosed with agoraphobia. Roughly 2% adolescents experience this condition. This condition is more common among women. It usually manifests before 35 years of age.
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In agoraphobia the patient would have fear of –
Being alone in social situations
Leaving home alone
Losing control in a public place
Waiting in queues
Being in places from where it would be difficult to escape (as in a car or elevator)
Enclosed spaces – movie theatres, elevators, small stores etc
Open spaces – malls, shopping areas, parking places, bridges,
Using public transportation – traveling in bus, train, plane etc
These people are also detached from others.
They are anxious or agitated.
Fear / anxiety is out of proportion to a given situation or danger than what it actually needs to be
Avoiding situation, need of companion to go out
Significant distress / problems with social situations / work or other areas in life due to fear or anxiety
Phobia / avoidance / or both usually lasts for 6 months or more
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Symptoms of panic attacks
Agoraphobia resembles panic attacks. The symptoms of both these conditions coincide. Panic attacks are the symptoms that occur in people with anxiety or any other mental disorders. This can include wide range of severe physical symptoms such as –
Shortness of breath / hyperventilation
Chills / flushing
Fear of losing control
Fear of dying
Patients of agoraphobia may experience panic attacks whenever they are in an uncomfortable situation or stressful scenario. This further increases their fear of being in an uncomfortable situation.
Agoraphobia may be associated with panic disorder. Panic disorder is a type of anxiety disorder wherein one would experience sudden attacks of extreme fear. The fear reaches peak levels within a few minutes and would trigger intense physical symptoms i.e. panic attacks. One would think that he or she is totally losing control or having a heart attack or even dying. They would fear that the panic attacks might recur. In these conditions they would avoid similar circumstances or places where those attacks occurred. This is a defense mechanism and an attempt to prevent future panic attacks.
Right time to see the doctor
This disease would limit one’s ability to work, attend events or socialize. If the signs and symptoms of agoraphobia and panic attack are observed, then seek medical intervention.
Causes are not well defined. Below mentioned can be considered the causes of agoraphobia –
Biology – health conditions and genetics
Agoraphobia is often associated with an already existing panic disorder. Also about one third of people who have panic disorder develop agoraphobia. But it is not a rule. Agoraphobia can also occur alone.
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This condition can begin in childhood but usually begins in late teen or early adult years. It usually occurs before 35 years of age. Older adults can also develop it. This condition is seen more in women in comparison to men.
The risk factors for agoraphobia are as below mentioned –
Having phobias – such as claustrophobia and social phobia
Having panic disorders
Showing excessive fear, apprehension and avoidance as response to panic attacks
Undergoing life events which are extremely stressful – like abuse, death of a parent or loved one, being attacked etc
Having blood relative with agoraphobia / family history of agoraphobia
Having nervous or anxious temperament / nature
Having another type of anxiety disorder like OCD or GAD (Generalized Anxiety Disorder)
History of physical or sexual abuse
History of physical or sexual abuse
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Agoraphobia limits life activities to a greater extent. It might get difficult to even leave home in severe condition of this disease. Gradually will become dependent on others for help and lose confidence. Agoraphobia can lead to or even be associated with one or more of the below mentioned conditions –
Alcohol / drug abuse
Preventive measures for agoraphobia are not clearly known. There is no sure way out. Anyways when you try to avoid situations that cause fear, anxiety tends to increase proportionally on the other side. You may have small quantum fears about some places that are usually safe and you are avoiding them due to fears. You should gradually make it a practice of visiting such places again and again and beat your fears before the fear becomes overwhelming and dominates you totally. You can also take help from a family member or friend to start with until you are confident of moving out alone. You may also seek professional help.
If you have panic attacks or experience ongoing anxiety to visit places you need to get treatment as soon as possible. Getting treatment early will prevent the symptoms from getting worse.
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Agoraphobia is diagnosed by the physician or psychiatrist after thoroughly examining the patient. This condition is diagnosed on the basis of signs and symptoms of the disease, conclusions drawn after interview with mental health professional, physical exam to rule out other physical conditions and on the basis of criteria for agoraphobia listed in the DSM-5 published by American Psychiatric Association.
For a given case to be diagnosed as agoraphobia one should feel extreme fear or panic in at least two of the below mentioned situations –
Using public transportation
Being in open space
Being in an enclosed space (movie theater, meeting room or small store)
Standing in line or being in crowd
Being out of your home alone
Additional criteria for diagnosis of panic disorder with agoraphobia – You must have recurrent panic attacks and at least one panic attack must have been followed by –
Fear of having more panic attacks
Fear of consequences of panic attacks (like having heart attack or losing control)
Change in behavior as a result of panic attacks
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Treatment of Agoraphobia includes psychotherapy and medication. Timely and effective treatment will help in good recovery and make the patients feel better.
It is also known as talk therapy. In this you will get to meet up with a therapist or other mental health professional on a regular basis and work with them towards your problem. It will be to set goals and also to learn practical skills to reduce symptoms of anxiety. You can speak to them about problems, fears and any issues that may be contributing to fears. This therapy is often done in combination with medications for maximum benefit. Usually it is a short-term treatment. Once you are able to cope up with fears and anxiety this therapy may be stopped.
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Cognitive Behavioral Therapy (CBT)
It is the psychotherapy. This teaches you
To understand the distorted feelings and views associated with agoraphobia
The specific skills to tolerate anxiety in a better way
To work through stressful situations (by replacing the distorted thoughts with healthy thoughts)
To challenge your worries and also
To gradually return to the activities you have been avoiding and running away because of anxiety
Factors which would trigger a panic attack / panic like symptoms and factors which make those symptoms worse
The symptoms of agoraphobia will gradually improve with constant therapy and monitoring along with proper follow-up. It will allow to regain a sense of control in life.
If you feel homebound and cannot leave your home to go to the hospital or therapist you may request your therapist or doctor to meet you at your home during initial sessions of therapy until you become comfortable enough to leave home. Else you can request to meet in a place which you consider as a safe zone. You may also ask for ‘over the phone’ sessions or sessions through email, using computer programs or other helpful media. You may also benefit from some intensive hospital programs by staying in that setting if the agoraphobia is very severe.
If you cannot go alone you may prefer taking trusted relative or friend while going for an appointment. These people can also offer comfort, help and coaching as and when needed.
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Herein you are gradually introduced and gently exposed to the situations or places you often have fear about. This will help in diminishing fears over a period of time.
SSRI (Selective Serotonin Reuptake Inhibitors)
Selective Serotonin and Norepinephrine Reuptake Inhibitors
Some types of antidepressants are used to treat agoraphobia. Anti-anxiety medicines are also used in a limited way to handle this condition sometimes. Among both these medications antidepressants are more effective.
Medications may take many weeks to relieve symptoms. There is no one kind of medicine which works for you or for everyone. You may have to try many kinds of medications before you can track down the medicines suitable for you.
Some kinds of herbal supplements and dietary supplements claim to have anti-anxiety benefits. You may take them after taking opinion from experts. Example – herbal supplement kava (kava kava).
Coping and support
It is difficult to live with agoraphobia. You can overcome this disorder or manage it in an efficient way with the help of professional treatment.
Strictly follow the treatment plan by –
Taking medications as directed by physician
Keep therapy appointments
Keep in touch with your therapist
Don’t avoid feared situations – Slowly practice to frequent those places and situations which scare you to mild or moderate levels. Go to more and more places.
Practice and learn calming skills – With the help of therapist or physician you can get into regular practice of Yoga, Meditation, herbal massage and visualization. These measures will help you to calm yourself and relax in a better way. With time and practice they will provide greater help. Practice them when you are in stressful situations.
Keep away from alcohol and recreational drugs – these may worsen your symptoms. You should also limit or avoid caffeine.
Lifestyle Changes / Self Care –
Eating healthy foods and well balanced diet
Including plenty of fruits and vegetables / whole grains, lean proteins in your diet
Keeping yourself physically active and exercise every day
Getting enough sleep
Regular practice of Yoga and meditation
Practice breathing exercises
Avoid alcohol, drugs and caffeine
Join a support group – This will help you in connecting with others in the group who are facing similar challenges and mutually share your experiences.
Relaxation and desensitization techniques – You will be made to imagine a scary situation and manage the feelings. Eventually with practice and as you gain confidence you will be able to take part in activities that produce anxiety. Gradually you will master the ways to manage your emotions. This therapy will train your brain to think differently over a period of time.
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Early treatment for anxiety or panic disorders will help. Treatment is easier and faster when it is started earlier. So, one should always seek medical help when gets suspicious if they are having agoraphobia. There is no cure as such but prompt treatment can relieve the symptoms to a greater extent and improve your quality of life.
About 1/3 people with agoraphobia overcome it and become symptom free. Other half of people learn to manage their symptoms in a better way but they will still have some anxiety.
Many people would need at least 12-20 weeks of CBT in spite of taking medication. When medicine is not taken CBT may take more than a year to provide agreeable relief.
Agoraphobia is frequently accompanied by panic disorder and causes considerable suffering.
A descriptive study of agoraphobic situations and correlates on panic disorder – It was found in the study that leaving home alone, being home alone, being in a crowd, and standing in line are the most common agoraphobic situations. Agoraphobia and panic disorders are poorly understood in primary mental health care systems. The screening and treating programs are needed for increasing the quality of life and early identification of these disorders. (Read more)
One study – has shown the neural effects of cognitive behavioral therapy in patients suffering from agoraphobia. (Read more)
Study – shows effectiveness of VRET (Virtual Reality Exposure Therapy) on agoraphobia and panic disorder. (Read here)
A case study suggested that agoraphobia can be a serious debilitating mental condition and gradual and patient treatment with regular follow ups can improve the patient’s condition.(Read more)
A case study – Hypnotherapy for agoraphobia
Agoraphobia Ayurveda Concept
Agoraphobia falls under the category of anxiety disorders. Bhayat Vayu – Excessive fear and panic would increase vata to blown out proportions and further lead to many diseases of body, mind or both. Agoraphobia is associated with such fears and panic attacks and treating increased vata and bringing it to a state of balance forms the main treatment strategy in Ayurveda.
The group of disorders which fall under the category of ‘anxiety disorders’ are correlated with ‘chittodvega’ explained in Ayurveda. Treatment of Chittodvega and principles of treating the mind disorders, and channels carrying the mind can be adopted in the treatment of Agoraphobia.