What is agoraphobia?

Published: 02-02-2020

Last modified: 29-03-2020

Agoraphobia is sometimes defined as fear of open space, but in fact it is not open space that causes fear in people who suffer from this disorder. It is a more complicated and not fully understood disorder.

People with agoraphobia are most often afraid of:

traveling by public transport
staying in open spaces, such as parking lots, bridges, squares
staying in closed places, such as shops, theaters, cinemas
standing in a queue or being in a crowd
being out of home alone

In general, these are places where escape can be difficult or embarrassing or where quick help cannot be obtained.

This disorder often occurs with panic disorder and has been diagnosed together by the American Psychiatric Association (APA) until recently. The classification of APA disorders distinguished panic disorder with agoraphobia, panic disorder without agoraphobia and agoraphobia without a history of panic disorder. Only the latest version of the classification – DSM-5, released in May 2013, treats these disorders as two separate entities.

Panic disorder

Agoraphobia often develops as a consequence of panic disorder, so to understand what agoraphobia is, you must first understand panic disorder.

This disorder is characterized by severe anxiety attacks not associated with a real threat. Panic attack begins suddenly, increases quickly, and lasts from a few minutes to two hours. It is characterized by the occurrence of four or more of the following symptoms:

increased heart beat (palpitations),
trembling or shaking,
feeling short of breath or suffocating,
feeling of choking,
chest pain or discomfort,
nausea or stomach discomfort,
feeling light-headed or dizzy,
derealization (feeling of unreality of the environment) or depersonalization (feeling of unreality of oneself, detachment from the body),
fear of losing control or becoming crazy,
fear of death,
paraesthesia (tingling, numbness),
hot or cold flush.

Panic disorder is diagnosed if there were at least several panic attacks within a month that were not the result of a real threat, medication or psychoactive substances, somatic diseases or other mental disorders. Panic disorder occurs about 2-3 times more often in women than in men and often coexists with depression and personality disorders.

The causes of panic anxiety are biological factors (the role of, among others, norepinephrine, serotonin, GABA and cholecystokinin) and psychological factors. One of the best known psychological models explaining this disorder is Clark’s Panic Model.

According to this model, panic attacks are triggered by the erroneous, catastrophic interpretation of somatic and psychological sensations. For example, a person with anxiety disorder may see a fast heart rate as a symptom of a heart attack and concentration problems as a sign of falling insane. Such misinterpretations lead to a “vicious circle” – a slight increase in blood pressure initially causes anxiety, which further raises blood pressure, which consequently increases anxiety and, as a result, causes a panic attack. During a panic attack, the patient is often convinced that he/she will soon die or go crazy, and although it never happens, attacks still occur. The reason for the persistence of panic disorder, despite objective signals, indicating incorrect interpretation of signals from the body, are protective behaviors and avoidance. Protective behavior is typical of a patient behavior during a panic attack, which, in his/her opinion, does not lead to death, craziness or other disaster. This can be, for example, deep breathing, sitting, leaning on something, taking medicine, or calling an ambulance or a loved one. Such behavior does not allow to see misinterpretation of the sensations, because the patient is convinced that his/her behavior prevented the disaster. People with panic disorder are also characterized by selective attention directed to somatic sensations. This leads to greater sensitivity to somatic symptoms, even the slightest ones that healthy people do not pay attention to. The behavior that causes panic disorder to persist is also to avoid any situations that may cause somatic symptoms and anxiety, e.g. physical activity, watching TV, or crowded places. This leads to persistent belief that if an anxiety attack occurs, its effects will be tragic.

Agoraphobia develops as a result of fear of fear (so-called anticipatory fear). For fear of having a panic attack, a person begins to avoid places where a panic attack has previously occurred, with time limiting the number of places he/she is not afraid of. People with advanced agoraphobia don’t leave home at all.

Agoraphobia without panic attacks

Little is known about people who only suffer from agoraphobia, without panic disorder. Psychologists and psychiatrists mainly come into contact with people who have both of these disorders. Those who only suffer from agoraphobia rarely use the help of a specialist.

What persons with agoraphobia may be afraid of is some signs of panic attack. Although they do not have full and frequent panic attacks that allow them to diagnose panic disorder, they may be afraid of e.g. dizziness or diarrhea. However, there is a group of people who show signs of agoraphobia even though they have never experienced any symptoms of a panic attack. However, there is little research on such people, so it is not known what actually causes them anxiety. It is possible that the mechanism of this disorder in such people is completely different than in people who previously had symptoms of a panic attack.

References:

Hackmann, A. (2007). Agoraphobia: clinical features and treatment strategies. Psychiatry, 6 (6), 254-257
Taylor, S., Asmundson, G., Wald, J. (2007). Psychopathology of panic disorder. Psychiatry, 6 (5), 188-192.
Wittchen, H. (2010). Agoraphobia: A review of the diagnostic classificatory position and criteria. Depression and Anxiety, 27, 113-133 (pdf na dsm5.org)
Wojtas, A., Jakuszkowiak-Wojten, K. (2010). Terapia lęku panicznego w ujęciu poznawczo-behawioralnym. Psychiatria 7 (6), 227?233. (pdf na viamedica.pl)
American Psychiatric Association: Highlights of Changes from DSM-IV-TR to DSM-5 (pdf na dsm5.org)
Domański, C. W. Zakładnicy lęku. Charaktery, 6/2014
AnxietyBC – Agoraphobia (pdf)
Counselling Resource – Agoraphobia Without History of Panic Disorder: Symptoms
Psychcentral – Agoraphobia Symptoms
Wikipedia – Agoraphobia