Agoraphobia (which comes from the Greek for ‘marketplace phobia’), is an anxiety disorder which is caused by a fear of open public spaces. In many cases the fear is actually of having a panic attack in public where there is no easy escape and where the occurrence could be a source of embarrassment or humiliation (though there are other agoraphobia causes that lead to it, and it can be closely linked to other phobias). The irony here obviously is that the fear of a panic attack is vastly increased through such a concern creating a vicious circle.
Agoraphobia symptoms then include sweating, shaking and severe nervousness when in large open spaces, particularly when they are densely crowded and/or when there are no potential ‘hiding places’. Common places to cause this phobic reaction are airports, shopping malls and airports. In many cases however agoraphobia symptoms can go unnoticed as sufferers construct elaborate excuses and strategies to stay indoors without arousing suspicion.
Diagnosis of agoraphobia normally takes place after the onset of a panic disorder and uses the DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorders) diagnostic criteria and agoraphobia symptoms displayed by the patient. The three diagnostic criteria of the DSM-IV are that the patient displays anxiety about being in places or situations where escape could be difficult or embarrassing, that they attempt to avoid the situation or show marked distress in enduring it, and finally that the symptoms could not be better explained by another condition. This however may focus too heavily on the social aspect of the condition, where agoraphobia may also stem from fear of being attacked or falling over.
Agoraphobia occurs twice as commonly in women as it does in men. This could be a result of social-cultural factors that allow women to use avoidant coping strategies when men might be frowned upon for acting fearfully. It is thought that women are more likely to engage in ‘helpless’ behaviours whereas men would turn to alcohol or other independent measures due to traditional gender roles. Another suggestion is that women are simply more commonly diagnosed with the problem; not that it is more prevalent (for similar reasons to those mentioned above). As IQ tests show females to demonstrate more empathy than males, it could also be that they are more sensitive to the derision of others.
Agoraphobia has also been linked to substance abuse and stressful living environments. Chronic use of sleeping pills and benzodiazepines has been demonstrated to cause patients to develop agoraphobia symptoms. After benzodiazepine dependency is treated however these symptoms gradually subside suggesting a link between the mechanisms of benzodiazepines. Another link has been found between agoraphobia and spatial orientation and one of the lesser known agoraphobia symptoms has been shown to be difficulty balancing and correlating input from their vestibular and visual systems (the vestibular system being the process by which we asses our orientation based on tiny hair follicles in the ears).
Many agoraphobia causes have been suggested but no one cause has been conclusively linked to the condition. One suggested cause of agoraphobia comes from attachment theory, a psychological theory that looks at the attachment of infants to their PMGs (Primary Care Givers) in early childhood and how this can affect their personalities in later life. This is thought to be based on various factors affecting the relationship between children and their parents. The type of attachment is then classified as one of several types. In dependent attachments, the infant is insecure in their relationship and can’t endure being left by the care giver for long periods of time. As the individual grows older then, it is thought that the ‘base’ or home might take the place of the care giver leading the adult to avoid leaving their home or secure environment for long periods of time. This theory demonstrates the weakness in the DSM-IV-TR diagnostic criteria in focussing solely on the feeling of embarrassment associated with panic attacks in public locations. At the same time those criteria demonstrate a weakness in this theory for ignoring that aspect.
On the other end of the spectrum, spatial theories look at the role of the environment in causing agoraphobia. As such many social scientists have postulated that agoraphobia may be a result of modernity and have looked into better design for public spaces. It is likely however that these two agoraphobia causes are only a small part of the larger picture and that other elements such as the personality of the patient and their brain chemistry also plays a role. This is supported by the links to benzodiazepine dependency and spatial difficulties.
Treatments for agoraphobia symptoms fall into several categories, those being exposure treatment, cognitive restructuring, relaxation techniques and psychopharmaceutical treatments. The first three of these methods are cognitive behavioural treatments from CBT or cognitive behavioural therapy which is currently the predominant form of therapy. Here the main agoraphobia causes are thought to be the ‘faulty’ thought patterns such as ‘if I have a panic attack everyone will think I’m an idiot’ as well as through classical conditioning, whereby unhealthy associations are developed, such as associating crowded spaces with fearful and unpleasant feelings.
In exposure treatment then the patient is taught not to have these associations anymore by being slowly subjected to larger and larger and more and more crowded spaces so they realise they’re okay. Meanwhile in cognitive restructuring they are taught to pay attention to the content of their thoughts through meditation and ‘mindfulness’ (where they watch their thoughts pass ‘like clouds’) and then to replace them with alternative positive thoughts such as ‘if I have a panic attack there are people here who will help me and they’ll realise I have a medical condition’. Finally CBT will teach patients relaxation techniques using biofeedback (to monitor their heart rate) and again meditation which will help them to calm themselves down when they notice their agoraphobia symptoms arising.
Psychopharmaceutical treatments then should be the last port of call for patients who fail to respond to cognitive behavioural therapy and for extreme cases where the patient can no longer live a normal life. The main medications prescribed are anti-depressants from the SSRI class (selective serotonin reuptake inhibitors) which leave more of the ‘feel good’ serotonin hormone in the brain. These include sertaline, paroxetine and fluoxetine. Benzodiazepines are also prescribes which can be dangerous seeing as the drugs themselves have actually been linked to agoraphobia themselves. This is a good example of why anti-depressants should be left out of the equation where possible as they could in fact exacerbate the problem rather than alleviating it. Furthermore, while anti-depressants will treat the agoraphobia symptoms they are not curative and can cause other side effects themselves.