agoraphobia

Agoraphobia is an anxiety disorder characterized by anxiety in situations where the sufferer perceives certain environments as dangerous or uncomfortable, often due to the environment's vast openness or crowdedness. These situations include, but are not limited to, wide-open spaces, as well as uncontrollable social situations such as the possibility of being met in shopping malls, airports, and on bridges. Agoraphobia is defined within the DSM-IV TR as a subset of panic disorder, involving the fear of incurring a panic attack in those environments. In the DSM-5, however, Agoraphobia is classified as being separate to panic disorder. The sufferer may go to great lengths to avoid those situations, in severe cases becoming unable to leave their home or safe haven.
Although mostly thought to be a fear of public places, it is now believed that agoraphobia develops as a complication of panic attacks. However, there is evidence that the implied one-way causal relationship between spontaneous panic attacks and agoraphobia in DSM-IV may be incorrect. Onset is usually between ages 20 and 40 years and more common in women. Approximately 3.2 million, or about 2.2%, of adults in the US between the ages of 18 and 54, suffer from agoraphobia. Agoraphobia can account for approximately 60% of phobias. Studies have shown two different age groups at first onset: early to mid twenties, and early thirties.
In response to a traumatic event, anxiety may interrupt the formation of memories and disrupt the learning processes, resulting in dissociation. Depersonalization and derealisation are other dissociative methods of withdrawing from anxiety.
Standardized tools such as Panic and Agoraphobia Scale can be used to measure agoraphobia and panic attacks severity and monitor treatment.

Agoraphobia is a condition where the sufferer becomes anxious in environments that are unfamiliar or where he or she perceives that they have little control. Triggers for this anxiety may include wide open spaces, crowds, or traveling . Agoraphobia is often, but not always, compounded by a fear of social embarrassment, as the agoraphobic fears the onset of a panic attack and appearing distraught in public. This is also sometimes called 'social agoraphobia' which may be a type of social anxiety disorder also sometimes called "social phobia".
Not all agoraphobia is social in nature, however. Some agoraphobics have a fear of open spaces. Agoraphobia is also defined as "a fear, sometimes terrifying, by those who have experienced one or more panic attacks". In these cases, the sufferer is fearful of a particular place because they have experienced a panic attack at the same location in a previous time. Fearing the onset of another panic attack, the sufferer is fearful or even avoids the location. Some refuse to leave their home even in medical emergencies because the fear of being outside of their comfort area is too great.
The sufferer can sometimes go to great lengths to avoid the locations where they have experienced the onset of a panic attack. Agoraphobia, as described in this manner, is actually a symptom professionals check for when making a diagnosis of panic disorder. Other syndromes like obsessive compulsive disorder or post traumatic stress disorder can also cause agoraphobia. Essentially, any irrational fear that keeps one from going outside can cause the syndrome.[12]
It is not uncommon for agoraphobics to also suffer from temporary separation anxiety disorder when certain other individuals of the household depart from the residence temporarily, such as a parent or spouse, or when the agoraphobic is left home alone. Such temporary conditions can result in an increase in anxiety or a panic attack or feel the need to separate themselves from family or maybe friends.
Another common associative disorder of agoraphobia is necrophobia, the fear of death. The anxiety level of agoraphobics often increases when dwelling upon the idea of eventually dying, which they may consciously or unconsciously associate with being the ultimate separation from their mortal emotional comfort and safety zones and loved ones, even for those who may otherwise spiritually believe in some form of divine afterlife existence.
Agoraphobia occurs about twice as commonly among women as it does in men.The gender difference may be attributable to several factors: social-cultural traditions that encourage, or permit, the greater expression of avoidant coping strategies by women, women perhaps being more likely to seek help and therefore be diagnosed; men being more likely to abuse alcohol in reaction to anxiety and be diagnosed as an alcoholic. Research has not yet produced a single clear explanation for the gender difference in agoraphobia. Although the exact causes of agoraphobia are currently unknown, some clinicians who have treated or attempted to treat agoraphobia offer plausible hypotheses. The condition has been linked to the presence of other anxiety disorders, a stressful environment or substance abuse.
Research has uncovered a linkage between agoraphobia and difficulties with spatial orientation. Individuals without agoraphobia are able to maintain balance by combining information from their vestibular system, their visual system and their proprioceptive sense. A disproportionate number of agoraphobics have weak vestibular function and consequently rely more on visual or tactile signals. They may become disoriented when visual cues are sparse (as in wide open spaces) or overwhelming. Likewise, they may be confused by sloping or irregular surfaces. In a virtual reality study, agoraphobics showed impaired processing of changing audiovisual data in comparison with non-suffering subjects. Exposure treatment can provide lasting relief to the majority of patients with panic disorder and agoraphobia. Disappearance of residual and subclinical agoraphobic avoidance, and not simply of panic attacks, should be the aim of exposure therapy. Similarly, Systematic desensitizationmay also be used. Many patients can deal with exposure easier if they are in the company of a friend they can rely on.It is vital that patients remain in the situation until anxiety has abated because if they leave the situation the phobic response will not decrease and it may even rise.
Cognitive restructuring has also proved useful in treating agoraphobia. This treatment involves coaching a participant through a dianoetic discussion, with the intent of replacing irrational, counterproductive beliefs with more factual and beneficial ones.
Relaxation techniques are often useful skills for the agoraphobic to develop, as they can be used to stop or prevent symptoms of anxiety and panic. Anti-depressant medications most commonly used to treat anxiety disorders are mainly in the SSRI class and include sertraline, paroxetine and fluoxetine. Benzodiazepine tranquilizers, MAO inhibitors and tricyclic antidepressants are also commonly prescribed for treatment of agoraphobia. Antidepressants are important because some have antipanic effects.Antidepressants should be used in conjunction with exposure as a form of self-help or with cognitive behaviour therapy.Some evidence shows that a combination of medication and cognitive behaviour therapy is the most effective treatment for agoraphobia. Eye movement desensitization and reprogramming (EMDR) has been studied as a possible treatment for agoraphobia, with poor results.[34] As such, EMDR is only recommended in cases where cognitive-behavioral approaches have proven ineffective or in cases where agoraphobia has developed following trauma.
Many people with anxiety disorders benefit from joining a self-help or support group. Sharing problems and achievements with others as well as sharing various self-help tools are common activities in these groups. In particular stress management techniques and various kinds of meditation practices as well as visualization techniques can help people with anxiety disorders calm themselves and may enhance the effects of therapy. So can service to others which can distract from the self-absorption that tends to go with anxiety problems. There is also preliminary evidence that aerobic exercise may have a calming effect. Since caffeine, certain illicit drugs, and even some over-the-counter cold medications can aggravate the symptoms of anxiety disorders, they should be avoided.