For a majority of the population, each day begins with the routine of maneuvering through the outside world--through crowds of people on public transit, in elevators, in schools and colleges, and in stores. For a smaller portion of the population, each day begins with fear, dread and potentially panicky symptoms—and the inability to get onto that bus, into that subway car, or into that grocery store.
For those individuals, agoraphobia is derailing their lives.
In her article published by Psychiatry Advisor this week, counselor and writer Batya Swift Yasgur provided a definition of the phobia taken from a 2010 study into anxiety disorders by O.J. Bienvenu et al. She wrote, “Agoraphobia can be defined as ‘irrational or disproportionate fear of a range of situations in which a person believes escape or access to help may be impossible.’”
According to Yasgur’s research looking at the American general population, the frequency with which agoraphobia may occur over a lifetime stands at about two percent, although one study suggested a higher incidence in adults over age 65—at 10.4 percent. Still, the “average age of onset is actually between ages 25 and 30 years,” she wrote. And the phobia is more “disabling in women” and occurs twice as often in them than in men.
Considering the prevalence of agoraphobia in the population, Yasgur described it as a phobia that continues to often be “misunderstood”, but medical science’s understanding of it--and of the best treatments for it—continues to evolve.
In an interview with Psychiatry Advisor, C. Alec Pollard, Ph.D., professor emeritus of family and community medicine at Saint Louis University School of Medicine, and Mark H. Pollack, director of the Center for OCD and Anxiety-Related Disorders at the Saint Louis Behavioral Medicine Institute explained that “a common misconception is that agoraphobia necessarily means fear of going outside or that individuals with [it] are usually housebound”.
According to Pollard, famed psychoanalyst Sigmund Freud’s idea of exposure was the precursor to one of the two current “trajectories of research and understanding” of the phobia. Following Freud’s idea, behavioral therapists now suggest Cognitive Behavioral Therapy (CBT), wrote Pollard, “working with exposure therapy and having people gradually face their phobias . . . [in] the external situation . . . going to the mall, being in crowds, . . . one step at a time.”
The second trajectory of understanding focused on panic attacks “which were often the center of the fear,” Pollard said. For individuals with agoraphobia, the actual fear tends not to be of the situation, “but of having a panic attack in that particular situation”.
The result of the two paths of understanding have led to agoraphobia recently being reframed as a “fear of fear”, wrote Yasgur. Pollard explained that the medical focus is on “stopping the panic attacks” with “an array of pharmacotherapies”. The CBT aims to “help patients become less afraid of [panic attacks] because when a person becomes less afraid, he or she has fewer attacks,” he said.
In the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5)—the official guide to the diagnosis of mental health—Agoraphobia and panic disorders are separated, in keeping with ongoing changes to the understanding of the phobia, wrote Yasgur.
The DSM-5 lists the latest criteria for Agoraphobia as : “Intense fear or anxiety prompted by the actual or predicted exposure to two or more of the following situations: using public transportation; being in open areas; being in closed-off areas; standing in line or [in] a crowd; [and] being alone outside of the house.”
In keeping with the understanding that Agoraphobia is a “fear of fear”, those with the phobia will avoid the listed situations “because [they] believe they may become stuck or help might be unavailable in the event that the individual begins to panic,” Yasgur added.
"Agoraphobia involves the fear of some type of attack that can come out of the blue,” Dr. Mark Pollack explained. While panic attacks tend to be unexpected, individuals do not worry about the symptoms when they occur. By contrast, he said, individuals with agoraphobia do not “know why the panic attack suddenly came on . . . [and] worry that they are losing control or having a heart attack.”
With agoraphobia, sufferers are actually not afraid of the setting (school, store, bus), but they “become afraid of having an attack in [the setting] and begin to avoid going,” Pollack clarified.
Like the evolving understanding of the disorder, successful treatment of agoraphobia is also changing, wrote Yasgur. “The most well-researched psychotherapeutic approach is CBT with clinical gains maintained at two-year follow-up,” she said.
And although a combination of CBT and pharmacotherapy has been found to be the best treatment during the disorder’s “acute” phase, Pollack acknowledged that over time, CBT proved better than medication, “with lower rates of relapse”.
For patients who choose both medicine and CBT, Pollack said the exposure therapy can be very helpful when patients are “tapering off” of medications or when facing future stressful life events.
Bienvenu, O.J., Wuyek, L.A., Stein, M.B., (2010). U.S. Natinal Library of Medicine. Anxiety disorders diagnosis: some history and controversies. https://www.ncbi.nlm.nih.gov/pubmed/21309103
Sideman, N., (Retrieved February 28, 2018). Anxiety and Depression Association of America. How I Achieved My Cure of Panic Disorder and Agoraphobia. https://adaa.org/living-with-anxiety/personal-stories/how-i-achieved-my-cure-panic-disorder-and-agoraphobia#
Yasgur, B.S., M.A., L.S.W., (February 28, 2018). Psychiatry Advisor. Agoraphobia: An Evolving Understanding of Definitions and Treatment. https://www.psychiatryadvisor.com/anxiety/agoraphobia-definitions-diagnosis-management/article/747238/