What is agoraphobia?
The term means a fear of public spaces. However, the disorder is more complex than that. Agoraphobia is an anxiety disorder in which individuals are driven by the fear of being trapped and overwhelmed in large, crowded buildings, or public gatherings. In order to circumvent the anxiety they use control strategies as such as standing close to an exit door, taking along someone for support and limiting the amount of time spent in the space.
Agoraphobia may start with a relatively trivial problem such as feeling nauseous for no particular reason in a train station. The thought develops that the station itself had something to do with it. From there on the individual starts to feel sick each time they enter the station, following which they become anxious over what might happen next. What starts as mild discomfort is intensified by anxious thoughts around personal safety or drawing attention to oneself, leading in time to panicky feelings. As the panic attacks get worse they start to avoid stations altogether.
As panicky feelings increase agoraphobia spreads to other sites, and the person begins to avoid public spaces altogether. However, the more they stay indoors and avoid going out, the worse their anxiety gets. This is due to the fact that running away from situations reinforces the anxious thoughts and the avoidance response. Thus leading to increasing reluctance to leave the comfort zone of the home and, in some cases, a refusal to go out altogether.
In this way the disorder creeps up almost unnoticed, until it turns into something overwhelming.
Most cases of agoraphobia start in early adulthood and are twice as likely in females as males. Some risk factors for agoraphobia are detailed below.
The causes of agoraphobia
Nearly all reported cases of agoraphobia also have panic disorder. Indeed, the problem often starts when individuals experience panicky feelings in a specific environment, such as a rock concert. Panic becomes associated with crowds, or closed spaces, and the individual develops anxious thoughts over having another episode – which becomes a self-fulfilling prophecy. Full-blown agoraphobia may however, take months, or years to develop.
Example: In the middle of a long-drawn out period of stress related to employment and financial problems, Nicole developed acute anxiety. One day, on the commute into work she experienced a severe panic attack on the Tube, which resulted in a visit to A & E. After that she experienced more panic attacks on Tube trains, and switched to using the bus. Only to find that she experienced panic on buses too. Eventually, a medical doctor signed her off on fitness leave (thereby enabling further avoidance) and she decided to hand in her notice.
As time went on she became increasingly trapped in her home as she avoided first public transport, then any large space (such as a shopping mall) where she was likely to encounter a crowd. In that way her specific anxiety over Tube train journeys was generalised into a fear of any public space. Eventually, she was only able to go out for short periods of time during off-peak hours when driven by her partner.
DSM-5 cites a prior history of anxiety as a risk factor for agoraphobia. Anxiety disorders, when untreated may escalate into panic disorder, and from there to agoraphobia. Some patients may use tranquillisers as a crutch for getting out, only to find that symptoms get worse when they come off prescription.
Surveys of individuals with agoraphobia also point to an over-protected childhood, dependency and separation anxiety as risk factors.
Signs of agoraphobia
- Dread of going out
- Procrastination over going out
- Obsessional behaviour related to safe-guarding when going out
- Racing thoughts that trigger anxiety
- Panic on going out: hyperventilation, dizziness, rapid heartbeat, feeling faint, nausea.
- Compulsion to position oneself near exits or quiet spots
- Difficulty in resisting the urge to run away
- Spending longer and longer periods at home, even when tasks have to be performed (e.g. shopping)
Agoraphobia and Depression.
Some patients develop depression related to their entrapment. As agoraphobia takes hold the individual gives up socialising and other activities outside the home. Should they give up work they may experience financial hardship and isolation. While recognising that their fears are exaggerated, they may feel powerless to overcome them. This gives rise to learned helplessness, a precursor for clinical depression. This may be accompanied by frustration, self-blame and low self-esteem.
Treatments for agoraphobia
Standard treatment programs include:
- Solution-focused therapy
- Acceptance and Commitment therapy
- Cognitive-Behaviour therapy
- Systematic Desensitisation
- Exposure therapy
Therapy aims at dismantling the three sources of agoraphobia: anxious thoughts, anxious feelings and avoidance. The length of therapy will vary according to how long the problem has persisted. The longer agoraphobia has been present the less tolerant the client will be to discomfort, and the more reluctant to leave the safe space of the home. The goal of therapy is to increase the amount of time the client spends in public space. To achieve that clients will need to learn how to tolerate discomfort.
Techniques and approaches include (links take you to articles on the blog page):
Identifying the values that motivate change (for example: going back to work, parenting, self-respect, improving relationships, etc).
Defusing from thoughts that trigger anxiety and inhibit action.
Learning how to tolerate panicky feelings.
Reducing the anxiety state through calming techniques
Behavioural activation: designing new behaviours in the unsafe space that replace avoidance. Taking the first (small) steps to rejoining life outside the safe space.
Exposure therapy: gradually increasing the amount of time clients spend outdoors, first with other people, then by themselves. This creates systematic desensitisation: the ability to tolerate discomfort, and resist the urge to leave the space.
Hypnosis is employed to create relaxation, and vivid experiences of future success linked to personal values, new thoughts, and new behaviours.
