Agoraphobia is a medical term that refers to an anxiety disorder characterized by an unnatural fear of entering in crowded or open places. The disorder is further characterized by intense anxiety regarding being in places where escape might be difficult or where help might not be readily available when things go amiss. According to Berger & Zieve (2018), agoraphobic individuals are particularly afraid of bridges, crowds, or even being outside alone. Addressing this disorder or rather focusing on it is essential as it demonstrates the challenges that face individuals living with the disorder. In essence, a person who has agoraphobia has a limited life owing to their constant avoidance of situations or places that trigger fear or anxiety. That means avoiding social functions such as parties, family get-togethers, or even going out with friends. These individuals become closed off from the society and have to persistently deal with isolation from the community and pleasures as well as experiences they once enjoyed. As such, understanding these concepts as well as the pertinent scope of the disorder, which includes treatment, causes, and symptoms is salient in tailoring interventions for this population to improve their health outcome. Moreover, understanding the background and history of the medical condition would be materialistic in the determination of innovative interventions, especially primary prevention that could alleviate the effects of the disorder. As such, the discourse of the paper will focus on the background of agoraphobia, its causes and symptoms, its treatment (first and second generation), as well as various studies regarding treatment of the disorder.
Agoraphobia as a medical phenomenon was first coined in 1871 following the description of three males who had experienced tremendous anxiety, (Telch, Cobb, Lancaster, 2013). The primary symptoms included burning, trembling, palpitations, and heat sensations. The term agoraphobia is a derivative of two words and a combination of two languages, Greek and English. The first part agora is a Greek word that refers to an open and populated place such as the marketplace while the second part phobia is an English word that refers to fear. As such, combined, the two words form agoraphobia meaning the fear of open and populated places. Historically, the disorder and the term trace their roots to Carl Friedrich Otto who first popularized the term in 1871, (Bilcik, 2018). He achieved this through his publication of his work titled Agoraphobia: A Neuropathic Phenomenon . As such, the disorder was first witnessed in three individuals who depicted panic sensations whenever the situation of being in public was hinted to them. As Bilcik ascertains, the earliest individual as far as the records go that was first diagnosed with the disorder was Charles Darwin, a phenomenon documented in the Journal of the American Medical Association . The Journal reports that a profound part of Charles Darwin’s lifelong work on evolution was completed in isolation following his Beagle voyage, which saw him experience panic and fear while in public spaces (Bilcik, 2018).
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According to Smith (2018), there is no specific cause of agoraphobia, but the general trend is that most individuals with the disorder began to dread or fear situations which caused their first extreme panic attack or profound anxiety. Indeed, these situations often mark the genesis of agoraphobia, and it is amplified by the subsequent overwhelming worry that the situation could repeat and they may not overcome it. As such, early diagnosis of the disorder is essential to minimize damage to the individual in terms of curbing the anxiety or fear from abounding and overwhelming the patient resulting in a panic attack. In worse situations, the attacks could exacerbate sending the patient to shock or cardiac arrest.
Background and General Facts
Agoraphobia as initially discussed refers to the fear and intense anxiety of entering or accessing crowded or public spaces or places where escape and help could be difficult. For such individuals, among the public spaces, they strive to avoid include theatres, marketplaces, bridges, restaurants, and any other crowded places. The disorder is particularly ubiquitous to individuals with a panic disorder whose world shrinks and becomes uncharacteristically smaller as they constantly stand guard anticipating the next panic attack. Part of this population develops fixed routes, routines, and territories. Thus, it may become extremely tough for them to break the habit or go outside their safety zones without suffering significant anxiety attacks. In the general US population, the prevalence of agoraphobia is approximately two percent with some studies showing that the incidence is higher (10.4%) in adults older than 65 years (Yasgur 2018).
Comorbidity of agoraphobia with panic disorder has revealed a positive correlation with different categorization under the DSM-III which contends that agoraphobia with panic attacks is conceptually different from agoraphobia without panic attacks. Nonetheless, in DSM-III-R 12 the distinction was dropped but still considers agoraphobia without panic attack a distinct diagnosis Yasgur (2018). Subsequently, in DSM-5 13 , the two (panic disorder and agoraphobia) were separated again additionally demonstrating a criterion that distinguished between agoraphobia from a specific phobia. In the criteria, the different phobias include being in public transportation, being in closed-off areas, being in open spaces, being alone outside the house, among other fears.
Causes and Symptoms
As mentioned earlier in the discussion, there is no known exact cause of agoraphobia. This conundrum stems from the fact that various factors and situations trigger phobia, anxiety, as well as the panic attacks. As such, no single factor satisfactorily explains the genesis of the disorder thus making diagnosis difficult as well. Diagnosis of agoraphobia, on the other hand, is worsened by the fact that the disorder has substantial comorbidity to other anxiety disorders such as panic disorder, specific phobia, social anxiety disorder, substance use disorder, and general anxiety disorder, which fall under different categories of agoraphobia as according to DSM-5 13 . However, there are several known conventional symptoms that physicians take into consideration during the diagnosis of the disorder. These include but are not limited to
Fear of being alone or loneliness
Fear of being in places where escape could be difficult
Fear of feeling helpless
Feeling that the body is not real (Berger & Zieve, 2018).
Feeling the surrounding environment is not real, (Berger & Zieve, 2018).
Unusual agitation and temper
As well as fear of being detached or separated from others
Despite the above symptoms being conceptual and abstract, they are as well accompanied by physical symptoms. These symptoms may not all occur at the same time but together with the conceptual symptoms bring the scope of the disorder in terms of causes and symptoms to full circle. The known physical symptoms include
Sweating
Choking
Trembling
Fainting and dizziness
Stomach distress an nausea
Increased heartbeat rate
Shortness of breath
Discomfort due to chest pains
Research and Studies on Agoraphobia Treatment
In the studies regarding treatment options of agoraphobia, Dr. Pollard and Freud broke ground in illustrating the basis for the different treatment options available today. While Dr. Pollard, a psychiatric advisor and a professor at the Saint Louis University School of Medicine was a key figure in providing insight regarding the disorder, Freud described agoraphobia as a disorder that required more than just insight and as such foreshadowed the eventual treatment of choice, which is exposure (Yasgurd, 2018). Freud suggested a couple of parallel areas of research and understanding; one focused on external situations while the other focused on panic attacks, which he referred to as the epicenter of fear. In this regard, Freud contended that fear is not of the situation but rather of having an anxiety or panic attack in that specific situation.
Further research materialistic in the tailoring of interventions and treatment debunks the common misconstrued belief that agoraphobia singularly refers to the fear of going outside or that agoraphobic individuals are often homebound. Indeed, agoraphobia refers to the fear of going outside, but it also relates to other fears such as loneliness, detachments, or being at home alone. In the current treatment regimen or second generation treatment of anxiety disorders, which includes agoraphobia, randomized controlled trials have become popular within the medical field. As such, studies reveal that comorbidity of agoraphobia with MDD can be treated through RCTs of vilazodone, (Murrough, Yaqubi, Sayed, & Charney, 2015). However, even though viladozone offers positive improvements in psychic and somatic symptoms, it has greatly been linked to sexual dysfunction. Nonetheless, further studies and research needs to be conducted to ascertain this allegation. In patients with GAD, which is comorbid to agoraphobia, two RCTs of agomelatine have proven efficacious.
Treatments
Regarding first generation treatment, the first recorded treatment appeared almost fifty years ago and predated the DSM-III. According to Telch, Cobb, & Lancaster (2013) among these first generation treatments is systematic desensitization, imaginal flooding, reinforced practice, self-observation, group in-vivo flooding, and guided mastery. Systematic desensitization involved teaching patients to produce inhibitory psychological responses such as muscle relaxation to inhibit anxiety response in threatening situations. Imaginal flooding entailed exposing the patients to high levels of the imagination of frightful situations for prolonged durations. On the other hand, self-observation was introduced by Emmelkamp and colleagues referring to a technique of gradually entering feared situations. Nonetheless, if the patient experiences undue stress or anxiety, he or she is instructed to return immediately. Ultimately, self-directed exposure offers substantial therapeutic benefits through self-directed routine or practice with guidance from family members, self-help manual, and the therapist, (Telch, Cobb, & Lancaster, 2013).
Further randomized controlled trials have shown the efficacy of second-generation antipsychotics SGAs in the treatment of anxiety disorders including agoraphobia. Same trials have as well indicated the saliency of SSRIs and SNRIs in reducing the adverse effects of anxiety symptoms. Cognitive behavioral therapy has been used to help the individual challenge and impugn their anxious thoughts and thereby access their safety in public spaces or places. On the same accord, exposure therapy techniques such as self-directed exposure have as well been employed as second generation treatment options for agoraphobia where the patient gradually learns to manage their anxiety and phobia in public places or at home, (Berger & Zieve, 2018).
Furthermore, in the contemporary medical practice, peer support groups as a second-line treatment are important in aiding the patient feel less isolated thereby overcoming the fear of being alone. This concept is as well forthcoming in not only curbing but also alleviating anxiety and panic attacks. More conventional interventions include education which also serves as a preventive measure to the disorder as well as a treatment option of the disorder when coupled with another second-generation treatment. As such, through education, individuals learn the importance of gradually exposing oneself to fearful situations as well as the differential techniques of managing fear and anxiety while in frightful situations. However, educators in this field maintain the need to report panic attacks or extreme anxiety immediately to avoid exacerbation or severe consequences.
Conclusion
Agoraphobia is a medical term that refers to an anxiety disorder characterized by an unnatural fear of entering in crowded or open places. The condition and the name were first popularized in 1871 by a German physician called Westphal. The name is derived from both the reek and English dialects whereby agora is Greek for fear of open places such as the market and phobia is English for fear. The condition has no known cause, but the known symptoms include conceptual symptoms such as fear of helplessness, fear of being alone, fear of separation and detachment, fear of losing control in public, as well as feeling the body and environment are not real. Physical symptoms include chest pains, sweating, choking, shortness of breath, trembling, among others. Treatment options include first-generation treatments such as self-observation, self-directed exposure, imaginal flooding, as well as desensitization. Second generation treatments include RCTs that as well incorporate placebo, SSRIs and SNRIs, education, as well as cognitive therapy. The danger of the condition arises from its tendency to exacerbate isolation making the patient’s world smaller cutting them off from the society and community. As such, it is crucial for efforts to be focused on the treatments specified in this discourse as well as other relevant ones to improve the health outcomes of the patients.
References
Berger, F.K. & Zieve, D. (2018). Agoraphobia. MedlinePlus . Retrieved from https://medlineplus.gov/ency/article/000923.htm
Bilcik, T. (2018). What You Need to Know About Agoraphobia. ThoughtCo . Retrieved from https://www.thoughtco.com/what-is-agoraphobia-4165635
Murrough, J. W., Yaqubi, S., Sayed, S., & Charney, D. S. (2015). Emerging drugs for the treatment of anxiety. Expert opinion on emerging drugs , 20 (3), 393-406. Doi: [10.1517/14728214.2015.1049996]
Smith, K. (2018). Agoraphobia: The Fear of Entering Open or Crowded Places. Vertical Health . Retrieved from https://www.psycom.net/agoraphobia/
Telch, M.J., Cobb, A.R., & Lancaster, C.L. (2013). Agoraphobia. ResearchGate. Retrieved from https://www.researchgate.net/publication/235962391_Agoraphobia
Yasgur, B.S. (2018). Agoraphobia: An Evolving Understanding of Definitions and Treatment. Haymarket Media . Retrieved from https://www.psychiatryadvisor.com/anxiety/agoraphobia-definitions-diagnosis-management/article/747238/
