Agoraphobia is an anxiety disorder. The origin of the word (Greek ἀγορά agorá = marketplace, φόβος phóbos = fear) refers to the fear of large places in this disorder.
In addition, there may also be a fear of crowds and traveling alone far from home.
Research assumes that biological factors and learning processes play an important role in the development of agoraphobia.
With regard to learning processes, the theory of avoidance learning by the American psychologist Mowrer is of particular importance. This means that those affected acquire fear reactions to certain stimuli.
For example, a woman argues with her husband in a crowd of people in a supermarket. She becomes anxious in the situation because he threatens to separate. From then on, all stimuli related to the topic of "crowded supermarkets" are associated with fear.
In the next step, the woman does not want to enter supermarkets in order to avoid her fear. The reduction in anxiety acts internally as a reward for avoiding the supermarket. As a result, this behavior increases in frequency.
This example illustrates the importance of learning processes for learning and unlearning agoraphobia.
In agoraphobia, people develop a fear of certain places and crowds © Jeff Bergen/peopleimages.com | AdobeStock
Those affected often state that the reason for their fears is that they are afraid they will not be able to escape from a certain situation. This can be large crowds of people, for example. They may also be afraid of fainting and not getting help.
Those affected are therefore worried that they will no longer be able to control a certain situation. They fear feeling helpless and at the mercy of others.
Agoraphobia with panic disorder
In the vast majority of cases, agoraphobia is associated with panic disorder. In these situations, a feeling of intense fear arises.
In this situation, agoraphobia patients fear that they will die acutely, e.g. from a heart attack. They assume that they are suffering from a life-threatening physical illness. This is why the patient or a relative often calls the emergency doctor. These patients are often examined in cardiology departments, for example to rule out an acute heart attack.
If the panic disorder recurs, it can lead to a long medical history of acute hospital stays with the corresponding examinations.
Those affected experience the extreme anxiety as very threatening. As a result, they develop a fear of the occurrence of these anxiety states, i.e. a fear of fear (phobophobia). They do everything they can to avoid the risk of suffering an anxiety attack. For this reason, they avoid the fear-inducing situations.
This can lead to patients no longer leaving the house.
The main elements of treatment for agoraphobia with or without panic disorder are
- psychotherapy and
- drug treatment.
The form in which the two treatment elements are used must be decided on a case-by-case basis.
In many cases, a combination of both treatment methods is chosen in practice.
Cognitive behavioral therapy for the treatment of agoraphobia
Psychotherapy is usually carried out using cognitive behavioral therapy. An important technique here is the communication of a logically comprehensible model of the development and maintenance of the disorder. The person affected recognizes that they often interpret their physical symptoms in a catastrophizing way. However, it is highly likely that completely different explanations apply.
A rapid heartbeat and shortness of breath typically occur when climbing stairs. An agoraphobia patient may interpret this as a harbinger of a heart attack. Even if repeated examinations have previously shown that the patient's heart is healthy. For this reason, the patient feels threatened by these symptoms. A vicious circle of fear takes its course.
A logical and sensible explanation in this situation would be the following: The physical symptoms are related to the fact that the body has an increased need for oxygen when exertion is increased. This has to be transported via the bloodstream. Palpitations and shortness of breath are therefore completely normal.
However, anxious patients are initially unable to explain this to themselves. Cognitive behavioral therapy suggests these rational explanations to the patient.
Exposure treatment for agoraphobia
First, an agoraphobia patient learns to recognize these irrational thoughts. The patient then counters these thoughts with other thoughts.
This involves repeated confrontation with fear-inducing situations and stimuli. The aim is to get used to these situations. As a result, the intense physical anxiety reaction diminishes over time and eventually disappears. Ultimately, the patient must learn that anxiety never disappears by avoiding an anxiety-inducing situation. It can only be combated through repeated successful coping in the context of a confrontation.
This change can be illustrated with an example. Most people would be anxious if they drove the same way by car the next day after a car accident. They fear that another accident could happen. If you drive this route again and again over the next few weeks without anything happening, the tension will soon subside.
After some time, there will be no increased tension compared to other routes because a habituation effect will have set in.
The fear would remain if the patient had not gotten back into the car after the accident.
Drug treatment for agoraphobia
The drugs(psychotropic drugs) of first choice for agoraphobia are antidepressant drugs from the group of so-called selective serotonin reuptake inhibitors (SSRIs). They are relatively well tolerated and do not cause addiction.
These include, for example, the active ingredients
- Citalopram,
- sertraline and
- paroxetine.
However, antidepressants from other drug groups can also be considered for agoraphobia. However, these often have more side effects with similar efficacy.
Caution is advised when using direct anxiolytic drugs from the benzodiazepine group (e.g. lorazepam, diazepam). They are extremely effective in the short term because they significantly reduce anxiety shortly after taking them. In the longer term, however, they lead to dependence, which is difficult to treat.
The prognosis for agoraphobia is influenced by various factors. Without treatment, agoraphobia can quickly become chronic, which can lead to considerable restrictions in everyday life. The prognosis is favorable if the disorder has not been present for very long. The patient must be prepared to face their fears.
It is unfavorable if the agoraphobia is accompanied by other illnesses. Depression or an addiction, for example, are particularly serious. Several previous unsuccessful treatments are also associated with less favorable prospects of recovery. A chronic course of agoraphobia is also associated with an increased risk of suicide.
The prognosis is also rather unfavorable if the patient has few opportunities to deal with their fears due to their social situation. An example of this would be a partnership conflict that the patient does not deal with openly because they feel financially dependent on their partner.
The patient's request for a pension also contributes to an unfavorable prognosis for recovery. In this case, the patient will not make any effort to confront their fears. This would contribute to a reduction in the chances of retirement.
A 29-year-old woman reports that after a violent argument with her long-term boyfriend, she had her first panic attack with
dizziness. The emergency doctor called by the boyfriend sends the young patient to hospital. A comprehensive medical examination including an ECG and cardiac catheterization is carried out. There were no indications of heart disease or any other physical illness.
After being discharged from hospital, the patient experiences repeated panic attacks in department stores and on a trip to visit a friend. After four weeks of repeated panic attacks, the patient feels unable to leave the house alone. She now only runs errands with her boyfriend. She is unable to continue working as a clerk in an insurance company and is put on sick leave.
After a detailed discussion with her GP, the patient consults a psychological psychotherapist. She begins outpatient behavioral therapy with her. During the therapy, she learns to confront her fears. She recognizes the connection between her agoraphobia and her fears of separation and loss.
After 25 hours of outpatient behavioral therapy, she is able to face the previously avoided situations again. In the further course of therapy, the partnership problem is dealt with intensively.
In the end, the patient breaks up with her boyfriend. She realizes that she has no common goals and future prospects with her boyfriend. In particular, her desire for a family and children remains unfulfilled.
One year after the symptoms first appeared, the patient is symptom-free. She faces up to all anxiety-inducing situations. She reports that she is less afraid of conflicts than before the therapy.
