Fear of feeling trapped, helpless or embarrassed – Agoraphobia

What is Agoraphobia

This is a cluster of phobias like leaving home, shops, crowds, public places, travel by train, bus or plane, with accompanying dizziness (not vertigo), faintness and sense of losing control. The fear worsens if it is hard to make a dignified escape from wherever panic strikes. In addition, non-phobic anxiety, panics and depression are common, as are day-to-day fluctuations of intensity of the agoraphobia. Agoraphobia is more common in women than men. It starts mostly in young adult life and can persist for years or decades, though a third had remitted at 11-year follow-up.

Onset and Course of Agoraphobia

The onset of agoraphobia can be sudden within minutes, or gradual over weeks, or slowly over years after initial vague intermittent anxiety. Some people start with an acute sustained panic, followed by phobias confining them to their homes within a few weeks. Others begin with vague fluctuating anxiety that gradually becomes agoraphobic over many years. Many feel uneasy for decades about going about alone but dextrously manage to hide their fears until the fear increases rapidly in new situations, when they seek help because the family cannot cope any longer. All kinds of variations appear between these two extremes. Agoraphobia may clear up after a few weeks or months without treatment.

Other sufferers may progress slowly or rapidly to severe disability with loss of job and becoming housebound for decades. For example, a woman aged 18 suddenly came home one day from work and screamed she was going to die. She spent the next two weeks in bed and thereafter refused to walk beyond the front gate of her home. She did not improve after four months in a psychiatric hospital and after discharge left her home only twice in the next seven years. She spent her time gossiping with neighbours, listening to the radio, and with a boyfriend by whom she had a child at age 27, though she continued to live with her mother.

From age 32 until last seen at 36 she improved slowly and became able to go on short bus rides and shopping expeditions. Although she had wet and soiled her bed until age 12, before her phobias started she was a good mixer, had many friends, and often went dancing. She was sexually cold until age 32, after which she had normal orgasm with her boyfriend.

By way of contrast, agoraphobia developed very gradually in a young woman of 17. She slowly developed fears of leaving home at 17, which improved at 20 when she had psychiatric treatment. They became more marked after she gave birth, at 26, to a son, when she became afraid of meeting people and of getting lost in a crowd.

For the next two years she was limited to travelling by bike or car to her mother’s home a mile away, and thereafter did not go beyond her own home and stopped shopping. She improved when admitted to hospital at age 29, became pregnant after discharge, and improved a bit more after her second child was born. For the next six years, until last seen, she only did local shopping, fetched her child from school, and went out with her husband. She had always been a shy, dependent person dominated by her mother.

Panics in Agoraphobia

Some agoraphobia starts with repeated episodes of panic away from home. The panic can become so intense that the sufferer is glued to the spot for minutes until it diminishes, after which he/she may just want to run to a safe haven—a friend or home. The panic may go on for a few minutes to several hours. Once it is over the sufferer may be reluctant to return to the scene of the panic.

In other cases the panic can pass, leaving the person feeling as fit as before, and many months may go by before another panic strikes. Panic episodes can be followed by periods of normal activity, and a succession of panics may occur for years. Such episodes may lead to consultation with a doctor, who will find nothing abnormal except for signs of anxiety. Eventually the agoraphobic will begin to avoid certain situations for fear they might precipitate further panic.

Because he cannot get off an express train immediately a panic starts, he restricts himself to slow trains; when these too become the setting for panic, he restricts himself to buses, then to walking, then just to walking across the street from home; finally he will not venture beyond the front gate without a companion. Rarely, he may become bedridden for a while, as bed is the only place where the anxiety feels bearable. Typically agoraphobics have periods when they feel better and times when they feel worse.

Differential Diagnosis

Conditions with which agoraphobia might be confused are discussed below roughly in the order of the frequency with which they might present.

. Social phobia. Social phobics tend to hate being looked at even by another person, whereas agoraphobics fear crowds rather than scrutiny from individuals per se. Social phobics feel fine in deserted public transport, 18  PHOBIAS whereas agoraphobics might be as phobic in a deserted train or bus as in crowded public transport. A minority of sufferers have both agoraphobia and social phobia.

Depression. Episodes of mild to moderate non-suicidal depression commonly accompany more enduring agoraphobia in cases consulting psychiatrists, and may merit a diagnosis of depression as well as agoraphobia. If the agoraphobic symptoms wax and wane with the depression and are absent between the episodes of low mood, then one diagnoses only depression. .

Panic disorder (panic disorder without agoraphobia). In this diagnosis the panics are not triggered by any particular cues, so there is no fear or avoidance of agoraphobic situations. .

Sphincteric phobia. A phobia of leaving home similar to that of agoraphobia is seen in people who fear urinating or defecating in public toilets or fear the opposite of being ‘‘caught short’’ and becoming incontinent when far from a toilet. These ‘‘sphincteric phobics’’ [19] do not have other agoraphobic fears that are the hallmark of agoraphobia or the generalized anxiety, uncued panic and non-suicidal depression that are common in agoraphobia. .

Dysmorphophobia (body dysmorphic disorder). Leaving home may be shunned by people who think inconsolably that they look grotesque or smell bad, contrary to all the evidence. The diagnosis is made from the presence of distorted ideas about their body. . Post-traumatic stress disorder. Leaving home or going to certain places or using certain forms of transport might be avoided after an accident or rape or other trauma people have suffered. The diagnosis of posttraumatic stress disorder depends on the fact that the sufferer fears situations mainly related to the trauma and had no such fears before the trauma occurred. .

Depersonalization–derealization syndrome. Here the sense that one is unreal or things around one are unreal is the main focus of the complaint rather than an incidental symptom among other major agoraphobic complaints. .

Obsessive–compulsive disorder. If the subject avoids leaving home alone or crowds or shops or public transport because these situations lead to urges to engage in washing, checking or other rituals, this earns a diagnosis of OCD, not of agoraphobia. .

Space phobia. See above (p. 12). .

Paranoid syndromes. People with paranoid delusions from any cause might stop leaving home for fear of persecution. The diagnosis is made from the fact that the sufferer is housebound due to paranoid feelings rather than because going out triggers inexplicable fear, panic, sense of losing control etc.

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