Agoraphobia

Agoraphobia is a disabling complication of panic disorder. Although originally conceptualized as separate disorders, research suggests that panic disorder and agoraphobia actually represent a single illness. In fact, agoraphobia in the absence of panic is unusual. The term agoraphobia translates literally from Greek as “fear of the marketplace.” Although many patients with agoraphobia are uncomfortable in shops and markets, their true fear is to be separated from their source of security. Agoraphobic patients often fear having a panic attack in a public place and embarrassing themselves or having a panic attack and not being near their physician or medical clinic. They tend to avoid crowded places, such as shops, restaurants, theaters, and churches, because they feel trapped. Many have difficulty driving long distances (because they fear being away from help should a panic attack occur), crossing bridges, and driving through tunnels. Many agoraphobic patients insist on being accompanied to places they might otherwise avoid. At its most severe, agoraphobia leads many patients to become housebound. Common situations that provoke people with agoraphobia are public transport, crowding, and shopping malls. Panic disorder is prevalent among the general population between 1.5 and 3 percent. The prevalence of agoraphobia is slightly higher. Many patients, however, will report that panic attacks began after an illness, an accident, or the breakup of a relationship; developed postpartum; or occurred after taking mind-altering drugs such as lysergic acid diethylamide (LSD) or marijuana.

Panic disorder generally is treated with a combination of specific medication and individual psychotherapy. Cognitive-behavioral therapy (CBT), a form of individual psychotherapy, also appears to be effective in the treatment of panic disorder; its combination with medication may be even more powerful. CBT usually involves distraction and breathing exercises, along with education to help the patient make more appropriate attributions for distressing somatic symptoms. Patients with agoraphobia, with or without panic attacks, should receive behavior therapy. Exposure in vivo is the most effective intervention and in its most basic form may consist of gentle encouragement for patients to enter feared situations, such as shopping in a grocery store.