Understanding Agoraphobia: Fear, Causes, and Impact

The protagonist Mehak, in the Indian psychological thriller Phobia, experiences an overwhelming and crippling fear at the mere thought of stepping outside her house. This might feel overly dramatic and fictional for people who are watching. However, this is a reality for millions of people around the world.

Phobia sheds light on Agoraphobia, which is a type of anxiety disorder characterised by an intense fear of crowded spaces or situations where an escape might be very difficult for the individual. About 1.6% of the population in India is diagnosed with agoraphobia. While on the other hand, 1.3% of people will experience agoraphobia once in their lifetime.

Even though media representation of phobias, particularly agoraphobia, has prompted discussions regarding it in India. Still, it is one of the most misunderstood conditions. Hence, in this article, we will cover what exactly is agoraphobia and why it is becoming relevant in today’s world.

What is Agoraphobia

Agoraphobia, as defined by the Diagnostic and Statistical Manual of Mental Disorders, refers to the crippling and intense fear of situations where an escape might be difficult, or help might not be available. People who have Agoraphobia tend to be very avoidant of crowded spaces, travelling alone, or even leaving their homes. This avoidance tends to limit their ability to engage in everyday activities.

This intense fear of even going out of your house can elicit symptoms across physical, emotional and psychological aspects. Individuals might experience dizziness, palpitation, and sweating. They might also experience psychological symptoms, such as persistent worry about countering such situations where escape might be difficult, which can lead to avoidant behaviour.

One of the most common misconceptions about agoraphobia is that it is the phobia of open space. However, this is not the entire truth. Agoraphobia involves a wide range of fears that are related to situations where an escape might be difficult, or help might not be available. Hence, this could include fear of using public transport, being in enclosed or open spaces, standing in front of a crowd or being outside of the house alone.

Causes of Agoraphobia

Agoraphobia is caused by a wide range of factors. This includes ;

1. Experiencing Trauma: Those who went through dramatic events, such as accidents, physical or sexual assault or natural disasters, tend to have a higher likelihood of developing an agoraphobia. For individuals who have faced trauma, they are usually fearful of being in a situation where they might feel trapped, or unable to escape. For example, someone who has experienced a violent attack in public parks may begin to avoid not only public parks but also various other spaces. This can become generalised to other areas of their lives, as well as making it difficult for them to even leave their house without the feeling of overwhelming anxiety.
2. Social Isolation: Since the COVID-19 pandemic, we have experienced an increase in the risk of developing agoraphobia. The lockdown forced individuals to stay in their houses for extended periods. While this isolation was necessary for public health, it created a new anxiety about going outside. This isolation or the lockdown period also tends to reinforce the fear people already had about being in public or in open spaces.
3. Life Stressors: Life events, such as the death of a loved one, financial hardship or loss of a job. All these factors can increase the likelihood of an individual developing agoraphobia. These life stressors often lead to a heightened state of arousal or hypervigilance. This tends to make the individual more sensitive to their surroundings.

Comorbidities

Agoraphobia Is also related to an increased likelihood of developing disorders, such as major depressive disorder (MDD), persistent depressive disorder (PDD) and substance use disorder. An agoraphobia frequently causes co-occurs with major depressive disorders. The feeling of isolation and avoidance behaviour, which is characteristic of agoraphobia, can also foster feelings of hopelessness, sadness, and despair.

Daily activities such as working or socialising are important for one’s well-being and sense of purpose. When a person with Agoraphobia tends to lack engagement in activities and people around them, it can increase feelings of worthlessness, guilt and hopelessness. Agoraphobia is also comorbid with persistent depressive disorder, which is characterised by chronic feelings of depression, which is persistent for at least two years. Due to the chronic nature of persistent depressive disorder, its prognosis tends to be worse than MDD.

People with Agoraphobia often tend to turn towards alcohol, drugs, or other substances as a way to cope with their intense anxiety. Depressants, such as alcohol or opioids, can reduce the anxiety response, making it easier for people with agoraphobia to manage their anxiety or panic attacks. However, this offer leads to dependency on the substance. Moreover, substance use can also worsen the symptoms of anxiety as well as depression, which we have already discussed is also comorbid with agoraphobia.

Impact on standard of life

Agoraphobia tends to affect every aspect of the individual’s life. From workspace to family, to friends and to personal life, it has detrimental effects on each of these areas. Agoraphobia tends to avoid shopping malls or getting onto public transport, which can negatively impact their daily functioning. Avoiding such places makes it almost impossible for them to engage in simple tasks, such as grocery shopping, running errands or attending social events.

Agoraphobia also tends to affect the professional life of an individual. As most of the job requires individuals to step out of their houses and interact with other people, this makes it very difficult for individuals with agoraphobia to maintain a job. Taking transportation to work, attending meetings, or even performing work-related tasks can be very daunting for them. The inability to sustain a job can often lead to financial instability, which again becomes another source of anxiety.

Agoraphobia tends to limit the frequency the individual goes out of their house or socially engages with people, which naturally leads to strained relationships with family and friends. This often leads to feelings of isolation and a lack of supportive networks.

Agoraphobia impacts the individual’s daily functioning, professional life and relationships with other people. However, proper treatment and gradual desensitisation from the field environment and surroundings can help individuals regain control of their lives and manage their anxiety.

Treatments

Treatment for agoraphobia often involves a combination of psychotherapy medication and sometimes a combination of both.

1. Psychotherapy

Most often, Cognitive Behaviour Therapy (CBT) and Exposure Therapy are considered the most effective treatment for agoraphobia. In CBT, the therapist helps the client to identify and challenge their negative and maladaptive thought patterns, which contribute to and reinforce their anxiety. In the context of agoraphobia, the therapist might aim at the thought patterns or beliefs that lead to avoidant behaviour.

CBT can also help the clients to find more adaptive and effective coping mechanisms to manage their anxiety related to the fear situations. Rather than opting for using alcohol, drugs, self-harm, etc, clients are encouraged to use more adaptive coping mechanisms, such as relaxation techniques and mindfulness exercises.

Exposure therapy is also often used to treat agoraphobia. In this, the client is exposed gradually and slowly to their fear, situation or object in a controlled manner and under the surveillance of the therapist. This desensitisation process helps to reduce the avoidant behaviour.

Both real-life exposure to situations and visualising the fear of situations can be used here. Over time as the individual becomes desensitised to the fear situation, at least to reduction in their avoidant behaviour, as well as the anxiety or worry that they experience.

2. Medication

Medications as a treatment method are also adopted for individuals with agoraphobia who tend to have very severe or extreme symptoms. Most of the time, the medications are prescribed in combination with the therapy.

The most commonly prescribed medicines for managing symptoms of agoraphobia include Zoloft, Prozac and Lexapro. All these medicines are classified under the category of selective serotonin reuptake inhibitors. These drugs tend to increase the amount of serotonin that is present in the brain. Xanax or Klonopin, which are categorised under benzodiazepines, are also used as a relief from anxiety.

The most effective approach for the treatment of moderate to severe cases of agoraphobia tends to be a combination of psychotherapy and pharmaceuticals. Combining therapeutic methodologies such as CBT and exposure therapy with the use of antidepressants tends to yield a better outcome rather than considering either of the treatments alone.

Conclusion

Agoraphobia is a very debilitating anxiety disorder. It included the crippling fear of situations where an espace might be difficult. People who experience this usually avoid going to open or enclosed spaces or using public transport and also avoid going to places unaccompanied. Agoraphobia tends to affect an individual’s interpersonal, professional and personal life. It greatly impacts their daily functioning. However, with proper psychotherapy and sometimes medications, the symptoms can be reduced to a great extent and the person is capable of living a well-adjusted and effective life.