Agoraphobia

Julia Dobmeier is currently completing her master's degree in clinical psychology. Since the beginning of her studies, she has been particularly interested in the treatment and research of mental illnesses. In doing so, they are particularly motivated by the idea of ​​enabling those affected to enjoy a higher quality of life by conveying knowledge in a way that is easy to understand.

More about the experts All content is checked by medical journalists.

People with agoraphobia are terrified of situations from which they will find it difficult to escape in an emergency or from which help will be difficult to obtain. You therefore avoid wide squares, crowds, cinemas, buses or elevators, among other things. Many experience threatening physical symptoms such as palpitations and dizziness in a fearful environment. Over time, fear increasingly determines their life. Read how agoraphobia develops, how it affects and how to treat it.

ICD codes for this disease: ICD codes are internationally recognized codes for medical diagnoses. They can be found, for example, in doctor's letters or on certificates of incapacity for work. F40

Agoraphobia: description

The term agoraphobia is derived from the Greek. The terms "agora" = "marketplace" and "phobia" = "fear" indicate that people with agoraphobia are afraid of public places. Agoraphobia is therefore also referred to as "claustrophobia". This is often confused with the fear of space (claustrophobia), which describes the fear of narrow and closed spaces, and which belongs to the so-called specific phobias.

Agoraphobia can also occur in confined spaces. However, those affected do not fear the crampedness or closedness of the room itself. They are afraid that in an emergency they will not be able to flee from there or that they will not receive any help. They also try to avoid situations where withdrawal due to an anxiety attack would be embarrassing - for example, during a theater performance. When entering a public space, they always try to be near an exit.

Unlike many other anxiety disorders, agoraphobia is not related to a specific situation or object. It can appear in very different places, such as in the cinema, on the bus or on bridges. Without therapeutic help, agoraphobia leads to a severe reduction in the quality of life. Some no longer dare to go outside at all or need someone to accompany them and always have their medication and a cell phone with them in an emergency.

Agoraphobia and panic disorder

Agoraphobia occurs very often in combination with panic attacks. Around 35 to 56 percent of patients suffer from agoraphobia with panic disorder. Panic attacks are violent anxiety attacks that usually last a few minutes. Those affected experience it as extremely threatening because, in addition to the psychological symptoms, severe physical complaints also occur. These include rapid heart palpitations, sweating, dizziness, and many other symptoms that patients rate as life-threatening. The fear increases more and more.

"Fear of fear"

A central feature of agoraphobia is that those affected are afraid of possible panic attacks or anxiety in public. This phenomenon is known as "fear of fear" or "phobophobia". The fear is mostly confirmed because the fear of fear triggers physical tension. Those affected pay close attention to the slightest physical changes that could indicate a panic attack and are overly anxious. In the interplay of psyche and body, such strong fear or even a panic attack can arise.

For fear of uncertain situations, those affected plan appointments or events down to the smallest detail. All that pondering and worrying beforehand is at least as excruciating for them, if not worse, than the actual situation.

How many are affected?

Anxiety disorders are common. About four percent of the population will suffer from agoraphobia at least once in their life. Women are three times as likely to be affected as men. The onset of the mental disorder lies in late adolescence or young adulthood.

Very few patients suffer from pure agoraphobia. Many also develop other anxiety disorders, but also depression, alcohol addictions and personality disorders.

Agoraphobia: symptoms

For the diagnosis of agoraphobia, those affected must show certain symptoms according to the ICD-10 classification of mental disorders.

As a main criterion, they must avoid or strongly and persistently fear at least two of the following situations:

• Crowds
• Public places
• Travel alone
• Traveling far from home

In addition, at least two of the following physical or psychological anxiety symptoms must be present, which also occur together.

Physical symptoms

People with agoraphobia always have one or more of the following symptoms:

• Palpitations, increased heart rate
• Sweats
• Tremble
• Dry mouth

Common chest and abdominal complaints are:

• Difficulty breathing
• Anxiety
• Chest pain or discomfort
• Nausea or feeling unwell in your stomach
• Feeling dizzy, unsteady, weak, or light-headed
• Feeling that oneself or the environment are not real (depersonalization or derealization)
• Fear of losing control
• Afraid of going crazy
• Fear of dying

Common mental symptoms

Most people with agoraphobia fear panic attacks or fainting attacks in public. All patients with agoraphobia fear the crowds. However, the reasons for this are different. People who suffer from pure agoraphobia without panic attacks are more likely to fear embarrassing situations, such as being afraid to wet themselves. In agoraphobia with panic attacks, it is less the embarrassment of the anxiety attacks that troubles the sufferer than the fear of not receiving help and dying as a result of the physical symptoms.

Those affected suffer a lot from their fears. However, you know that these are excessive. This knowledge alone does not, however, tame fear. It gets stronger over time and occurs when the patient only imagines the dreaded situation.

At first they only avoid a few places, later on hardly any place seems safe to them. They severely limit their leisure activities, and doing their work also becomes a challenge. Agoraphobia therefore has serious effects, both professionally and financially, as well as in private and social life.

Agoraphobia: causes and risk factors

There is evidence of a hereditary component of agoraphobia. Children whose parents have agoraphobia are at increased risk of developing this mental disorder as well. The messenger substances in the brain also have an influence on the development. Malfunctions of the serotonin and noradrenaline-releasing system are possible causes. Whether the disorder actually develops, however, also largely depends on the psychosocial factors.

Stress as a cause

Stressful life events increase the likelihood of agoraphobia in fear-prone people. People with agoraphobia often have traumatic experiences in childhood. The loss of a parent through death or divorce but also illness or sexual abuse can later contribute to an anxiety disorder. Stress can also trigger agoraphobia in adulthood. People in partnerships are less likely to suffer from the anxiety disorder than single people.

Fear sensitivity

Some people are more anxious than others and therefore more prone to agoraphobia. They perceive physical changes, such as palpitations, more strongly and perceive them as threatening. Often they then imagine catastrophic scenarios. The result is fear, which in turn increases the physical symptoms.

In many cases, agoraphobia begins with a panic attack. In a safe, public place, those affected suddenly experience strong body reactions such as racing heart or dizziness. Such complaints can originally be caused or aggravated by the consumption of coffee, hypoglycemia or other factors.

The actual trigger for the panic attack is that those affected overestimate the symptoms and experience them as a threat. Fear and physical reactions then rock each other further and further. As a result of this experience, people avoid the place where these symptoms occurred. Over time, the fear spreads to other situations and places.

Psychological factors

An important factor that contributes to anxiety is the feeling of not having control over the physical reactions during the anxiety state. Therefore, those affected avoid unknown places. They fear that they are helplessly at the mercy of the situation and strangers.

Agoraphobia: examinations and diagnosis

At the start of treatment, the doctor must conduct a medical examination to rule out physical illnesses as the cause of the symptoms. There are a number of physical problems that can trigger severe anxiety. These include, for example, heart problems, thyroid and lung diseases or disorders of balance. In addition to a detailed discussion, the examination includes a blood count and an electrocardiogram (EKG) to check the heart. If necessary, the doctor will carry out further tests.

To determine if your fears are psychological, the doctor may ask you the following questions:

• Do you ever experience severe anxiety related to physical symptoms, such as palpitations, sweating, or shortness of breath?
• Are there places or situations that you avoid for fear of an anxiety attack?
• How do you feel in large crowds or in public places?

If your descriptions match the agoraphobia disorder, the doctor will refer you to an outpatient psychotherapist or a psychosomatic clinic. A psychotherapist or psychologist is able to make an accurate diagnosis. Using a questionnaire, the specialist can find out whether there are other mental disorders that require treatment.

Agoraphobia: treatment

Psychotherapy and / or medication are used for agoraphobia therapy. Experts particularly recommend cognitive behavioral therapy for the treatment of agoraphobia. Psychodynamic psychotherapy is an alternative.

Cognitive behavioral therapy

Cognitive behavioral therapy starts with the excessive fearful thoughts and works on the avoidance strategies that the patients have developed over time. For a successful therapy, the person affected has to deal intensively with their fears.

According to reports by the poet Johann Wolfgang von Goethe and the psychoanalyst Sigmund Freud, these great personalities also suffered from agoraphobia. Both of them avoided certain places out of fear. They were able to overcome the fear of fear by intuitively using the confrontation with their fears for therapy.

Nowadays therapists refer to the confrontation with fearful places and situations as exposure. Patients are encouraged to expose themselves to situations where symptoms of anxiety or panic attacks occur. After exposure, the patient reports what symptoms he felt during the attack. As part of the therapy, he experiences first-hand that, for example, the faster heartbeat is not a life-threatening threat and that it calms down on its own after a while. The patient experiences that the fear of fear is worse than the experience itself.

The therapist also teaches the person concerned to observe their thoughts closely and to recognize unreal fears. The severity of the mental disorder is not related to the intensity or frequency of the anxiety symptoms, but to how dangerous they are perceived by the patient. Therefore, the review and, if necessary, the revision of thoughts as well as the appropriate interpretation of physical reactions are very important therapy contents. They enable the crucial steps to be able to overcome the fear of fear.

Over time, there will be fewer and fewer places where the fear occurs. After about fifteen sessions, most patients are able to enter many dreaded situations without fear.

Psychodynamic psychotherapy

In the context of psychodynamic psychotherapy, the therapist assumes that there is an unresolved conflict behind the anxiety symptoms. This conflict must be recognized and dealt with so that the fear can be overcome. For example, it can be about separation, suppressed anger or even sexual problems. The therapist's concern is to make unconscious processes clear in the conversation so that the patient can recognize and process them.

Medication

Selective serotonin reuptake inhibitors (SSRIs), for example citalopram or paroxetine, are mainly used for the drug treatment of agoraphobia. Another possible drug is venlafaxine, a serotonin-norepinephrine reuptake inhibitor (SNRI). All reuptake inhibitors ensure that the respective messenger substance (serotonin or northern adrenaline) can act longer in the cell.

Tricyclic antidepressants are used less frequently because they have more severe side effects. SSRIs and SNRIs do not lead to dependency. Common side effects, however, include nausea, vomiting, sleep disorders, and sexual dysfunction. The drugs take about fourteen days to take effect. The tolerability of the respective drug varies greatly from person to person.

Additional treatment measures

In addition to therapy, experts also recommend physical activity. Endurance training is said to help improve symptoms. Participation in self-help groups is often helpful for those affected.

Agoraphobia: disease course and prognosis

Agoraphobia often starts suddenly with a first attack of anxiety in a public place. Only in a few cases does the mental disorder go away on its own. Without treatment, agoraphobia is usually chronic. The longer the mental disorder persists, the more likely it is to add other problems, such as alcohol abuse or depressive symptoms.

Agoraphobia often runs in phases. The condition of those affected can fluctuate from day to day. The symptoms of anxiety can reappear even after a long period of symptom-free treatment.

The earlier patients seek therapeutic help, the better the prognosis usually is. Exposure therapy, in particular, has been able to help many people cope with their agoraphobia and regain their lives.

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