22nd February 2024

Agoraphobia

Background

Agoraphobia is described as worrying about being somewhere where there is no escape or being anxious about having a panic attack where help is not available. This leads to persistent avoidance of a variety of things. Agoraphobic avoidance can range from avoiding crowds or travelling in certain modes of transport to never leaving the house. Agoraphobia is most likely to develop in people with panic disorder; however, it can also occur on its own.  Risk factors include having a panic disorder, presence of phobia or being female. Almost a third of sufferers also struggle with substance misuse. Due to its disabling nature, sufferers struggle with their everyday functions and staying in employment. 

Presentation

The primary presentation is avoidance of certain places due to worry about being suddenly incapacitated and not being able to escape, with individuals often displaying symptoms of panic. Common situations include public areas such as stadiums, parks, supermarkets or anywhere with a large crowd.  Individuals may often avoid places where they feel they could become trapped, which is called agoraphobic avoidance. Agoraphobic avoidance is most likely in those who have panic symptoms, as sufferers become worried about having a panic attack somewhere where they will have no control or feel like they will die because they can’t get help or escape. 

Individuals often report having a zone of safety that they feel comfortable being within, such as their home or local area. They feel distressed if they are out of the safety zone and avoid leaving this area. Agoraphobia can occur independently, soon after a panic attack or over time. 

Investigations

Assessment tools include:

• The Diagnostic Assessment Research Tool (DART) 
• Agoraphobia subscale of the Fear Questionnaire
• Anxiety and Related Disorder Interview Schedule for DSM-5 (AIDS-5) – a thorough, often time-consuming tool mostly used in a mental health setting.

The severity of symptoms can be assessed using:

• The mobility inventory helps assess the level of avoidance by listing 26 different situations.
• The severity measure for Agoraphobia
• The Oxford Agoraphobic Avoidance Scale

Diagnosis

Agoraphobia is defined by the DSM-5 as having the following:

1. Fear or anxiety about being in >2 situations where the individual can’t escape, such as: 
   • Being in a mode of transportation, for example in cars, buses, trains, planes or ships
   • Being in open spaces e.g. car parks, markets, parks
   • Being alone outside the house
   • Being in a queue or in a crowd
   • Being in enclosed public settings such as shops, libraries, or cinemas
2. Avoidance of being in these places due to fear of being trapped or not being able to get help if they develop a panic attack or lose control or something embarrassing happens.
3. Presence of fear or anxiety whenever they are physically in one of the agoraphobic locations (as mentioned in point no 1)
4. Active avoidance of agoraphobic location
5. Fear or anxiety is disproportionate to what should be expected.
6. Symptoms present for >6 months.
7. If a health condition is present, the fear avoidance is disproportional to the threat to their health
8. The fear, anxiety or avoidance is not due to another anxiety or mood disorder.

Management 

The treatment for agoraphobia is the same as for panic disorders, described above. 

Antidepressants, particularly SSRIs, are usually the first line drug treatment for agoraphobia. They are effective in reducing the intensity and frequency of panic attacks and can substantially improve a patient’s quality of life. 

If SSRIs are contraindicated or ineffective, clomipramine or imipramine may be trialled. If the treatment is effective after 3 months, it should be continued for at least 6 months in total.

References

• Streeruwitz A, Hagger M, Webb S, Walker D, Jakeman N. Anxiety, obsession, and reactions to stress. In: Psychiatry PRN. Oxford, New York: Oxford University Press; 2009. p. 152–153. 
• Introduction: Common mental health problems: Identification and pathways to care: Guidance [Internet]. NICE. NICE; 2011 [cited 2023May1]. Available from: https://www.nice.org.uk/guidance/cg123/chapter/1-guidance