Examine individual changes

'{{DiseaseDisorder infobox | Name = Agoraphobia | ICD10 = {{ICD10|F|40||f|40}}<br />F40.00 Without panic disorder, F40.01 With panic disorder | ICD9 = {{ICD9|300.22}} Without panic disorder, {{ICD9|300.21}} With panic disorder | MeshID = D000379 }} '''Agoraphobia''' (from [[Greek language|Greek]] aγορά, "[[Agora|marketplace]]"; and φόβος/φοβία, [[-phobia]]) is an [[anxiety disorder]]. Agoraphobia was traditionally thought to involve a fear of public places and open spaces. However, it is now believed that agoraphobia develops as a complication of panic attacks.<ref>http://helpguide.org/mental/panic_disorder_anxiety_attack_symptom_treatment.htm</ref> But there is evidence that the implied one-way causal relationship between spontaneous panic attacks and agoraphobia in DSM-IV appears incorrect.<ref>Br J Psychiatry. 2006 May;188:432-8.</ref> Agoraphobia may arise by the fear of having a [[panic attack]] in a setting from which there is no easy means of escape. As a result, sufferers of agoraphobia avoid public and/or unfamiliar places, especially large, open, spaces such as [[shopping malls]] or [[airports]] where there are few 'places to hide'. In severe cases, the sufferer may become confined to his or her home, experiencing difficulty traveling from this "safe place." ==Definition== Agoraphobia is a condition where the sufferer becomes anxious in environments that are unfamiliar or where he or she perceives that they have little control. Triggers for this anxiety may include wide open spaces, crowds, or traveling (even short distances). Agoraphobia is often, but not always, compounded by a fear of social embarrassment, as the agoraphobic fears the onset of a [[panic attack]] and appearing distraught in public. This is also sometimes called 'Social Agoraphobia' which may be a type of [[social anxiety disorder]] also sometimes called [[social phobia]]. Not all agoraphobia is social in nature, however. Some agoraphobics have a fear of open spaces. Other syndromes like [[obsessive compulsive disorder]] or [[post traumatic stress disorder]] can also cause agoraphobia, basically any irrational fear that keeps one from going outside can cause the syndrome.<ref>[http://psychcentral.com/disorders/sx29.htm Psych Central: Agoraphobia Symptoms<!-- Bot generated title -->]</ref> ===Gender differences=== Agoraphobia occurs about twice as commonly among women as it does in men.<ref>Magee, W. J., Eaton, W. W. , Wittchen, H. U., McGonagle, K. A., & Kessler, R. C. (1996). ''Agoraphobia, simple phobia, and social phobia in the National Comorbidity Survey'', Archives of General Psychiatry, 53, 159–168.</ref> The gender difference may be attributable to social-cultural factors that encourage, or permit, the greater expression of avoidant coping strategies by women. Other theories include the ideas that women are more likely to seek help and therefore be diagnosed, that men are more likely to abuse alcohol as a reaction to anxiety and be diagnosed as an alcoholic, and that traditional female sex roles encourage women to react to anxiety by engaging in dependent and helpless behaviors.<ref>{{cite web | last = Agoraphobia Research Center | first = | title = Is agoraphobia more common in men or women? | url=http://www.agoraphobia.ws/whogets.htm | accessdate = 2007-11-15 }}</ref> Research results have not yet produced a single clear explanation as to the gender difference{{Fact|date=November 2009}} in agoraphobia. ==Causes and contributing factors== The causes of agoraphobia are currently unknown. It is linked however to the presence of other anxiety disorders, a stressful environment or substance abuse. More women than men are affected.<ref>{{cite web |url= http://www.mayoclinic.com/health/agoraphobia/DS00894/DSECTION=risk%2Dfactors|title=Agoraphobia |accessdate= |format= |work= }}</ref> Chronic use of tranquilizers and sleeping pills such as [[benzodiazepines]] has been linked to causing agoraphobia. When [[benzodiazepine dependence]] has been treated and after a period of abstinence, agoraphobia symptoms gradually abate.<ref>{{cite journal | author =Professor C Heather Ashton | url =http://www.benzo.org.uk/ashbzoc.htm | year =1987 | title =Benzodiazepine Withdrawal: Outcome in 50 Patients | journal =British Journal of Addiction | volume =82 | pages =655–671 }}</ref> Research has uncovered a linkage between agoraphobia and difficulties with spatial orientation.<ref> R. Spiti: Primary Agoraphobia's specific Symptoms: from natural information to mental representations http://docs.google.com/View?docID=dc45mkq9_1ftdhjn2d&revision=_latest</ref><ref>{{cite journal | last = | first = | authorlink = Yardley L, Britton J, Lear S, Bird J, Luxon LM | coauthors = | title = Relationship between balance system function and agoraphobic avoidance. | journal = Behav Res Ther. | volume = 33 | issue = 4 | pages = 435–9 | date = 1995 May | url = | doi =10.1016/0005-7967(94)00060-W | pmid = : 7755529 | accessdate = | author =Yardley, L | last2 =Britton | first2 =J | last3 =Lear | first3 =S | last4 =Bird | first4 =J | last5 =Luxon | first5 =LM }}</ref><ref>{{cite journal | last = | first = | authorlink = RG Jacob, JM Furman, JD Durrant and SM Turner | coauthors = | title = Panic, agoraphobia, and vestibular dysfunction | journal = Am J Psychiatry | volume = 153 | issue =4 | pages = 503–512 | year = 1996 | url = | doi = | id = | accessdate = | pmid =8599398 | last1 =Jacob | first1 =RG | last2 =Furman | first2 =JM | last3 =Durrant | first3 =JD | last4 =Turner | first4 =SM }}</ref> Individuals without agoraphobia are able to maintain balance by combining information from their [[vestibular system]], their [[visual system]] and their [[proprioceptive]] sense. A disproportionate number of agoraphobics have weak vestibular function and consequently rely more on visual or tactile signals. They may become disoriented when visual cues are sparse as in wide open spaces or overwhelming as in crowds. Likewise, they may be confused by sloping or irregular surfaces.<ref>{{cite journal | last = | first = | authorlink = Jacob RG, Furman JM, Durrant JD, Turner SM | coauthors = | title = Surface dependence: a balance control strategy in panic disorder with agoraphobia | journal = Psychosom Med. | volume = 59 | issue = 3 | pages = 323–30 | date = 1997 May-June | url = | doi = | pmid = : 9178344 | accessdate = | last1 =Jacob | first1 =RG | last2 =Furman | first2 =JM | last3 =Durrant | first3 =JD | last4 =Turner | first4 =SM }}</ref> Compared to controls, in [[virtual reality]] studies, agoraphobics on average show impaired processing of changing audiovisual data.<ref>{{cite journal | last = | first = | authorlink = Viaud-Delmon I, Warusfel O, Seguelas A, Rio E, Jouvent R. | coauthors = | title = High sensitivity to multisensory conflicts in agoraphobia exhibited by virtual reality. | journal = Eur Psychiatry | volume = 21 | issue = 7 | pages = 501–8 | date = 2006 October | url = | doi =10.1016/j.eurpsy.2004.10.004 | pmid = : 17055951 | accessdate = | author =Viauddelmon, I | last2 =Warusfel | first2 =O | last3 =Seguelas | first3 =A | last4 =Rio | first4 =E | last5 =Jouvent | first5 =R }}</ref> ==Alternate theories== ===Attachment theory=== {{main|Attachment theory}} Some scholars <ref>G. Liotti, (1996). ''Insecure attachment and agoraphobia'', in: C. Murray-Parkes, J. Stevenson-Hinde, & P. Marris (Eds.). Attachment Across the Life Cycle.</ref><ref>J. Bowlby, (1998). ''Attachment and Loss'' (Vol. 2: Separation).</ref> have explained agoraphobia as an attachment deficit, i.e., the temporary loss of the ability to tolerate spatial separations from a secure base.<ref>K. Jacobson, (2004). "Agoraphobia and Hypochondria as Disorders of Dwelling." ''International Studies in Philosophy'' 36, 31-44.</ref> Recent empirical research has also linked attachment and spatial theories of agoraphobia.<ref>J. Holmes, (2008). "Space and the secure base in agoraphobia: a qualitative survey", Area, 40, 3, 357 - 382.</ref> ===Spatial theory=== In the social sciences there is a perceived clinical bias <ref>J. Davidson, (2003). ''Phobic Geographies''</ref> in agoraphobia research. Branches of the social sciences, especially [[geography]], have increasingly become interested in what may be thought of as a [[spatial]] phenomenon. One such approach links the development of agoraphobia with modernity.<ref>J. Holmes, (2006). "Building Bridges and Breaking Boundaries: Modernity and Agoraphobia", Opticon1826, 1, 1, http://www.ucl.ac.uk/opticon1826/archive/issue1</ref> ==Diagnosis== Most people who present to mental health specialists develop agoraphobia after the onset of [[panic disorder]] ([[American Psychiatric Association]], 1998). Agoraphobia is best understood as an adverse behavioral outcome of repeated panic attacks and subsequent anxiety and preoccupation with these attacks that leads to an avoidance of situations where a panic attack could occur.<ref>{{cite book | year=1988| author=Barlow, D. H.| title='''Anxiety and its disorders: The nature and treatment of anxiety and panic'''| publisher=Guilford Press}}</ref> In rare cases where agoraphobics do not meet the criteria used to diagnose [[Panic Disorder]], the formal diagnosis of [[Agoraphobia Without History of Panic Disorder]] is used (Primary Agoraphobia).<ref> R. Spiti: Primary Agoraphobia's specific Symptoms: from natural information to mental representations http://docs.google.com/Doc?docid=0AbHhNqXIspq4ZGM0NW1rcTlfMWZ0ZGhqbjJk&hl=en_G</ref> ===DSM-IV-TR diagnostic criteria=== A) Anxiety about being in places or situations from which escape might be difficult (or embarrassing) or in which help may not be available in the event of having an unexpected or situationally predisposed panic attack or panic-like symptoms. Agoraphobic fears typically involve characteristic clusters of situations that include being outside the home alone; being in a crowd, or standing in a line; being on a bridge; and traveling in a bus, train, or automobile. B) The situations are avoided (e.g., travel is restricted) or else are endured with marked distress or with anxiety about having a panic attack or panic-like symptoms, or require the presence of a companion. C) The anxiety or phobic avoidance is not better accounted for by another mental disorder, such as [[Social Phobia]] (e.g., avoidance limited to social situations because of fear of embarrassment), Specific Phobia (e.g., avoidance limited to a single situation like elevators), Obsessive-Compulsive Disorder (e.g., avoidance of dirt in someone with an obsession about contamination), [[PTSD|Posttraumatic Stress Disorder]] (e.g., avoidance of stimuli associated with a severe stressor), or [[Separation Anxiety Disorder]] (e.g., avoidance of leaving home or relatives).<ref>{{cite book | last = | first = | authorlink = American Psychiatric Association | title = Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DVM-IV-TR) | publisher = | year = 2000}} </ref> ==Association with panic attacks== Agoraphobia patients can experience sudden [[panic attack]]s when traveling to places where they fear they are out of control, help would be difficult to obtain, or they could be embarrassed. During a panic attack, [[epinephrine]] is released in large amounts, triggering the body's natural [[fight-or-flight]] response. A panic attack typically has an abrupt onset, building to maximum intensity within 10 to 15 minutes, and rarely lasts longer than 30 minutes.<ref name="NIH4.2">{{cite book | year=1999 | chapter=Chapter 4.2| author=David Satcher etal.| title='''Mental Health: A Report of the Surgeon General'''| url=http://www.surgeongeneral.gov/library/mentalhealth/chapter4/sec2.html}}</ref> Symptoms of a panic attack include palpitations, a rapid heartbeat, sweating, trembling, vomiting, dizziness, tightness in the throat and shortness of breath. Many patients report a fear of dying or of losing control of emotions and/or behavior. <ref name="NIH4.2"/> ==Treatments== Treatment options for agoraphobia and [[panic disorder]] are similar. ===Cognitive behavioral treatments=== [[Graduated exposure therapy|Exposure treatment]] can provide lasting relief to the majority of patients with panic disorder and agoraphobia. Disappearance of residual and subclinical agoraphobic avoidance, and not simply of panic attacks, should be the aim of exposure therapy.<ref> {{cite journal | last1=Fava | first1=G.A. | last2=Rafanelli | first2=C. | last3=Grandi | first3=S. | last4=Cinto | first4=S. | last5=Ruini | first5=C. | title=Long-term outcome of panic disorder with agoraphobia treated by exposure | journal=Psychological Medicine | volume=31 | pages=891–898 | publisher=Cambridge University Press | doi=10.1017/S0033291701003592 | year=2001 | author=Fava, G. A. | pmid=11459386 | last6=Mangelli | first6=L | last7=Belluardo | first7=P | issue=5}}</ref> Similarly, [[Systematic desensitization]] may also be used. [[Cognitive restructuring]] has also proved useful in treating agoraphobia. This treatment uses thought replacing with the goal of replacing one's irrational, counter-factual beliefs with more accurate and beneficial ones.{{Fact|date=January 2008}} [[Relaxation techniques]] are often useful skills for the agoraphobic to develop, as they can be used to stop or prevent symptoms of anxiety and panic.{{Fact|date=January 2008}} ===Psychopharmaceutical treatments=== Anti-depressant medications most commonly used to treat anxiety disorders are mainly in the SSRI ([[selective serotonin reuptake inhibitor]]) class and include [[sertraline]], [[paroxetine]] and [[fluoxetine]]. [[Benzodiazepine]] tranquilizers, [[MAO inhibitors]] and tricyclic antidepressants are also commonly prescribed for treatment of agoraphobia.{{Fact|date=January 2008}} ===Alternative treatments=== [[EMDR|Eye movement desensitization and reprogramming]] (EMDR) has been studied as a possible treatment for agoraphobia, with poor results.<ref> {{cite journal | coauthors = Goldstein, Alan J., de Beurs, Edwin, Chambless, Dianne L., Wilson, Kimberly A. | title = EMDR for Panic Disorder With Agoraphobia : Comparison With Waiting List and Credible Attention-Placebo Control Conditions | journal = Journal of Consulting & Clinical Psychology | volume = 68 | issue = 6 | pages = 947–957 | year = 2000 | doi = 10.1037/0022-006X.68.6.947 | author = Goldstein, Alan J. }}</ref> As such, EMDR is only recommended in cases where cognitive-behavioral approaches have proven ineffective or in cases where agoraphobia has developed following trauma.<ref>{{Cite web | last = Agoraphobia Resource Center | first = | title = Agoraphobia treatments - Eye movement desensitization and reprogramming | url= http://www.agoraphobia.ws/treatment-emdr.htm | accessdate = 2008-04-18}} </ref> Many people with anxiety disorders benefit from joining a [[self-help]] or [[support group]] (telephone conference call [[support groups]] or online support groups being of particular help for completely housebound individuals). Sharing problems and achievements with others as well as sharing various self-help tools are common activities in these groups. In particular stress management techniques and various kinds of meditation practices as well as visualization techniques can help people with anxiety disorders calm themselves and may enhance the effects of therapy. So can service to others which can distract from the self-absorption that tends to go with anxiety problems. There is also preliminary evidence that aerobic exercise may have a calming effect. Since caffeine, certain illicit drugs, and even some over-the-counter cold medications can aggravate the symptoms of anxiety disorders, they should be avoided.<ref>{{Cite web | last = National Institute of Mental Health | first = | title = How to get help for anxiety disorders | url=http://www.nimh.nih.gov/health/publications/anxiety-disorders/how-to-get-help-for-anxiety-disorders.shtml | accessdate = 2008-04-18}} </ref> ==Notable agoraphobes== <!-- Please don't list people here without references. they will be deleted according to wikipedia rules. --> <div style="-moz-column-count:2; column-count:2;"> *[[Woody Allen]] (1935-), [[United States|American]] actor, director, musician.<ref>[http://www.vanityfair.com/culture/features/2005/12/woodyallen200512?currentPage=4 "Reconstructing Woody"]</ref> *[[Kim Basinger]] (1953-), American Actress.<ref>{{cite web|url=http://www.nndb.com/people/310/000025235 |title=Kim Basinger |publisher=Nndb.com |date= |accessdate=2009-08-19}}</ref> *[[Paula Deen]] (1947-), American [[Chef]].<ref>[http://www.nytimes.com/2007/02/28/dining/28deen.html?_r=1&ref=dining]</ref> *[[H.L. Gold]] (1914-1996), science fiction editor; as a result of trauma during his wartime experiences, his agoraphobia became so severe that for more than two decades he was unable to leave his apartment. Towards the end of his life he acquired some control over the condition.<ref>{{cite web|url=http://en.wikipedia.org/enwiki/w/index.php?title=H._L._Gold&action=edit&section=4 |title=Editing H. L. Gold (section) - Wikipedia, the free encyclopedia |publisher=En.wikipedia.org |date=2009-02-05 |accessdate=2009-08-19}}</ref> *[[Brian Wilson]] (1942-), American singer and songwriter; Primary songwriter of the Beach Boys. A former recluse and agoraphobic who underwent bouts of [[schizophrenia]].<ref>[http://www.independent.co.uk/news/people/profiles/brian-wilson-here-comes-the-sun-401202.html Profile of Brian Wilson]. The Independent. Retrieved 3 September 2007.</ref> *[[Daryl Hannah]] (1960-), American actress.<ref>[http://www.imdb.com/name/nm0000435/bio Biography for Daryl Hannah]. Internet Movie Database. Retrieved 28 November 2007.</ref> *[[Howard Hughes]] (1905-1976), American [[aviator]], [[industrialist]], [[film producer]] and [[philanthropist]].<ref>[http://www.crimelibrary.com/criminal_mind/forensics/psych_autopsy/4.html Psychological Autopsy can help understand controversial deaths -- The Crime Library on truTV.com<!-- Bot generated title -->]</ref> *[[Olivia Hussey]] (1951-), Anglo-[[Argentinian|Argentine]] Actress.<ref>[http://www.oliviahussey.com/olivia_scrapbook/clippings/people.htm Olivia Hussey - People Magazine – March 16, 1992<!-- Bot generated title -->]</ref><ref>[http://www.imdb.com/name/nm0001377/bio Olivia Hussey Biography - Internet Movie Database<!-- Bot generated title -->]</ref> *[[Bolesław Prus]] (1847–1912), [[Poles|Polish]] journalist and [[novelist]].<ref>Stanisław Fita, ed., ''Wspomnienia o Bolesławie Prusie'' (Reminiscences about Bolesław Prus), Warsaw, Państwowy Instytut Wydawniczy (State Publishing Institute), 1962, p. 113.</ref> *[[Marilyn (musician)|Peter Robinson]] (1962-), British musician known simply as Marilyn.<ref>''Whatever Happened to the Gender Benders?'', Channel 4 documentary, United Kingdom.</ref> </div> <!-- Please don't list people here without references. they will be deleted according to wikipedia rules. --> ==See also== *[[Hikikomori]] *[[List of phobias]] ==References== {{reflist|colwidth=30em}} {{NIMH}} {{Mental and behavioural disorders}} [[Category:Phobias]] [[Category:Neurotic, stress-related and somatoform disorders]] [[af:Agorafobie]] [[ar:رهاب الخلاء]] [[bs:Agorafobija]] [[bg:Агорафобия]] [[ca:Agorafòbia]] [[cs:Agorafobie]] [[da:Agorafobi]] [[de:Agoraphobie]] [[et:Agorafoobia]] [[el:Αγοραφοβία]] [[es:Agorafobia]] [[eu:Agorafobia]] [[fa:هراس از مکان‌های باز]] [[fr:Agoraphobie]] [[gl:Agorafobia]] [[ko:광장 공포증]] [[hr:Agorafobija]] [[io:Agorafobio]] [[it:Agorafobia]] [[he:אגורפוביה]] [[ka:აგორაფობია]] [[lt:Agorafobija]] [[nl:Agorafobie]] [[ja:広場恐怖症]] [[no:Agorafobi]] [[pl:Agorafobia]] [[pt:Agorafobia]] [[ru:Агорафобия]] [[sk:Agorafóbia]] [[sl:Agorafobija]] [[sr:Агорафобија]] [[sh:Agorafobija]] [[fi:Agorafobia]] [[sv:Agorafobi]] [[tl:Agorapobya]] [[th:อาการกลัวที่โล่ง]] [[uk:Агорафобія]] [[zh:廣場恐懼症]]'