Agoraphobia

What Causes Agoraphobia?

Scientists don’t yet fully understand what causes agoraphobia and other anxiety disorders. However, an individual’s risk for developing agoraphobia is probably due to a complex interaction of genetic and environmental factors.

Risk factors for agoraphobia include:

• History of panic disorder or other phobias
• Exposure to traumatic experiences such as abuse, violent crime, or loss of a loved one
• Certain personality traits, such as anxiety or general fearfulness
• Family history of agoraphobia

Is Agoraphobia Hereditary?

People with a family history of agoraphobia or panic disorder have a higher risk of developing agoraphobia themselves, suggesting an inherited component to the two disorders. About two-thirds of people with agoraphobia have a relative with the same disorder. People who have a parent or sibling with agoraphobia are 3-4 times more likely than the general population to develop it themselves.

However, scientists have not identified a single gene or a group of genes definitively associated with agoraphobia. Instead, agoraphobia is likely the result of a coincidence of multiple genetic and environmental factors.

How Is Agoraphobia Detected?

Agoraphobia most often begins in early adulthood, but it can start earlier in some cases. Signs that situational anxiety might rise to the level of diagnosable agoraphobia include:

• Being away from home alone causes you significant distress.
• You’re always looking for a way to escape from anxiety-causing situations.
• You take steps to avoid stressful situations.
• You have a history of panic attacks.
• Your anxiety lasts for six months or more.

How Is Agoraphobia Diagnosed?

Diagnosis of agoraphobia begins with determining that the patient has a cluster of symptoms that meet the diagnostic criteria for the disorder. A doctor will start with a physical exam to rule out biological problems that may be causing symptoms. After these exams, if the doctor suspects that agoraphobia or panic disorder is the cause of the symptoms, they may recommend a psychological or psychiatric assessment to solidify the diagnosis further.

Diagnostic steps may include:

• A physical exam. This exam will rule out physical conditions that could be causing the symptoms.
• Psychological assessments. These assessments may take the form of questionnaires or talk sessions with a mental health professional to assess the patient’s mood, mental state, and mental health history. Family members or caregivers may also be asked to participate in these assessments.

The results of the psychological assessments will be compared to the diagnostic criteria for agoraphobia in the Diagnostic and Statistical Manual of Mental Disorders (DSM). The DSM criteria for agoraphobia include:

• Anxiety or fear is associated with open spaces, enclosed spaces, public transportation, crowds, or being alone outside the home.
• These situations almost always cause anxiety.
• The anxiety is out of proportion to the danger posed by the situation.
• Anxiety-inducing situations are avoided or endured under intense distress.
• The anxiety lasts for six months or more.
• The anxiety causes significant distress or impairment.
• Another mental illness does not explain the symptoms.

Agoraphobia may be diagnosed either with or without an association with panic disorder.

PLEASE CONSULT A PHYSICIAN FOR MORE INFORMATION.

How Is Agoraphobia Treated?

A combination of medications and psychotherapy is often used to treat the symptoms of agoraphobia.

Medication

Different medications may be used to treat and manage agoraphobia. Individual medication plans depend on the patient’s age, responsiveness to treatments, and the severity of their symptoms.

• Selective serotonin reuptake inhibitors (SSRIs). These antidepressant drugs work by increasing the levels of serotonin, a neurotransmitter chemical in the brain. Common SSRIs include citalopram, escitalopram, fluoxetine, paroxetine, sertraline, and vilazodone.
• Benzodiazepines. These anti-anxiety medications work relatively quickly to control symptoms. However, they may lose their effectiveness over time.

Psychotherapy

The most common therapeutic approaches used to treat agoraphobia include:

• Exposure therapy. This therapy involves gradual, controlled exposure to the situations that trigger symptoms. The goal is to help the patient understand and change their fear response to the situation. Exposure therapy is successful in the majority of cases when it is practiced correctly.
• Cognitive-behavioral therapy (CBT). This process focuses on helping the patient identify a pattern of harmful thoughts and construct strategies and solutions for dealing with them.

How Does Agoraphobia Progress?

Untreated agoraphobia often varies in severity intermittently over time. Some people may learn to manage symptoms on their own by gradually exposing themselves to anxiety-producing situations. Others may experience less anxiety simply because they avoid stressful situations. However, long-term avoidance of fear-inducing situations can lead to complications, including:

• Depression
• Anxiety
• Relationship problems
• Problems at school or work
• Isolation
• Substance abuse

How Is Agoraphobia Prevented?

There is no known way to prevent agoraphobia. However, progression of the disorder may be slowed or stopped if you address symptoms when they first begin to appear. Steps you can take to keep your anxiety from getting worse include:

• When you feel anxiety in situations such as going places by yourself, practice putting yourself in those situations while the fear is still mild.
• Ask your friends and family to help you.
• Seek help from a mental health professional, especially if you experience panic attacks.

Agoraphobia Caregiver Tips

Agoraphobia often exists alongside other mental health conditions, a condition called co-morbidity. Here are a few of the disorders commonly associated with agoraphobia:

• Panic disorder and agoraphobia are very often comorbid.
• People with agoraphobia often suffer from depression.
• Alcoholism and substance abuse are commonly comorbid with agoraphobia.
• People with agoraphobia may have other anxiety disorders as well, including social anxiety disorder.
• Obsessive-compulsive disorder (OCD) and agoraphobia are sometimes associated with one another.
• People who experience traumatic brain injuries sometimes develop agoraphobia.

Agoraphobia Brain Science

Scientists believe that symptoms of agoraphobia and other anxiety disorders come from activity in the parts of the brain that control emotions and our reactions to them. These parts of the brain are collectively called the limbic system. The limbic system is associated with anxiety in several ways:

• The amygdala, the part of the brain responsible for detecting threats, may be hyperactive and may misidentify causes for fear or worry when none exist.
• An overactive amygdala may persistently cause the hypothalamus to trigger the hormonal response that produces the physical symptoms of phobias.
• Communication between the amygdala and the prefrontal cortex (PFC) may be impaired. The PFC is responsible for triggering a rational response to threats, and it may not be able to do so when it is unable to communicate with the amygdala effectively.

Agoraphobia Research

Title: Use of CBD Oil in the Treatment of Panic Attack-Related Fear

Stage: Recruiting

Principal investigator: Michael J. Telch, PhD

University of Texas

Austin, TX 

The purpose of this study is to test whether cannabidiol (CBD) can interfere with the reconsolidation (storage) of pathological fear memory in humans.

The overarching goal of the proposed research project is to contribute towards the development of a novel ultra-brief intervention for anxiety-related psychiatric disorders such as panic disorder and post-traumatic stress disorder (PTSD). Building off innovative work in the basic neuroscience of fear memory interference (see Stern et al., 2018 for a review), this experiment will be the first to evaluate whether cannabidiol (CBD) can interfere with the reconsolidation of naturally acquired pathological interoceptive fear memory in humans.

Participants who meet DSM-5 criteria for panic disorder or subthreshold elevated concerns about having additional panic attacks will be randomly assigned to one of three conditions: (1) Memory reactivation + CBD, (2) Memory reactivation+ Placebo, or (3) CBD alone.

NOTE: Due to the COVID-19 Pandemic, all study procedures will occur online and over videoconference with study staff. Additionally, CBD or placebo oil will be mailed to the participant’s location.

Title: Comparing Individual Therapies for Veterans With Depression, PTSD, and Panic Disorder

Stage: Recruiting

Principal investigator: Daniel F. Gros, PhD, MA, BS

Ralph H. Johnson VA Medical Center

Charleston, SC 

Cognitive-behavioral therapy (CBT) is a brief, efficient, and effective treatment for depressive/anxiety disorders. However, CBT is largely underutilized within the Department of Veterans Affairs due to the cost and burden of training necessary to deliver all of the related disorder-specific treatments (DSTs). Transdiagnostic Behavior Therapy (TBT), in contrast, is specifically designed to address numerous distinct disorders within a single protocol in Veterans with depressive/anxiety disorders, including post-traumatic stress disorder. The proposed research seeks to evaluate the efficacy of TBT by assessing psychiatric symptomatology and related impairment outcomes in Veterans with depressive/anxiety disorders via a randomized controlled trial of TBT and existing DSTs in Veterans with major depressive disorder, post-traumatic stress disorder, and panic disorder. Assessments will be completed at pre-, mid-, and post-treatment and 6-month follow-up. Process variables also will be investigated.

Title: Building an Outcomes Assessment Infrastructure to Assess Anxiety Treatment

Stage: Recruiting

Principal investigator: Jacqueline Sperling, PhD

McLean Hospital

Cambridge, MA

The collection of patient self-report and diagnostic data will allow us to examine the efficacy of the treatment delivered in the McLean Anxiety Mastery Program. Using data gathered through routine clinical care, the investigators seek to explore whether patients in treatment show improvements from admission to discharge compared to patients on the waitlist and whether these gains are maintained three months post-discharge. The following are included as examples of some of the study’s hypotheses.

The study population will involve all assenting/consenting patients, both male and female, admitted to the McLean Anxiety Mastery Program at McLean Hospital. This program provides intensive group-based treatment for anxious youth (aged 6-19). Patients in the McLean Anxiety Mastery Program participate in a minimum of four weeks of treatment and attend the program for four days per week. Three days per week, patients attend group-based treatment for two-and-a-half hours per day. The fourth day of each week consists of a one-hour group-based treatment, a one-hour family meeting, and a one-hour exposure session that includes children and their caregivers. One day per week, parents also attend a one-hour parent guidance group as part of the overall treatment package. Patients also have psychopharmacology consultations with the program psychiatrist on a case-by-case basis. On their first birthday that falls after the discharge date, patients are sent a birthday card that includes a greeting and reminders about coping skills they learned in the program.

The investigators expect to recruit at least 45 assenting/consenting patients in the first year of the study. The plan is to treat six to eight patients during each one-month module and to have a waitlist if interest in the program exceeds the program’s capacity. If a waitlist exists, patients on this waitlist will be evaluated as the study’s control group once they are four weeks away from their target admission date.

Before the patient’s first assessment through the program, a clinician will inform the patient and caregivers about the opportunity to participate in a voluntary research study at the McLean Anxiety Mastery Program. Assent/consent will be requested to utilize these data for research purposes. The patient and caregivers will be told that all of the information gathered from the child- and caregiver-report measures are part of routine clinical practice, and permission is being sought to use this de-identified data for research purposes. The patient and caregivers will be reminded that their decision to, or not to, participate in the research study will not affect the treatment they receive.

The assessments are conducted at the following time points: 1) upon admission, 2) weekly while the patients are participating in treatment, 3) upon discharge, and 4) at a three-month follow-up visit.

The child- and parent-reported questionnaires are administered through REDCap Survey, a secure, HIPAA-compliant program for building and managing online surveys. The measures are completed on families’ devices at home. If a patient or family member does not complete the online survey within 48 hours, a clinician will contact them with a reminder one time via phone or e-mail. The survey does not include questions assessing risk (e.g., for suicidal ideation, self-harm, substance use).