Agoraphobia - Anatomy of Psych

What is agoraphobia?

Agoraphobia is an anxiety disorder characterized by intense fear . The annual prevalence of agoraphobia is roughly 1.7%, and incidence peaks in the late teenage years to early adulthood. Like other anxiety disorders, agoraphobia is about twice more likely to occur in women than in men.

Individuals with agoraphobia who are homebound

33%

What does agoraphobia look like?

Signs & Symptoms

Fear of:
- Leaving home alone
- Crowds or waiting in line
- Enclosed spaces, such as movie theaters, elevators or small stores
- Open spaces, such as parking lots, bridges or malls
- Using public transportation, such as a bus, plane or train
Fear or anxiety almost always results from exposure to the situation
The fear or anxiety is out of proportion to the actual danger of the situation
Avoiding the situation, needing a companion to go with you, or enduring the situation with extreme distress
Experiencing significant distress or problems with social situations, work or other areas in your life because of the fear, anxiety, or avoidance

DSM-5 Criteria

Criterion A. Marked fear or anxiety about at least 2 of the 5 following situations:

Public transportation (e.g. cars, trains, planes, ships)
Open spaces (e.g. parking lots, malls, bridges)
Enclosed spaces (e.g. stores, theaters, rooms)
Crowds or standing in line
Being outside of home

Criterion B.The individual fears or avoids these situations because of thoughts that:

Escape might be difficult, or
Help might not be available in the event of developing panic-like symptoms or other incapacitating or embarrassing symptoms (e.g. - fear of falling or fear of incontinence in the elderly)

Criterion C.The agoraphobic situations almost always provoke fear or anxiety.

Criterion D. The agoraphobic situations are actively avoided, require the presence of a companion, or are endured with intense fear or anxiety.

Criterion E. The fear or anxiety is out of proportion to the actual danger posed by the agoraphobic situations and to the sociocultural context.

Criterion F. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.

Criterion G. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Criterion H. If another medical condition (e.g. inflammatory bowel disease, Parkinson’s disease) is present, the fear, anxiety, or avoidance is clearly excessive.

Criterion I. The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder:

The symptoms are not confined to a specific phobia, situational type
Do not involve only social situations (social anxiety disorder)
Do not relate exclusively to obsessions (obsessive-compulsive disorder)
Do not relate to defects or flaws in physical appearance (body dysmorphic disorder)
Do not relate to reminders of traumatic events (post-traumatic stress disorder)
Do not relate to fear of separation (separation anxiety disorder)

Specifiers

Specifiers:

Panic attacks
- Recurrent unexpected panic attacks. An abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time at least 4 of the following symptoms occur (Note: The abrupt surge can occur from a calm state or an anxious state):
  - Sweating
  - Trembling or shaking
  - Unsteady, dizziness, light-headed, or feeling faint
  - Derealization (feelings of unreality) or depersonalization (being detached from one self)
  - Excessive/accelerated heart rate, palpitations, or pounding heart
  - Nausea or abdominal distress
  - Tingling, numbness, parathesesias
  - Shortness of breath
  - Fear of losing control or “going crazy”
  - Fear of dying
  - Choking feelings
  - Chest pain or discomfort
  - Chills or heat sensations

Risk Factors

Temperamental factors such as anxiety sensitivity (belief that anxiety symptoms are harmful)
Overbearing parenting
Adverse childhood events
Low extraversion
High neuroticism
Severe depression, trait anxiety, and poor visuospatial memory are the chief risk factors for late-onset (elderly) agoraphobia

Differential Diagnosis

Specific phobia, situational type
Separation anxiety disorder
Social anxiety disorder (social phobia)
Panic disorder
Acute stress disorder, post-traumatic stress disorder
Major depressive disorder
Other medical conditions

How is agoraphobia investigated?

Screening/Scale	Rater	Description
Panic and Agoraphobia Scale (PAS)	Clinician/Client	13 questions rated on a 5-point scale to measure the severity of agoraphobia with or without panic attacks

How is agoraphobia treated?

See treatment for panic disorder.

Nursing Management

Social isolation

Causes & Behaviors:

Panic levels of anxiety
Past experiences of difficulty in interaction with others
Repressed fears
Stays at home alone, afraid to venture out alone
Uncommunicative
Withdrawn
No eye contact
Insecurity in public
Expression of feelings of rejection
Preoccupation with own thoughts; repetitive meaningless actions

Interventions:

Convey an accepting and positive attitude by making brief, frequent contacts to increase feelings of self-worth and to build rapport
Be with the client to offer support during group activities that may be frightening or difficult for him or her to provide emotional security
Ensure the client has adequate space and an avenue for exit
Give recognition and positive reinforcement for client’s voluntary interaction with others

Fear

Causes & Behaviors:

Phobic stimulus
Physiological symptoms - mental or cognitive behaviors indicative of panic
Behavior directed toward avoidance of a feared object or situation

Interventions:

Provide reassurance that the client is safe
Explore client’s perception of threat to physical integrity or threat to self-concept to help build an understanding of the the client's own condition so that they can work toward desensitization
Encourage the client to explore underlying feelings that may be contributing to irrational fears. Help client to understand that facing these feelings, rather than suppressing them, can result in more adaptive coping abilities
Discuss the process of thinking about the feared object/situation before it occurs, as anticipation of a future phobic reaction allows client to be prepared to deal with the physical manifestations of fear
Encourage the client to use relaxation techniques

References

[1] American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.

[2] Bienvenu, O. J., Hettema, J. M., Neale, M. C., Prescott, C. A., & Kendler, K. S. (2007). Low extraversion and high neuroticism as indices of genetic and environmental risk for social phobia, agoraphobia, and animal phobia. The American Journal of Psychiatry, 164(11), 1714-1721.

[3] Boyd, M. A. (2019). Psychiatric & mental health nursing for Canadian practice. Wolters Kluwer.

[4] Ritchie, K., Norton, J., Mann, A., Carriere, I., & Ancelin, M. (2013). Late-onset agoraphobia: General population incidence and evidence for a clinical subtype. The American Journal of Psychiatry, 170(7), 790-798.

[5] Townsend, M. C. (2015). Psychiatric mental health nursing. F.A. Davis.