Introduction

Agoraphobia is a type of mental health problem where a person gets fear of open spaces because person thinks there is a chance of having terror to these open spaces.

Because of this fear the person usually avoids to go open and public places such as fair, market, train, bus, flight, shopping plaza, shops or sometimes in a queue. The person affected goes out to these places only with the escort who should be family members or friends. Some people get affected by this disorder so severely that they feel it's safe to stay in home rather than going outside.

The fear of open spaces can be extremely embarrassing, and limits the person's social and personal growth in terms of academics, career and economic sustainability.

As per one study done by the NIMH (National Institute of Mental Health) about 1.8 million adult people of USA which is approximately 0.8 percent of the total population of adult living with this mental disorder. The average age of the people with this mental disorder is 20 years.

Symptoms of Agoraphobia
The symptoms of the agoraphobia can be categorized into three areas viz. physical, behavioral and psychological. The physical symptoms can be observed easily when the people affected with it will find himself or herself in crowded open place. The physical symptoms may include:
• Uneven heart rate or heart pounding
• Excessive sweat and hot
• Short of breath
• Fainting sensation
• Nausea and trembling in body
• Pressure in stomach
• Feeling of motion or bowel upset
• Darkness in front of eyes
• Chill or hot flush in the body
• Chest pain
• Numbness / tingling sensation in body (mainly in fingers and foot).

The behavioral symptoms may include:
• Unable to leave home- People affected try to avoid such environments which they feel that can trigger their anxiety and remain bound to home.
• Safety Concern- Sufferer are over concern about their safety and only go out after several spells of reassurance from someone who is very close to the patient like family members or close friends. In some cases the patient demands for escort to go out in open environment.
• Escape – The patient affected usually tries to leave the anxiety triggering places or situations and straight back to home.

The psychological symptoms may include:
• Feelings of unreality
• Fear of crowds
• Feelings of choking
• Fear of dying
• Fear of losing control
• Social Isolation
• Fear of panic attacks
• Fear of staying alone
• Low self esteem and self confidence
• Dependency on others for most of the out of home activities
Remember that these one or more symptoms can vary from individual to individual case and it can also vary from the level of severity eg it may be of mild level problem to different level problem in different individual.

Causes of Agoraphobia

The exact cause of agoraphobia is not known but experts give different hypotheses which are related to some or more with physical and psychological factors.
• Overuse of medicines – Long term dependence on medicines which induced sleep and pain relief has been linked by the experts for the induction of agoraphobia. Drugs such as benzodiazepines (Alprazolam and Diazepam), tranquilizers (piperazine, phenothiazines, butyrophenes etc) and other sleeping medications have been linked to agoraphobia. These drugs are mostly prescribed as treatment of anti-psychotic syndromes.

• Alcohol and tobacco dependence – Experts have also linked the overused of alcohol and tobacco in the development of agoraphobia. The direct dependence on chemical related to alcohol and tobacco overdose ie ethyl alcohol and nicotine has a capacity to distort the brain chemistry and can further lead to agoraphobia. Some people take drugs with alcohol to enhance mood which has also potential to aggravate agoraphobia.

• Spatial Orientation-Expert has related that the sufferers with agoraphobia have typically poor vestibular function which helps the body orientation with the spatial condition. Vestibular organ is a component in inner ear which helps the body in spatial condition such as deep inside the water or in dark place.

• Frequent Panic Attack- Experts also suggested that agoraphobia is different form of panic disorder in which sufferer gets regular intuition about attacks or freight situations. Sometimes sufferer gets intuition and fear about dying without any apparent reason. Sometimes sufferers may link any previous situations with their intuitions and try to justify their avoidance from escaping such situations.

• Other Factors- It may be a disturbing childhood with history of abuse, accident, marital discord among parents, drug abuse, mental illness, depression syndrome or experience with any natural (cyclone, earthquake) or manmade calamities (such as war, chemical hazard , fire etc).

Diagnosis of agoraphobia

Usually there are no medical or laboratory tests to diagnoseose agoraphobia in the lab. Most of the experts use screening interviews to ascertained that the person is suffering from agoraphobia.

A general practitioner is the one who usually diagnoses the symptoms of agoraphobia, with the help of; Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). This manual is published by the American Psychiatric Association and it is a guidebook used by mental mental health professionals to diagnose different mental conditions and it is also used by insurance companies for the reimbursement of treatment.
GP typically takes the help of psychiatrist who examines the sufferer history and symptoms through different detailed interview process. A psychiatrist is a medical professional who deals with problems of mental disorders.

The psychiatrist also drives to locate whenever agoraphobia has any link with another mental health conditions. In such situations the identified mental health condition needs to be addressed as a priority before treating agoraphobia.

Manual of DSM-IV (American Diagnostic manual) and ICD-10 (European diagnostic manual) has led down the criteria for the diagnosis of agoraphobia. Both the manuals differ on presence of different criteria for diagnosis of agoraphobia but 'avoidance or escaping from the anxiety situation' is one of the diagnostic criteria which are common in both the manuals.

The manual of DSM-IV has described that a patient is suffering from agoraphobia:
• If the patient gets anxiety or get panic attack
• If the patient avoids crowded places
• If the patient seek the help of family person, friend or cohort while going to open spaces.
• If the patient can not provide any satisfactory statements about his or her own behavior.

ICD-10 has described that a patient is suffering from agoraphobia if any of these two criteria are presented by patient:
• Anxiety in crowded place
• Fear in going out from home
• Anxiety in traveling alone or
• Fear in traveling out from home.

Treatment of agoraphobia

The clinical team usually prefers to go forward with the situation analysis of an individual. Some patients have only mild level of problem because they need to go for only some sessions of psychotherapy but in other cases where the problem is severe the combination of psychotherapy and medication is used. In most of these cases cases patient receives the treatment well and they learn to keep phobia under their control.

When agoraphobia is associated with other panic disorder, treatment begins with creating a learning platform for the patient so that the patient understands the problem related to panic and patient can develop response slowly to overcome his or her panic. Usually small activities are planned in between the sessions to give the patient firsthand experience to overcome his or her anxiety disorder.
Later the problem tree of agoraphobia is constructed to design mode of treatment with the situation analysis of problems of the patient.
Medical Treatment

Antidepressants and anti-anxiety drugs are generally prescribed for agoraphobia. 'Imipramine' is one of the famous tricyclic antidepressants and effectively used to treat agoraphobic symptoms. Venlafaxine is the other option for the experts which has proved effectively for long-term treatment of agoraphobia while TCA is considered as second option for the treatment of panic disorder when patient does not respond adequately to SSRI. SSRIs class antidepressants (sertaline or fluoxetine) which are actually selective serotonin reuptake inhibitors are also used for the treatment of agoraphobic situation. But these drugs have potential to give side effects such as:

• Nausea and vomiting sensation
• Dizziness and headache
• Sleeplessness and restlessness
• Sexual dysfunction

Benzodiazepines such as alprazolam is also used for panic disorder treatment, but long duration use of this medicine can create tolerance and dependency and overdose may have side effects such
• Balance and orientation loss
• Loss of memory
• Lethargy and perplexity
• Fainting sensation

It is the medical experts who typically decide the doze and selection of the medicine and in some cases doctor tries out trial and error method before selecting the right shot for the patient. Doctor normally increases the doze of medicine to get the appropriate results and slowly reduces the doze at the end of treatment before finally stopping it.

Psychotherapeutic Treatment

Psychotherapeutic treatment is a branch of psychology which uses the different psychotherapeutic techniques to deal with different mental disorders.

Cognitive-behavioral therapy (CBT) – It is the best experienced technique which is used for the treatment to agoraphobia. It has two components. First component focuses on exploration concerning agoraphobia and panic attacks and methods to control them and the other component focussing on coping mechanism of agoraphobia such as self control exercises. Through this therapy a patient learn about the symptoms of panic situations and their initiators as well as about the basic of relaxation therapy to control his or her anxiety.

For example, patient with agoraphobia have the thought that if he or she will use the train as a transport there will have an accident and it or she will die in that accident.

The therapist usually start the therapy with desensitization exercise in which anxiety stimulation is provided to the patient in small and structured way so that the patient initiates a stimulus to overcome its anxiety. Slowly with each session the therapist increases the stimulus of anxiety so that the patient learns to respond those stimuli with the help of therapist under guidance. Therapist usually chooses to initiate the session from patient home because the therapist office may have several initiators to increase the anxiety level. CBT usually consist of 10 -15 sessions, with each session length last for an hour.

Exposure Therapy (ET) – Experts typically combine Cognitive Behavioral Therapy (CBT) with exposure therapy. Exposure therapy can provide long term solution to most of the patients with agoraphobia and panic disorders. Departure of residual agoraphobic symptoms and not simply the occurrence of panic attacks is the sole aim of the exposure therapy. Systematic desensitization is also used with exposure therapy as it is known fact that patients can deal with exposure easily if a friend or close companion remains with them during the exposure therapy.

Therapist gives small exposure to the patient in initial session so that the patient reacts and develops control on its anxiety. eg by giving exposure on buying some grocery to nearby shop or paying electricity bill in nearby center and then gradually the exposure increases once the patient gets confidence and react perfectly on small exposures.

Relaxation Therapy (RT) – Relaxation techniques are also useful techniques to control for the agoraphobic as they make necessary endurance level in the patients to so that they can stop or prevent stimulus of anxiety. It is based on the thought that people affected with agoraphobia are very restless and their ability to relax themselves goes away with the anxiety. The relaxation therapy uses different methods to teach the patient to relax. It is easy therapy to learn and costs very less.

Different relaxation techniques are:
• Control and slow the breath rate
• Mediation
• Lowering blood pressure through slowing heart rate
• Counting breath and number technique
• Control on anger and depression
• Increasing self esteem and confidence to handle problems

The three steps guide for relaxation is:
1. Indentify the sign of beginning the tension and fear
2. Start using relaxation technique to relieve tension and fear
3. Practice every day the same technique to prevent the feeling of tension and fear.

Alternative Medicines – Some alternative techniques are also used as a choice for treatment of acrophobia. These are:
• Hypnotherapy – The expert hypnotherapist will hypnotize the mind and try to remove the negative thoughts by stimulating the positive thoughts.
• Reiki- It is the ancient Japanese technique in which reiki expert use its hands to remove negative energy from the body and induce the positive energy in the body to make the patient healthy. This therapy works on energy transfer and sort of cleaning the body and mind

Complications of agoraphobia

Severe complications may arise if the symptoms of agoraphobia are not taken seriously. The physical and social mobility of the patient hampers in the initial stage and later the person have to live in isolation without any social contact.

The economic capacity of the person decreases as the job prospects are also hampered. The educational as well as other learned skills are slowly eroded and the patient is not able to compete anywhere in the market. It further leads into the vicious cycle of depression and severe anxiety. The person deteriorates his or her health and economic capacity and it further leads him or her to substance abuse like alcohol or drug abuse.

Simple lifestyle changes and self-help techniques to control anxiety

Controlling anxiety not only helps in controlling panic attacks and agoraphobia but it also helps in controlling other health problems like high blood pressure, depression and heart problem.
These self-help techniques are:
• Walk slowly and start deep breathing. Be patient and concentrate to increase the deep breath as anxiety will make the situation worse.
• Start Counting – Do not be panic with your anxiety but try to accept and reassure yourself. Start counting 1-10 and again back 10-1 and try to divert from the trigger points.
• Meditation- Meditation helps you to understand your strength and weakness. It also helps the person to concentrate strongly in case of anxiety.
• Positive-Be positive. Do not fear from accepting the weakness. But take a challenge to face the situation with positive determination.
Change in lifestyle techniques which can also help:
• Regular exercise like brisk walking, cycling or swimming relieves anxiety and gains self esteem.
• A timely nutritional diet makes you active and prompt.
• Reduce smoking as it will reduce nicotine from the body as well as the negative particles.
• Reduce intake of alcohol and go for fruit juice and veggies.
• Take proper sleep and rest to your body and mind
• Become social with more interaction with family, kids and friends.
• If possible enroll with some pet club or some charity club.

Summary

• With the advancement of science and medicines no special treatment has been developed to fix agoraphobia problem. Experts are using various combinations of behavior, medicinal and cognitive therapies for getting the desired results and these combinations are showing the best results. The major difficulty in treating the agoraphobia disorder is lack of trained specialist in the field.
• Lack of proven medicines is also one of the pitfalls in dealing agoraphobia. Most of the drugs are psychological in nature and they deals with removing the symptoms temporarily and can not treat the root causes of agoraphobia. Furthermore, medicines overdose and long usage can bring dependency as well as chances of severe side-effects. The best method is to use multiple therapies under the guidance of an expert for the greatest benefit.