ARE YOU AGORAPHOBIC?

It is estimated that approximately 22% of the population suffers from agoraphobia at some point in their lives. This fear of public places occurs when the person panics at the idea of not being able to escape easily or to be rescued. The agoraphobic fears places such as public transport, large spaces, enclosed spaces, public places etc. This disorder mainly concerns personalities of an anxious nature following a trauma but can also affect anyone. Agoraphobia manifests itself in a more or less intense way and should not be taken lightly.

There is a test to measure panic and agoraphobia from a strictly medical point of view: Panic and Agoraphobia Rating Scale (PARS)

1. What is agoraphobia? 

Agoraphobia belongs to the family of panic disorders. That is, a sudden and intense panic attack, lasting on average 30 minutes, is triggered when the anxiety-provoking stimulus is visible or imagined (Bandelow, 1995). At the very beginning, agoraphobia was characterized as “the fear of spaces” (Legrand du Saule, 1878). But agoraphobia has been the subject of much research that has gradually supported the definition. Today, it is a fear of places in which it is difficult to escape. This may be because the space is closed and access is restricted, or because there is a crowd. The latter would limit the possibility of easily escaping from the place or receiving the necessary help in case of danger (Preti, & al., 2021). This is why it is difficult for sufferers to take public transport, go to supermarkets or outdoor markets, go to concerts, stand in a queue etc. Going out alone is also very difficult for them. In a more general way, it is estimated that the agoraphobic person is anxious when he is far from a figure of safety (person, place, object…) (Snaith, 1968). Moreover, they anticipate the fear of their exit, which generates a vicious circle of anguish. The person will feel destroyed by everything that the agoraphobia has upset in their life (Reydellet, 2009).

It is estimated that approximately 22% of the population suffers from agoraphobia at some point in their lives (Wittchen & al., 2010).

2. What are the symptoms and characteristics of agoraphobia?

The phobia, in a general way, can be considered in itself as a symptom; the symptom of a malaise, of an unhealed wound, of a maladjustment to an environment… (Wiener, 2005). In any case, it is almost impossible to dissociate phobia and anxiety. Indeed, the anxiety generated by the anxiogenic situation leads, in the majority of cases, to a panic attack (Breier & al., 1986). This reaction is nervous and can be qualified as emotional (Legrand du Saulle, 1878).

Panic attacks are characterized by tachycardia, breathing difficulties, choking, abdominal or chest pain, numbness, excessive sweating, tremors, nausea, dizziness, etc. In addition, they very often involve various fears, such as that of death, loss of control, madness, sometimes with a feeling of unreality (Meuret & al., 2006). The person could also feel chills or a sensation of strong heat. He or she might feel as if he or she no longer really belongs to his or her own body (Chapelle, 2018).

Agoraphobia is characterized by difficulty leaving one’s home and moving about freely without being accompanied by a trusted person (Goldstein & Chambless, 1978). The DSM-5 (APA, 2013) refers to particularly high anxiety when using public transportation, being in covered or open areas, in a crowd, or alone outside. Thus, the person will avoid all situations where he or she feels in danger without being able to be rescued (Preti & al., 2021). Indeed, if he/she cannot avoid it, the person will feel overwhelmed by anxiety, realizes that his/her behavior is inappropriate, but cannot help feeling it. Awareness of this dysfunctional attitude only makes the anxiety in the situation worse (Peyré, 2011).

3. Where does the fear of public places come from?

The causes can be multifactorial. Initially, agoraphobia may come from the family environment: much like a ghost that follows the person from generation to generation and keeps the fear alive (Nachin, 2014). On peut même se demander si nous sommes génétiquement programmés pour être agoraphobe.

Secondly, agoraphobia can come from the family climate in which the person was raised. Indeed, an environment where the parent overprotects his or her child may make him or her think that the outside world is nothing but danger, and that at any moment, danger may arise. As a result, they will want to be in an environment where they can feel that they can be saved at any moment (Wittchen, 2010). In addition, a lack of support from parents in the face of the child’s anxious emotions can lead to a growing agoraphobia (Raila, & al., 2021). And as the child grows and becomes an adolescent, their search for independence is more anxiety-provoking as their anxieties have not been sufficiently addressed (Liebowitz, 2016). Thus, parents will then care for their young adult longer. They will further reinforce their fears by changing their lifestyle habits to accommodate their child. (Thompson-Hollands & al., 2014). On the other hand, it cannot be said that agoraphobia is genetic.

In addition, a life event that occurred in childhood can have an impact on the child’s view of the world. Indeed, some studies have shown that the risk of developing agoraphobia increases when a child has experienced a negative event, such as the premature death of a parent (Kendler & al., 1992). A traumatic childhood suggests an impact on possible agoraphobia. There are some indications that the child may be at risk for agoraphobia. For example, the fact that the child is very fearful, in general. Or that he or she has difficulty falling asleep due to nighttime anxieties (Balaram & Marwaha, 2021).

On the other hand, the event may be more recent and agoraphobia develops as a result of post-traumatic stress. Indeed, unconsciously, agoraphobia is a specific way of dealing with the trauma. Therefore, staying in the protective environment of the home is both an escape from one’s traumatic memory and a fear of an event that may be repeated (Reydellet, 2009).

Finally, certain personality disorders increase the risk of agoraphobia, such as dependent personalities, people with obsessive-compulsive disorder or people with major neurotic disorders (Tearnan & al., 1984).

But whatever the cause, no situation is irreparable.

4. What are the consequences for daily life and for the future?

First of all, it is important to note that agoraphobia is a disorder that has been continuously increasing over the years on a global scale (Wittchen & al., 2010). As such, it is not to be taken lightly as it heavily impacts the quality of life of sufferers (Preti & al., 2021).

Agoraphobia is a source of severe psychological suffering, and has a significant impact on the professional and social life of a person with this disorder (Grant & al., 2006). Initially, the panic attacks of an agoraphobic person become more and more severe, leading, in most cases, to panic disorder (Barzegar & al., 2021). That is, panic attacks are no longer triggered only in anxiety-provoking situations, but very frequently and unexpectedly (APA, 2013). This therefore often leads the agoraphobic to a generalized anxiety disorder if left untreated (Cousineau, 2015). 

Half of the people with agoraphobic disorder also develop mood disorders (Arthus, & al., 1997) due to their existing malaise. 

It is also common to trigger depressive symptoms, often tending towards severe depression (Kim & al., 2021). In addition, panic attacks and anticipatory anxieties significantly increase suicidal ideation, and therefore, the risk of acting out (Smith & al., 2020). It is also true that the anxiety generated by phobias often leads to sleep disturbances. It is reported that approximately 95% of phobic patients have concerns about getting restful rest (Chase & Pincus, 2011). 

Furthermore, the level of distress associated with agoraphobia is such that it is not uncommon to see an increase in excessive substance use such as alcohol, thus promoting dependence on this beverage (Norton & al., 2014). In agoraphobia, heavy drinking is a form of anxiolytic self-medication (Richa & al., 2008). Alcohol addiction, in turn, can create a negative impact on an individual’s social, financial, professional, and personal life (Azar & al., 2010). 

For children, agoraphobia has a particularly high comorbidity with separation anxiety (and therefore possibly a school phobia). In adulthood, the agoraphobic individual may have had strong separation anxiety that was not adequately addressed (Petot, 2004).

5. How to treat this phobia? 

The vast majority of agoraphobics have lost hope of recovery (Clum & Knowles, 1991). Therefore, the only strategy they have in place is avoidance (Shin & al., 2020). Indeed, the term “phobia” comes from the Greek word “phobos” which means “flight” (Kapsambelis, 2012). In general, and because we are animals with a survival instinct, we avoid situations that make us vulnerable and that are for us, a source of stress. Furthermore, agoraphobics tend to seek help late in life as they are panicked at the idea of having to place themselves in an anxiety-provoking situation, leaving their safe home (Perreault, & al., 2009). But there are solutions.

Therefore, in order to reduce avoidance behavior, suppress fear and automatic stress responses, exposure therapies are most effective (Richter & al., 2021). This allows one to learn to accept one’s anxiety in a given situation, and to erase it little by little (Emmelkamp, 1974). This is why, more generally, cognitive-behavioral therapy (CBT) is preferred (Marchand & al., 2004). Indeed, exposure to cognitive-behavioral therapies has made it possible to drastically reduce the use of medication, also in the long term, for these sufferers (Arthus & al., 1997). 

6. What is the Panic and Agoraphobia Rating Scale (PARS)?

There are very few scientifically validated scales to assess agoraphobia specifically. In fact, we generally find scales that measure anxiety in a general way. The existing assessments were very long and not objective enough to be considered sufficiently significant (Roberge & al., 2003). This is why Bandelow (1995) created and validated the “Panic and Agoraphobia Scale” with 235 patients, based on the DSM-III criteria. Several years later, seeing the lack of scales on agoraphobia validated in French, Roberge and his collaborators translated and validated the “Panic and Agoraphobia Rating Scale” (PAS) in 2003.

Through this questionnaire, you will be able to get an idea of your level of anxiety when you are registered in a place that may cause agoraphobia. Answer in a completely honest and natural way. Please note that your answers are neither recorded nor consulted. Indeed, the sole purpose of this test is to help you understand the anxiety you may be feeling and to give you an idea of your possibilities. 

7. What are the prevalences of agoraphobia? 

Agoraphobia, associated with other panic disorders, such as generalized anxiety and/or panic disorder is considered to be quite common, even if there are great disparities in scientific research (Roest, & al., 2019). Therefore, it is estimated that between 1.5% (Ramage-Morin, 2004) and 18.1% (Kessler & al., 2005) of the population has an anxiety disorder with agoraphobia.

Women tend to be more prone to this phobia than men (some studies speak of two women for one man) (Perreault, 2009). Coping strategies are particularly variable: depressive disorders, alcohol abuse, anxiety disorders, etc. (Lépine, 2005).

Adolescents and young adults tend to be at greater risk of developing agoraphobia than older people. This does not exclude, however, a risk at any age (McCabe & al., 2006). However, it is not uncommon to encounter an older person with agoraphobia, as the disorder, having gone untreated, may have persisted over time (Manela & al., 1996). Thus, people suffer in their social relationships and are particularly prone to isolation and loneliness (Russell & al., 1997).

8. Virtual reality as a treatment for agoraphobia?

It is particularly important not to let an anxiety-provoking situation in an outside setting fester at the risk of developing strong comorbidities. Exposure in cognitive-behavioral therapy allows, in fact, to modify erroneous beliefs in the face of panic attacks but also in anxiogenic situations (Mirabel-Sarron, 2011). Exposure therapies allow the appropriation of physiological sensations of panic, and thus reduce its frequency (Audet, 1997). Thus, therapeutic work is done on the attitude towards the situation, on the emotions felt and on the cognitions linked to the difficulty (Mirabel-Sarron, 2011). Thus, virtual reality makes it possible to have the same effects as classical exposure without having the constraints, since the cost-benefit ratio is largely superior to that of classical exposure (Bottela & al., 2007). In fact, virtual reality allows us to habituate to the situation, just as cognitive-behavioral therapy would do in in-vivo exposure (Rothbaum & al., 2001).

It has, moreover, been proven that after therapeutic follow-up with virtual reality for patients suffering from agoraphobia, their mood improved, their anxiety and avoidance decreased and the fear related to agoraphobia associated with its negative thoughts reduced (Malbos & al., 2013). It is true that virtual reality allows for a similar environment to reality, yet is easily accessible (Valmaggia & al., 2016). The exposure is completely safe as the therapist has direct access to what they are offering their patient, and can interact at any time so that the phobic person can manage their difficulties more easily (Rizzo & Kim, 2005). The feeling of presence offers the most total immersion (Slater, 2004). From then on, it has been shown that the treatment of agoraphobia in virtual reality allows for visible and lasting changes on the patients (Gebera & al., 2016). The patient advances according to his or her temporality and is followed in his or her progress while being exposed to situations that he or she would not have thought were surmountable.