The nature of Agoraphobia

Agoraphobia is a diagnostic entity separate from Panic Disorder but closely associated with it. Whereas the panic experience is characterized by a set of somatic symptoms associated with intense fear, agoraphobia is the end product of the sufferer’s effort to avoid the fear of a panic attack. Therefore, the panic experience is equivalent with the emotion of fear. Agoraphobia is the result of an effort that has not succeeded in protecting from fear. Although agoraphobia can be diagnosed in the absence of panic attacks (in cases where the emotion of fear has not reached attack level manifestations) usually there is a gradual progression from fear to panic to agoraphobia.

The person who has experienced panic attacks and has grown fearful of them engages in imaginary or actual behaviours that aim to reduce the possibility of a future panic attack. The behaviours are perceived as protective only when they succeed at neutralizing the fearful thoughts and when they introduce a feeling of emotional reassurance and internal calmness in the patient. For most patients the best way to feel emotionally secure and protect themselves from panic is to know that they are in a familiar environment. The most familiar environment for the majority of patients is their home or neighborhood or  the presence of a familiar and trusted person (in cases of traveling away from home).

Therefore, the patient who is afraid of panic experiences tries to avoid them by remaining within the boundaries of emotional security. Soon s/he mistakenly concludes that real emotional security is to be found only within the boundaries of his/her own home, because this is the only place that s/he can experience a panic attack in absolute privacy, if such an attack ever happened. In extreme cases, even one’s home does not offer enough protection from the fear of panic. In the end of this process the patient realizes that the effort to protect from the fear of panic through the avoidance strategy has in reality placed him/her within the boundaries not of emotional security but of “a prison without walls”.