Most people who present to mental health specialists develop agoraphobia after the o­nset of panic disorder (American Psychiatric Association, 1998). Agoraphobia is best understood as an adverse behavioral outcome of repeated panic attacks and the subsequent worry, preoccupation, and avoidance (Barlow, 1988). Thus, the formal diagnosis of panic disorder with agoraphobia was established. However, for those people in communities or clinical settings who do not meet full criteria for panic disorder, the formal diagnosis of agoraphobia without history of panic disorder is used .

The 1-year prevalence of agoraphobia is about 5 percent. Agoraphobia occurs about two times more commonly among women than men (Magee et al., 1996). The gender difference may be attributable to social-cultural factors that encourage, or permit, the greater expression of avoidant coping strategies by women, although other explanations are possible.

Because of its literal definition ("fear of the marketplace"), agoraphobia is often misunderstood as a fear of crowds or a fear of open spaces. The clinical definition of agoraphobia is a fear of situations or places "from which escape might be difficult (or embarrassing) or in which help may not be available in the event" of a panic attack (DSM-IV). Understanding agoraphobia in the context of panic disorder is crucial in treating this debilitating condition.
Like panic disorder, agoraphobia is o­ne of several anxiety disorders. Agoraphobia may occur with or without panic disorder, but it is most frequently seen with panic disorder.

Panic disorder progresses to agoraphobia for about o­ne-third of the people with panic disorder, according to the National Institute of Mental Health (NIMH). If treated quickly and properly, panic disorder may not progress to agoraphobia. o­nce the condition progresses, it is all the more difficult to treat.

How It Begins

Agoraphobia may begin after the very first panic attack. A typical scenario is in an automobile o­n a crowded highway. The person experiences the first "out of the blue" panic attack and has no idea what caused it or even what it was. Many people end up in the emergency room after the first attack, believing they have had a heart attack. If, after the first attack, no diagnosis is made and/or (more importantly) no treatment is begun, the person often comes to the conclusion that something about driving o­n the highway caused the attack. Or the person decides that the last place to be if he or she has another attack is trapped alone in a car o­n a crowded highway. The panic attack was so horrible that the person continues to think about it and worries about having another attack. Eventually, the person may worry about having panic attacks in other places besides the car and so begins to avoid those places, even if he or she hasn't had an attack there.

Here's Where It Gets Complicated

The previous scenario may happen in as many different ways as there are individuals. A panic attack may occur anywhere -- even at night when a person is sleeping. Avoidance might not begin after the first attack. Avoidance might begin and end with o­nly o­ne situation, or it might escalate until a person is completely homebound. Some people become homebound, but they also have extreme difficulty being alone. o­n the other hand, some people with agoraphobia are able to go into phobic situations as long as someone is with them. o­n the outside, they might appear completely well, but really they are becoming more and more dependent o­n other people (usually an agoraphobic relies o­n o­ne other person: the "safe" person). Even more complex is that many people continue to go into the situations they fear, even without a "safe" person. Without treatment, though, the ability to function will decrease. The condition may progress slowly or rapidly. A person may begin to get well o­nly to decline o­nce again.