Editing Agoraphobia (section)

== Causes ==
Agoraphobia is believed to be due to a combination of [[Genetics|genetic]] and environmental factors. The condition often runs in families, and stressful or traumatic events such as the death of a parent or being attacked may be a trigger.<ref name=DSM5 />

Research has uncovered a link between agoraphobia and difficulties with spatial orientation.<ref>{{cite journal |vauthors=Yardley L, Britton J, Lear S, Bird J, Luxon LM | title = Relationship between balance system function and agoraphobic avoidance | journal = Behav Res Ther | volume = 33 | issue = 4 | pages = 435–9 | date = May 1995 | pmid = 7755529 | doi = 10.1016/0005-7967(94)00060-W }}</ref><ref>{{cite journal |vauthors=Jacob RG, Furman JM, Durrant JD, Turner SM | title = Panic, agoraphobia, and vestibular dysfunction | journal = Am J Psychiatry | volume = 153 | issue = 4 | pages = 503–512 | year = 1996 | pmid = 8599398 | doi=10.1176/ajp.153.4.503}}</ref> Individuals without agoraphobia are able to maintain balance by combining information from their [[vestibular system]], their [[visual system]], and their [[proprioceptive]] sense.  A disproportionate number of agoraphobics have weak vestibular function and consequently rely more on visual or tactile signals.  They may become disoriented when visual cues are sparse (as in wide-open spaces) or overwhelming (as in crowds).<ref name="Jacob et al 1997">{{cite journal |vauthors=Jacob RG, Furman JM, Durrant JD, Turner SM | title = Surface dependence: a balance control strategy in panic disorder with agoraphobia | journal = Psychosom Med | volume = 59 | issue = 3 | pages = 323–30 | year = 1997 | pmid = 9178344 | doi =  10.1097/00006842-199705000-00016| s2cid = 9789982 }}</ref> Likewise, they may be confused by sloping or irregular surfaces.<ref name="Jacob et al 1997" />

In a [[virtual reality]] study, agoraphobics showed impaired processing of changing audiovisual data in comparison with subjects without agoraphobia.<ref>{{cite journal |vauthors=Viaud-Delmon I, Warusfel O, Seguelas A, Rio E, Jouvent R | title = High sensitivity to multisensory conflicts in agoraphobia exhibited by virtual reality | journal = Eur. Psychiatry | volume = 21 | issue = 7 | pages = 501–8 | date = October 2006 | pmid = 17055951 | doi = 10.1016/j.eurpsy.2004.10.004 | s2cid = 6932961 | url = https://hal.archives-ouvertes.fr/hal-03411683/file/EurPsy2006.pdf }}</ref>

=== Substance-induced ===
Chronic use of [[tranquilizer]]s and sleeping pills such as [[benzodiazepine]]s has been linked to onset of agoraphobia.<ref>{{cite book |veditors=Palmer S, Dainow S, Milner P |title=Counselling: The BACP Counselling Reader |volume=1 |year=1996 |publisher=Sage |isbn=978-0-8039-7477-7 |pages=211–4 |chapter-url=https://books.google.com/books?id=wnIBEQKQi7IC |vauthors=Hammersley D, Beeley L |chapter=The effects of medication on counselling }}</ref> In 10 patients who had developed agoraphobia during [[benzodiazepine dependence]], symptoms abated within the first year of assisted withdrawal.<ref>{{cite journal | author = Ashton H | title = Benzodiazepine withdrawal: outcome in 50 patients | journal = Br J Addict | volume = 82 | issue = 6 | pages = 665–71 | date = June 1987 | pmid = 2886145 | doi = 10.1111/j.1360-0443.1987.tb01529.x }}</ref> Similarly, alcohol use disorders are associated with panic with or without agoraphobia; this association may be due to the [[long-term effects of alcohol consumption]] causing a distortion in brain chemistry.<ref name="pmid17592911">{{cite journal |vauthors=Cosci F, Schruers KR, Abrams K, Griez EJ | title = Alcohol use disorders and panic disorder: a review of the evidence of a direct relationship | journal = J Clin Psychiatry | volume = 68 | issue = 6 | pages = 874–80 | date = June 2007 | pmid = 17592911 | doi = 10.4088/JCP.v68n0608 }}</ref>

Tobacco smoking has also been associated with the development and emergence of agoraphobia, often with panic disorder; it is uncertain how tobacco smoking results in anxiety-panic with or without agoraphobia symptoms, but the direct effects of nicotine dependence or the effects of tobacco smoke on breathing have been suggested as possible causes. [[Self-medication]] or a combination of factors may also explain the association between tobacco smoking and agoraphobia and panic.<ref name="pmid19961810">{{cite journal |vauthors=Cosci F, Knuts IJ, Abrams K, Griez EJ, Schruers KR | title = Cigarette smoking and panic: a critical review of the literature | journal = J Clin Psychiatry | volume = 71 | issue = 5 | pages = 606–15 | date = May 2010 | pmid = 19961810 | doi = 10.4088/JCP.08r04523blu }}</ref>

=== Attachment theory ===
{{Main|Attachment theory}}
Some scholars<ref>G. Liotti, (1996). ''Insecure attachment and agoraphobia'', in: C. Murray-Parkes, J. Stevenson-Hinde, & P. Marris (Eds.). Attachment Across the Life Cycle.</ref><ref>J. Bowlby, (1998). ''Attachment and Loss'' (Vol. 2: Separation).</ref> have explained agoraphobia as an attachment deficit, i.e., the temporary loss of the ability to tolerate spatial separations from a secure base.<ref>{{cite journal | author = Jacobson K | year = 2004 | title = Agoraphobia and Hypochondria as Disorders of Dwelling | journal = International Studies in Philosophy | volume = 36 | issue = 2| pages = 31–44 | doi=10.5840/intstudphil2004362165}}</ref> Recent empirical research has also linked attachment and spatial theories of agoraphobia.<ref>{{cite journal | author = Holmes J | year = 2008 | title = Space and the secure base in agoraphobia: a qualitative survey | journal = Area | volume = 40 | issue = 3 | pages = 357–382 | doi = 10.1111/j.1475-4762.2008.00820.x | bibcode = 2008Area...40..375H }}</ref>

=== Spatial theory ===
In the social sciences, a perceived clinical bias<ref>J. Davidson, (2003). ''Phobic Geographies''</ref> exists in agoraphobia research. Branches of the social sciences, especially [[geography]], have increasingly become interested in what may be thought of as a [[Three-dimensional space|spatial]] phenomenon. One such approach links the development of agoraphobia with [[modernity]].<ref>{{cite journal | author = Holmes J | year = 2006 | title = Building Bridges and Breaking Boundaries: Modernity and Agoraphobia | journal = Opticon 1826 | volume = 1 | page = 1 | url = http://www.ucl.ac.uk/opticon1826/archive/issue1 | doi = 10.5334/opt.010606 | url-status=live | archive-url = https://web.archive.org/web/20160303233808/http://www.ucl.ac.uk/opticon1826/archive/issue1 | archive-date = 2016-03-03 | doi-access = free }}</ref> Factors considered contributing to agoraphobia within modernity are the ubiquity of cars and urbanization. These have helped develop the expansion of public space and the contraction of private space, thus creating a conflict in the mind of agoraphobic individuals.

=== Evolutionary perspectives ===
Some [[Evolutionary psychiatry|evolutionary models]] propose that agoraphobia—like other specific phobias—may be rooted in adaptive mechanisms that helped early humans avoid threats in open or unfamiliar environments. From this viewpoint, fear and avoidance behaviors could have been selectively favored if they aided survival—for instance, by prompting individuals to steer clear of potentially dangerous surroundings or minimize exposure to predators and pathogens. According to preparedness models, human defensive systems are especially sensitive to cues linked to ancestral threats and can rapidly form strong, lasting fear associations with them. In modern life, such defenses might become mismatched to relatively low-risk environments, producing disproportionate anxiety responses.<ref>{{Cite book |last=Del Giudice |first=Marco |title=Evolutionary psychopathology: a unified approach |date=2018 |publisher=Oxford University Press |isbn=978-0-19-024684-6 |location=New York, NY |pages=335–342}}</ref>

An additional [[evolutionary psychology]] view is that the more unusual primary agoraphobia without panic attacks may be due to a different mechanism from agoraphobia with panic attacks. Primary agoraphobia without panic attacks may be a [[specific phobia]] explained by it once having been evolutionarily advantageous to avoid exposed, large, open spaces without cover or concealment. Agoraphobia with panic attacks may be an avoidance response secondary to the panic attacks, due to fear of the situations in which the panic attacks occurred.<ref>{{cite journal | author = Bracha HS | title = Human brain evolution and the "Neuroevolutionary Time-depth Principle:" Implications for the Reclassification of fear-circuitry-related traits in DSM-V and for studying resilience to warzone-related posttraumatic stress disorder | journal = Progress in Neuro-Psychopharmacology and Biological Psychiatry | volume = 30 | issue = 5 | pages = 827–853 | year = 2006 | pmid = 16563589 | pmc =  7130737| doi = 10.1016/j.pnpbp.2006.01.008 | url = http://cogprints.org/5013/1/2006_P.N.P._Neuro-evolution_of_fear_circuit_disorders.pdf }}</ref><ref>{{cite journal|vauthors=Raffaello S, Alessandra SM, Alessandra S |year=2011 |title=[Primary agoraphobia specific symptoms: from natural information to mental representations] |language=it |journal=Italian Journal of Psychopathology |volume=17 |issue=3 |pages=265–276 |url=http://www.gipsicopatol.it/issues/2011/vol17-3/02%20Spiti.pdf |url-status=dead |archive-url=https://web.archive.org/web/20120426082624/http://www.gipsicopatol.it/issues/2011/vol17-3/02%20Spiti.pdf |archive-date=2012-04-26 }}</ref>