Agoraphobia

What is agoraphobia?

Agoraphobia is a type of social anxiety disorder. It causes people to have an extreme and irrational fear of situations that might make them feel trapped, embarrassed or scared, and unable to escape. These situations can include taking public transport, or being in large, open spaces or small and crowded spaces. People living with agoraphobia often avoid the situations and locations they fear, which, in severe cases, can lead to extreme isolation.

Panic disorder is often the root of agoraphobia, with around one-third of cases developing into agoraphobia. ^[1] Other causes include traumatic events and having a relative with agoraphobia.

Agoraphobia treatment includes lifestyle changes, psychological therapy, and medication. Some people may be completely cured, while others find that treatment reduces the periods of time they experience the disorder’s symptoms.

Types of agoraphobia

There are two types of agoraphobia: agoraphobia with panic disorder, which is the most common, and agoraphobia without panic disorder.

Agoraphobia with panic disorder

Most cases of agoraphobia develop as a complication of panic disorder. Panic disorder is a type of anxiety disorder that causes sudden onsets of extreme fear, which peak in the intense physical symptoms of a panic attack. Following a panic attack in a certain place or situation, a person developing agoraphobia begins to fear having another panic attack in a similar environment so much that they avoid that particular place or situation.

Agoraphobia without panic disorder

Less common is agoraphobia without panic disorder or a history of panic attacks. In these cases, it is often a different phobia that can trigger agoraphobia symptoms, including the fear of acquiring a terrible illness in a crowded space, or becoming the victim of a violent crime if a person leaves his or her house.

Agoraphobia symptoms

Symptoms of agoraphobia vary depending on the severity of the disorder, and fall into three categories: behavioral, physical, and cognitive.

Behavioral symptoms

Behavioral symptoms are perhaps most commonly associated with agoraphobia, and are a response to a fear of the physical and cognitive symptoms, manifesting as avoidance of certain situations.

Avoidance of a given situation is often developed when the person has previously experienced a panic attack in the same situation. Fearful that they will have another panic attack, the person starts to avoid this situation, as well as other locations where a panic attack might occur.

Situations and locations that people with agoraphobia fear might include:

• Large, open spaces like shopping malls or parking lots
• Small, crowded spaces like elevators, grocery stores, or movie theaters
• Using public transportation, like a train, bus, or airplane
• Leaving your home alone

Depending on the severity of the disorder, some people with agoraphobia are able to confront these situations, while for others, avoidant behavior can deeply impact their social and professional lives.

As the disorder advances, people with agoraphobia become less able to travel to work or to see friends and family, leading to isolation, detachment, and estrangement. In the most extreme cases, activities like going to the grocery store or even leaving the house become too overwhelming, causing people to remain inside for most of the day.

Many people living with agoraphobia recognize that their fear is out of proportion to the reality of the situation, but feel like they cannot do anything about it.

Physical symptoms

Similar to a panic attack, physical symptoms are triggered by intense feelings of anxiety, and can include:

• Chest pain or rapid heart rate
• Body shakes
• Shortness of breath
• Lightheadedness or dizziness
• Sudden chills or hot flushes
• Excessive sweating
• Nausea and/or upset stomach

Physical symptoms might only be experienced in the early stages of agoraphobia, as the disorder leads to a person fearing and then avoiding situations in which they might experience anxiety and panic attacks. However, people with agoraphobia might also experience panic attack symptoms simply by imagining the situations they fear.

Cognitive symptoms

• Cognitive symptoms often manifest as an intense fear of experiencing the physical symptoms. Examples might include:
• Feeling anxious that people will stare at you when you have a panic attack or lose control in a public place.
• Being worried that you will be unable to escape the situation or location in which you are having a panic attack.
• Being afraid that you will die or become critically unwell when having a panic attack, and be unable to find help.

Agoraphobia diagnosis

If you think you have agoraphobia, speak to a doctor or mental health professional.. If you’re unable to visit a doctor in person, it should be possible to organize a telephone or video appointment.

Your doctor will ask you to describe your symptoms, their frequency, when they started, and in what situations you experience them. They might also ask you about your family medical history. Examples of some questions they might ask include:

• Do you avoid certain locations or situations?
• Do you rely on others to do everyday tasks that you fear doing yourself?
• Do you find it scary or stressful to leave your house?

Your doctor may also want to do a physical examination, including a blood test, to rule out any underlying medical conditions that might be causing your symptoms. If they do not find any physical explanation for your symptoms, a diagnosis of agoraphobia can be confirmed based on the following criteria listed in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5). You must feel intense fear or anxiety in two or more of the following situations:

• Using public transport, such as a train or bus
• Being in open spaces, such as a store or parking lot
• Being in enclosed spaces, such as an elevator or car
• Being in a crowd or standing in line
• Being outside of your home alone

For a diagnosis of panic disorder with agoraphobia, there are additional criteria that must be met. Your symptoms must include recurrent panic attacks, and at least one panic attack must have been followed by:

• Fear of having more panic attacks
• Fear of the outcome of panic attacks, such as having a heart attack
• Changed behavior as a result of the panic attacks

If your doctor has any doubt about diagnosing agoraphobia, you may be referred to a specialist for a more detailed assessment.     

What causes agoraphobia?

The exact cause of agoraphobia is not known, but there are various factors that can increase the risk of developing the disorder.

Women are about twice as likely to have it than men. While symptoms can develop at any age, it is more common in teenagers and young adults, with an average onset age of 20. ^[3]

Other risk factors that raise your chances of developing agoraphobia include having:

• Panic disorders
• Other anxiety disorders, such as obsessive compulsive disorder
• Other phobias, such as claustrophobia
• A family history of agoraphobia
• Experience of trauma in your past, such as abuse or the death of a parent

Complications

Without treatment, agoraphobia can lead to isolation and a very limited lifestyle. Unable to work, socialize, or carry out other normal daily activities, people living with agoraphobia may also develop the following conditions:

• Depression
• Alcohol and drug abuse
• Other mental health disorders, including personality disorders like avoidant personality disorder

Prevention of agoraphobia

There is no proven way to prevent agoraphobia, but the earlier you address it, the easier it is to treat. The anxiety associated with certain situations tends to increase the more you avoid them, so if you start to feel fearful about going to certain places, practice going to these places over and over again, either alone, or with somebody you trust if it is too overwhelming. If this proves ineffective or you need more support, seek advice from your doctor.

Agoraphobia treatment

Your doctor may suggest a combination of therapy and medication to treat agoraphobia.

Therapy

Cognitive Behavioral Therapy (CBT)

CBT focuses on helping you to identify and challenge the thoughts that cause anxiety symptoms, and use this adjusted mindset to react more productively in stressful situations.

Exposure Therapy

Exposure therapy slowly and gently encourages you to confront the situations that cause anxiety, helping you to overcome your fear.

Applied relaxation

Based on the idea that people with agoraphobia have lost their ability to relax, applied relaxation uses a series of exercises to help cope with panic and tension.

Medication

Antidepressants

Antidepressants are more effective than anti-anxiety medications in the treatment of agoraphobia. Selective serotonin reuptake inhibitors (SSRIs) such as sertraline and serotonin-norepinephrine reuptake inhibitors (SNRIs) like venlafaxine work by balancing your serotonin levels. Other types of antidepressants may also treat agoraphobia effectively. It can take weeks for medication to relieve symptoms, and treatment lengths can vary from six months to over a year.

Anti-anxiety medication

For short term relief, your doctor might prescribe a brief course of benzodiazepines like alprazolam (Xanax). These sedatives are designed to treat acute flare-ups of anxiety, and are not a long term solution, as they can become addictive.

Self-care for agoraphobia

Professional treatment can help to relieve symptoms of agoraphobia, but there are also measures you can take yourself to support your treatment:

• Learn to manage your anxiety through activities like meditation and breathing exercises
• Exercise regularly to relieve stress and boost your mood
• Eata well-balanced and healthy diet
• Avoid recreational drugs, alcohol and caffeine, all of which can make your symptoms worse
• Join a support network to help you connect to others facing similar challenges

How to help someone with agoraphobia

Increasing your knowledge about the disorder is a good place to start when supporting somebody with agoraphobia. Helping them to seek professional help is an important step, but it is recommended to avoid pressuring them into a specific treatment.

People with agoraphobia need to feel like they can trust their support network not to judge their symptoms and behaviors, especially if they find themselves in a situation that triggers a panic response. Ask them how best you can help them, and try to be patient and understanding regardless of where they are on their journey to recovery.