Agoraphobia: Symptoms, Causes, Diagnosis and Treatment

01Basics

What is agoraphobia?

The NHS defines agoraphobia as a fear of being in situations where escape might be difficult or help would not be available if things go wrong. Many people assume it is simply a fear of open spaces, but it is a more complex condition. Mayo Clinic describes it as a type of anxiety disorder that involves fearing and avoiding places or situations that might cause panic and feelings of being trapped, helpless or embarrassed.

The fear can be about an actual situation or an upcoming one. Mayo Clinic says agoraphobia usually starts in the late teens or early adult years, usually before 35, although older adults can develop it too, and that females are diagnosed more often than males.

02Feared situations

Situations people with agoraphobia fear

Typical feared situations described by the two sources include:

• leaving home, especially alone
• using public transportation, such as a bus, train or plane
• shopping centers, small stores and supermarkets
• crowds and waiting in line
• enclosed spaces, such as movie theaters or elevators
• open spaces, such as parking lots, bridges or malls

The fear is not only of panic. Mayo Clinic notes that people may fear getting lost, falling, fainting, dizziness or having diarrhea and not reaching a bathroom.

03Symptoms

Symptoms and avoidance

In a stressful situation, a person with agoraphobia usually feels the symptoms of a panic attack: a rapid heartbeat, rapid breathing, feeling hot and sweaty or feeling sick. Over time they avoid the situations that cause anxiety. The NHS gives examples: only leaving the house with a friend or partner, or ordering groceries online instead of going to the supermarket. This change in behavior is called avoidance.

Mayo Clinic lists further features: the fear is out of proportion to the actual danger; the person avoids the situation, needs a companion or endures it with great distress; and the fear causes major problems in social life, work or other areas. In severe cases people may feel they cannot leave home at all, and without treatment some become housebound for years.

04Panic attacks

Agoraphobia and panic attacks

Agoraphobia can develop as a complication of panic disorder. The NHS explains that a person may link panic attacks with the places where they occurred and then avoid them; Mayo Clinic says most people with agoraphobia develop it after one or more panic attacks. A panic attack is a sudden feeling of extreme fear that peaks within minutes, with symptoms such as a racing heart, trouble breathing, chest pain, dizziness, trembling, sweating, chills, stomach upset and fear of losing control or dying.

But not everyone with agoraphobia has had panic attacks. The NHS says that in these cases the fear may relate to issues such as crime, terrorism, illness or having an accident. Our guides on panic attacks and panic disorder treatment cover those topics in depth.

05Causes

What may contribute to agoraphobia

Mayo Clinic says biology (including health conditions and genetics), personality, stress and learning experiences may all play a role. Risk factors include:

• having panic disorder or other phobias
• responding to panic attacks with a lot of fear and avoidance
• stressful life events such as abuse, the death of a parent or being attacked
• an anxious or nervous personality
• a blood relative with agoraphobia

These are factors that may increase the chance of developing it, not certain causes, and they do not mean anyone is to blame. Agoraphobia can also lead to depression, alcohol or drug misuse and suicidal thoughts, which is another reason to seek help early.

06Diagnosis

How agoraphobia is diagnosed

Mayo Clinic says agoraphobia is diagnosed based on the symptoms, an in-depth interview with a health care or mental health provider, and a physical exam to rule out other conditions that could cause the symptoms. The NHS explains that the doctor will ask how often symptoms occur and in what situations, whether leaving the house is stressful, which places you avoid and whether you rely on others, for example to do your shopping.

Mayo Clinic’s criteria mention fear and avoidance that usually last six months or longer. That describes the condition; it is not a reason to wait. Mayo Clinic advises getting treatment as soon as possible, because anxiety can be harder to treat the longer you wait.

07Getting help

Asking for help when leaving home is hard

Both sources recognize that going to an appointment can itself be difficult. The NHS says it should be possible to arrange a telephone consultation with a GP if you do not feel ready to go in person, and that in England you can refer yourself for talking therapies. Mayo Clinic suggests starting with a video visit or phone call, looking for a therapist who can offer alternatives to office appointments at first, and taking a trusted relative or friend for comfort. For very severe cases it mentions intensive outpatient or residential programs.

In our psychology practice in Bilbao we offer therapy for adults with anxiety and agoraphobia (consultations are in Spanish).

08Treatment

Treatment: CBT, gradual exposure and medicine

Mayo Clinic says cognitive behavioral therapy (CBT) is the most effective talk therapy for anxiety disorders, including agoraphobia. It teaches skills to tolerate anxiety, challenge worries and gradually return to avoided activities. The most important part is exposure therapy: approaching feared situations in a gradual, predictable, controllable and repeated way, so that anxiety decreases and feared outcomes tend not to happen. Exposure is planned with the therapist step by step; it is not about being pushed into a situation all at once.

A companion can help by agreeing the steps in advance with the person and, ideally, the therapist: which place, for how long, where the companion will be, and how their presence will be reduced little by little. Mayo Clinic notes that family, friends and the therapist can help with practicing going to more places.

Medicine may also be used. The NHS says that if self-help and lifestyle changes are not enough, a course of selective serotonin reuptake inhibitors (SSRIs) is usually prescribed. Mayo Clinic adds that it may take weeks to work, several may need trying, and doses are raised and lowered gradually. Lifestyle steps from both sources include regular exercise, a healthy diet, enough sleep, and avoiding alcohol, drugs and caffeine.

09Sources

Where the sources differ

Role of panic attacks. Mayo Clinic says most people develop agoraphobia after one or more panic attacks. The NHS stresses that not everyone with agoraphobia has had them, and that some fear crime, terrorism, illness or accidents instead.

Order of treatment. The NHS presents lifestyle changes and self-help first, then talking therapies, and medicine if these are not effective, combining treatments in severe cases. Mayo Clinic says treatment usually includes both psychotherapy and medicine. The right combination is decided with the professional.

Duration criterion. Mayo Clinic mentions fear and avoidance lasting six months or longer; the NHS overview gives no time frame and simply advises speaking to a GP if you think you may be affected.

10Summary

In summary

Agoraphobia is fear and avoidance of places or situations where escape or help seems difficult: public transport, shops, crowds, queues, enclosed or open spaces, or leaving home. It often follows panic attacks, but not always, and it can make life much smaller.

It is diagnosed through an interview and examination. CBT with gradual, planned exposure is the core treatment, sometimes with SSRIs, plus healthy habits. Phone or video contact can be a first step, and a companion can help by agreeing steps rather than pushing.