The word agoraphobia means "a fear of wide, open spaces." The word originates from the ancient Greek word "agora," referring to a place of assembly or market place.
Agoraphobia is an anxiety disorder involving anxiety and intense fear of any situation where escape may be difficult, or where help may not be available. It often involves a fear of crowds, bridges or of being outside alone.1
About 1.8 million American adults aged over 18 (about 0.8% of adults) have agoraphobia without a history of panic disorder.2 This is about 0.8 % of people in this age group in a given year. The average age of onset is 20 years.3
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You will also see introductions at the end of some sections to any recent developments that have been covered by MNT's news stories. Also look out for links to information about related conditions.
Fast facts on agoraphobia
Here are some key points about agoraphobia. More detail and supporting information is in the main article.
- It is not known precisely what causes agoraphobia.
- Agoraphobia often develops after having one or more panic attacks.
- Agoraphobia can make it extremely difficult for a person to leave their house.
- Agoraphobia can lead to various fears, such as the fear of open spaces and the fear of places where escape is difficult, such as elevators.
- People with agoraphobia can experience feelings of helplessness and loss of control.
- People with agoraphobia may experience physical symptoms of a panic attack such as chest pains, dizziness and shortness of breath.
- Agoraphobia is usually diagnosed following an interview with a health care provider.
- Agoraphobia is often treated medically with antidepressants or anxiety-reducing medicine.
- Agoraphobia is also commonly treated with psychotherapy such as cognitive behavioral therapy.
- Most people with agoraphobia can get better through treatment.
What is agoraphobia?
An anxiety disorder is when a feeling of anxiety does not go away and tends to grow worse over time.4 One type of anxiety disorder is a panic disorder, where panic attacks and sudden feelings of terror can occur without warning.5
Agoraphobia can lead to a feeling of detachment from others, as well as fear of open spaces.
Agoraphobia is one such panic disorder. Agoraphobia panic attacks are linked with a fear of places where it is hard to escape or where help may not be available. Places that can induce agoraphobia include those that can make a person feel embarrassed, helpless or trapped, such as crowded areas, bridges, public transport and remote areas.
Most people develop agoraphobia after having had one or more panic attacks, causing them to fear further attacks and avoid the situation in which the attack occurred.6
People with agoraphobia may need help from a companion in order to go to public places, and may at times feel unable to leave home.
What causes agoraphobia?
The cause or causes of agoraphobia and other panic disorders remain unknown, but it is thought that areas of the brain that control the fear response may play a role, as could environmental factors. As there is evidence that anxiety disorders run within families, it also seems likely that genetic factors play a role in agoraphobia and other panic disorders.7
Agoraphobia also sometimes occurs after a person has had one or more panic attacks and begins to fear situations that could potentially lead to panic attacks in the future. Other panic disorders or phobias can play a developmental role.8
Recent developments on agoraphobia causes from MNT news
Researchers from the University of Missouri and the University of Nebraska-Lincoln discovered that people with the genotype 5-HTTLPR - linked to higher social anxiety - were less likely to engage in prosocial behavior, compared with those missing this genotype.
Signs and symptoms15910
Agoraphobia can manifest itself as a combination of fears, feelings and bodily symptoms.
People with agoraphobia can become housebound for long periods of time.
Common fears associated with agoraphobia are:
- Fear of spending time alone
- Fear of being in crowded places
- Fear of open spaces
- Fear of being in places where escape might be hard, such as public transport and elevators
- Fear of losing control in a public place
- Fear of death.
A person with agoraphobia may experience the following feelings:
- Detachment from others
- Loss of control
- As though the body is not real
- As though the environment is not real.
People with agoraphobia may become overly dependent on others, or remain housebound for long periods of time. In addition to these symptoms, people with agoraphobia can also experience the physical symptoms of panic attacks, such as:
- Chest pain or discomfort
- Racing heart
- Shortness of breath
- Upset stomach, nausea and diarrhea
- Flushing and chills
People who experience panic attacks may change their behavior and how they function at home, school or work. They may try to avoid situations that could trigger off further attacks. They may become sad, depressed or suicidal, and in some cases may abuse alcohol and other drugs.
A Swiss study recently found that compared to similar people without agoraphobia, people with agoraphobia had significantly higher levels of markers for inflammation (including C-reactive protein and tumor-necrosis-factor-α), and lower levels of adiponectin (a marker for cardioprotection).16
Levels of low-grade inflammation also appeared to increase over time in people with agoraphobia, suggesting that those suffering from the condition may have a higher risk of atherosclerosis and coronary heart disease.
Tests and diagnosis111
Agoraphobia is usually diagnosed following an interview with a health care provider, who assesses signs and symptoms. Descriptions of behavior may be requested from family or friends. In addition, a physical exam may be suggested to rule out other conditions that could potentially be causing the symptoms.
The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) published by the American Psychiatric Association is used to diagnose agoraphobia and other mental health conditions in the US. It is used by health care providers for this purpose, as well as by insurance companies to reimburse any treatment.
Extreme fear regarding being on public transport is one of the diagnostic criteria for agoraphobia.
The diagnostic criteria for agoraphobia within DSM-5 include anxiety or extreme fear regarding being in at least two of the following situations, characterized by being difficult to escape from or find help in:
- On public transport
- In an open space
- In an enclosed space
- In a crowd or queue
- Out of home alone.
Additional diagnostic criteria for agoraphobia include the following:
- Fear or anxiety caused almost always by exposure to a particular situation
- Fear or anxiety out of proportion to the actual danger of a particular situation
- Avoidance of a particular situation or requiring a companion in order to deal with it
- Endurance of a situation with extreme distress
- Distress or problems in areas of life caused by fear, anxiety or avoidance
- Long-term persistent phobia and avoidance.
Agoraphobia is usually treated with a combination of medication and psychotherapy. Most people with agoraphobia can get better through treatment, though it can become more difficult to treat if people do not get early, effective help.
Health care providers can prescribe either one or both of the following types of medication.
A group of antidepressants called selective serotonin reuptake inhibitors (SSRIs) can be prescribed to treat panic disorder with agoraphobia. Other types of antidepressants can also be prescribed, but they have a greater risk of side effects than SSRIs.
Anti-anxiety medications, also known as benzodiazepines, are sedatives that can relieve the symptoms of anxiety on a short-term basis. Benzodiazepines are a habit-forming medication.
A health care provider is likely to increase the dosage of prescribed antidepressants when treatment begins, and slowly decrease the dosage when the treatment is ready to finish. This caution is because starting and ending a course of antidepressants can sometimes lead to side effects that are similar to a panic attack.
Psychotherapy involves working with a therapist in order to reduce symptoms of anxiety and make a person with agoraphobia feel and function better.
One of the most common and effective forms of psychotherapy for anxiety disorders, including agoraphobia, is cognitive-behavioral therapy (CBT). It focuses on changing the thoughts that cause the condition. It can involve learning the following:
Psychotherapy is often used to treat agoraphobia. Sessions can sometimes be carried out at the patient's home to help.
- That it is unlikely that fears will come true
- That anxiety decreases over time and that symptoms can be managed until it does
- How to cope with the symptoms of agoraphobia
- How to understand and control a distorted view of stress-inducing situations
- How to recognize and replace thoughts that cause panic
- How to manage stress
- How to imagine the situations that cause anxiety, working from the least to the most fearful (referred to as systematic desensitization and exposure therapy).
Therapists who treat agoraphobia are often able to offer initial treatment without the need for the person with agoraphobia to visit the therapist's office. Therapy may be provided over the phone or via email, the therapist may conduct a home visit, or treatment sessions may be arranged in a place that the patient considers safe.
Research has also found that family support can aid the treatment of agoraphobia.13 Hostility towards agoraphobic family members increases the risk of them not completing their prescribed treatment plan. Equally, relatives that are too overbearing can also hinder therapy.
In addition to these treatment methods, there are several steps of self-care that can be utilized by a person with agoraphobia in order to help care for themselves and to cope with their condition:14
- Sticking to a plan of treatment
- Learning relaxation skills and how to achieve and maintain a sense of calm
- Trying not to avoid feared situations, making them less frightening
- Avoiding alcohol and illegal drugs
- Staying healthy with physical activity, a healthy balanced diet and getting enough sleep.
Due to the effect that agoraphobia can have on a person's ability to function day to day, it is recommended that anyone experiencing symptoms of agoraphobia contacts their health care provider. Treatment of the condition is easier the earlier that it begins.
Unfortunately, changes in the DSM-V definition of agoraphobia as distinct from panic disorder may affect the likelihood of some people obtaining a diagnosis of agoraphobia, which would then limit their ability to access treatment.
In particular, researchers found that in an analysis of 151 anxious youth seeking treatment for their anxiety, 25% of those who met the criteria for agoraphobia in the DSM-IV no longer met the criteria for agoraphobia in the DSM-V, despite the severity and impairment being the same for those youth who did meet the new criteria for diagnosis.17
Recent research suggests that a combination of medication, psychodynamic therapy and virtual reality may help people with agoraphobia to confront phobic stimuli.15
Recent developments on agoraphobia treatment from MNT news
New research suggests that cognitive behavioral therapy is more effective at reducing health anxiety in medical patients, compared with standard care. This is according to a study published in The Lancet.