Agoraphobia is an anxiety disorder that manifests as a fear of situations where escape could be difficult, or in which help would not be available if something bad were to happen.
The word comes from the ancient Greek word “agora,” referring to a place of assembly or market place.
The condition is often misunderstood as a fear of open spaces but is, in reality, more complex.
Agoraphobia may involve a fear of crowds, bridges or of being outside alone
About 1.8 million Americans aged over 18 years, or about 0.8 percent of adults, have agoraphobia without a history of panic disorder.
The median onset age is 20 years.
Agoraphobia is listed in the Diagnostic and Statistical Manual of Mental Disorder 5 (DSM-5) as an anxiety disorder.
An anxiety disorder is when a feeling of anxiety does not go away and tends to grow worse over time.
One type of anxiety disorder is a panic disorder, where panic attacks and sudden feelings of terror can occur without warning.
Agoraphobia is one such panic disorder. Agoraphobic panic attacks are linked to 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. These attacks cause them to fear further attacks, so they try to avoid the situation in which the attack occurred.
People with agoraphobia may need help from a companion to go to public places, and may at times feel unable to leave home.
Recent changes in diagnostic criteria
The terms of diagnosis have recently changed. Since 2013, DSM-5 states that people with agoraphobia no longer need to acknowledge the excessiveness of their anxiety in relation to the cause of the phobia.
In DSM-4, a person aged under 18 years had to have the condition for at least 6 months to receive a diagnosis.
In DSM-5, the 6-months duration has been extended to all patients. This is to avoid the overdiagnosis of transient, or fleeting, unrelated fears.
DSM-4 also linked the diagnoses for panic disorder and agoraphobia, but this changed in DSM-5 because a considerable number of patients with agoraphobia do not experience panic symptoms.
Panic disorder and agoraphobia are now two separate diagnoses, and the labeling of “agoraphobia with or without panic disorder” no longer applies.
Agoraphobia is usually treated with a combination of medication and psychotherapy.
Treatment is effective for most people with agoraphobia, but it can be harder to treat if people do not get early help.
Healthcare professionals can prescribe either one or both of the following types of medication.
Selective serotonin reuptake inhibitors (SSRIs) are a type of antidepressant that can be prescribed to treat agoraphobia.
Other types of antidepressants can also be prescribed, but the adverse effects may be greater.
Anti-anxiety medications, also known as benzodiazepines, are sedatives that can relieve the symptoms of anxiety in the short term.
Benzodiazepines can be habit-forming.
The antidepressants may start on a higher dosage and slowly decrease when the treatment is ready to finish.
Starting and ending a course of antidepressants can sometimes lead to side effects that are similar to a panic attack, and caution is therefore advised.
Psychotherapy involves working with a therapist to reduce symptoms of anxiety so that the person will feel safer and able to function better.
Cognitive-behavioral therapy (CBT) focuses on changing the thoughts that cause the condition.
The person may learn:
- 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
- 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
One task might be to imagine the situations that cause anxiety, working from the least to the most fearful.
Therapists who treat agoraphobia may offer initial treatment without the patient needing to visit the therapist’s office.
Options may include telephone or online therapy, home visits, or treatment sessions in a place that the patient considers safe.
Family support can also help by showing understanding and by not pushing the individual too far.
Self-help tips for managing symptoms
Self-care that may help include:
- sticking to a recommended treatment plan
- learning how to relax and achieve and maintain a sense of calm
- trying to face feared situations, as this can make them less frightening
- avoiding alcohol and recreational drugs
- staying healthful with physical activity, a balanced diet, and enough sleep
Agoraphobia can present as a combination of fears, feelings, and physical symptoms.
A person with agoraphobia will commonly fear:
- spending time alone
- being in crowded places, open spaces, or small spaces
- embarrassment, or of showing embarrassment
- losing control in a public place
- others staring
- losing sanity
- death, or that a panic attack will be life-threatening
The main fear is of being in a situation where help or escape will not be possible if danger arises.
Apart from fear, a person with agoraphobia may experience the following feelings:
- detachment from others
- loss of control
- a feeling that the body is not real
- a feeling that the environment is not real
Some people become overly dependent on others or remain housebound for long periods of time.
Physical symptoms can also occur, 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 how they behave and function in the home, in school, or in the workplace.
They may try to avoid situations that could trigger off further attacks.
They may become sad or depressed, and they may consider suicide. Some may abuse alcohol and other drugs.
A Swiss study recently found that levels of low-grade inflammation also appeared to increase over time in people with agoraphobia.
Why agoraphobia happens remains unclear, but it is thought that areas of the brain that control the fear response may play a role.
Environmental factors, such as a previous break-in or physical attack, also contribute.
As there is evidence that anxiety disorders run in families, genetic factors may also play a role in agoraphobia and other panic disorders.
In some people, it occurs after they have had one or more panic attacks, and they begin to fear situations that could potentially lead to future panic attacks.
Other panic disorders or phobias can play a developmental role.
Agoraphobia is usually diagnosed following an interview with a healthcare professional, ordinarily within the field of psychiatry.
The specialist will assess the signs and symptoms.
Family or friends may help by describing the person’s behavior. A physical exam may rule out other conditions that could potentially be causing the symptoms.
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:
- on public transport
- in an open space
- in an enclosed space
- in a crowd or queue
- out of the home alone
Additional diagnostic criteria include:
- fear or anxiety that normally relates to a particular situation
- fear or anxiety out of proportion to the actual danger of the situation
- avoidance of a situation or requiring a companion to deal with it
- the 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
With treatment, one in three people are thought to eventually overcome agoraphobia and do not experience it again. Around half experience some improvement, but they may still have symptoms at times of stress, for example.
Around 1 in 5 people do not see any improvement and continue to live with their condition.
Agoraphobia can impact a person’s day-to-day functioning profoundly. Anyone experiencing symptoms should contact their doctor. Early treatment is more likely to lead to positive outcome.