Agoraphobia
Agoraphobia is a fear of being in situations where escape might be difficult or that help wouldn't be available if things go wrong.
Many people assume agoraphobia is simply a fear of open spaces, but it's actually a more complex condition. Someone with agoraphobia may be scared of:
- travelling on public transport
- visiting a shopping centre
- leaving home
If someone with agoraphobia finds themselves in a stressful situation, they'll usually experience the symptoms of a panic attack, such as:
- rapid heartbeat
- rapid breathing (hyperventilating)
- feeling hot and sweaty
- feeling sick
They'll avoid situations that cause anxiety and may only leave the house with a friend or partner. They'll order groceries online rather than going to the supermarket. This change in behaviour is known as avoidance.
Read more about the symptoms of agoraphobia.
What causes agoraphobia?
Agoraphobia usually develops as a complication of panic disorder, an anxiety disorder involving panic attacks and moments of intense fear. It can arise by associating panic attacks with the places or situations where they occurred and then avoiding them.
A minority of people with agoraphobia have no history of panic attacks. In these cases, their fear may be related to issues like a fear of crime, terrorism, illness, or being in an accident.
Traumatic events, such as bereavement, may contribute towards agoraphobia, as well as certain genes inherited from your parents.
Read more about the possible causes of agoraphobia.
Diagnosing agoraphobia
Speak to your GP if you think you may be affected by agoraphobia. It should be possible to arrange a telephone consultation if you don't feel ready to visit your GP in person.
Your GP will ask you to describe your symptoms, how often they occur, and in what situations. It's very important you tell them how you've been feeling and how your symptoms are affecting you.
Your GP may ask you the following questions:
- Do you find leaving the house stressful?
- Are there certain places or situations you have to avoid?
- Do you have any avoidance strategies to help you cope with your symptoms, such as relying on others to shop for you?
It can sometimes be difficult to talk about your feelings, emotions, and personal life, but try not to feel anxious or embarrassed. Your GP needs to know as much as possible about your symptoms to make the correct diagnosis and recommend the most appropriate treatment.
Read more about diagnosing agoraphobia.
Treating agoraphobia
With psychological treatment (talking therapies), most people with agoraphobia will make significant improvements, particularly if the three steps described below are followed.
A stepwise approach is usually recommended for treating agoraphobia and any underlying panic disorder:
- step one – educate yourself about your condition, possible lifestyle changes you can make, and self-help techniques to help relieve symptoms
- step two – enrol yourself on a guided self-help programme
- step three – more intensive treatments, such as cognitive behavioural therapy (CBT) or medication
Lifestyle changes may include taking regular exercise, eating more healthily, and avoiding alcohol, drugs and drinks that contain caffeine, such as tea, coffee and cola.
Self-help techniques that can help during a panic attack include staying where you are, focusing on something that's non-threatening and visible, and slow, deep breathing.
If your agoraphobia fails to respond to these treatment methods, your GP may suggest trying a guided self-help programme. This involves working through self-help manuals that cover the types of issues you might be facing, along with practical advice about how to deal with them.
Medication may be recommended if self-help techniques and lifestyle changes aren't effective in controlling your symptoms. You'll usually be prescribed a course of selective serotonin reuptake inhibitors (SSRIs), which are also used to treat anxiety and depression.
In severe cases of agoraphobia, medication can be used in combination with other types of treatment, such as CBT and relaxation therapy.
Read more about treating agoraphobia.
Outlook
Around a third of people with agoraphobia eventually achieve a complete cure and remain free from symptoms.
Around half experience an improvement in symptoms, but they may have periods when their symptoms become more troublesome – for example, if they feel stressed.
Despite treatment, about one in five people with agoraphobia continue to experience troublesome symptoms.
Symptoms
The severity of agoraphobia can vary significantly between individuals.
For example, someone with severe agoraphobia may be unable to leave the house, whereas someone who has mild agoraphobia may be able to travel short distances without problems.
The symptoms of agoraphobia can be broadly classified into three types:
- physical
- cognitive
- behavioural
These are explained in more detail below.
Physical symptoms
The physical symptoms of agoraphobia usually only occur when you find yourself in a situation or environment that causes anxiety.
However, many people with agoraphobia rarely experience physical symptoms because they deliberately avoid situations that make them anxious.
The physical symptoms of agoraphobia can be similar to those of a panic attack and may include:
- rapid heartbeat
- rapid breathing (hyperventilating)
- feeling hot and sweaty
- feeling sick
- chest pain
- difficulty swallowing (dysphagia)
- diarrhoea
- trembling
- dizziness
- ringing in the ears (tinnitus)
- feeling faint
Cognitive symptoms
The cognitive symptoms of agoraphobia are feelings or thoughts that can be, but aren't always, related to the physical symptoms.
Cognitive symptoms may include fear that:
- a panic attack will make you look stupid or feel embarrassed in front of other people
- a panic attack will be life threatening – for example, you may be worried your heart will stop or you'll be unable to breathe
- you would be unable to escape from a place or situation if you were to have a panic attack
- you're losing your sanity
- you may lose control in public
- you may tremble and blush in front of people
- people may stare at you
There are also psychological symptoms that aren't related to panic attacks, such as:
- feeling you would be unable to function or survive without the help of others
- a fear of being left alone in your house (monophobia)
- a general feeling of anxiety or dread
Behavioural symptoms
Symptoms of agoraphobia relating to behaviour include:
- avoiding situations that could lead to panic attacks, such as crowded places, public transport and queues
- being housebound – not being able to leave the house for long periods of time
- needing to be with someone you trust when going anywhere
- avoiding being far away from home
Some people are able to force themselves to confront uncomfortable situations, but they feel considerable fear and anxiety while doing so.
When to seek medical advice
Speak to your GP if you think you have the symptoms of agoraphobia.
You should also seek medical advice if you have any of the following:
- chest pain
- shortness of breath
- headaches
- dizziness
- fainting episodes
- unexplained weakness
- the sensation your heart is beating irregularly (palpitations)
- depression
- thoughts of suicide or self-harm
Causes
Most cases of agoraphobia develop as a complication of panic disorder.
Agoraphobia can sometimes develop if a person has a panic attack in a specific situation or environment.
They begin to worry so much about having another panic attack that they feel the symptoms of a panic attack returning when they're in a similar situation or environment.
This causes the person to avoid that particular situation or environment.
Panic disorder
As with many mental health conditions, the exact cause of panic disorder isn't fully understood.
However, most experts think a combination of biological and psychological factors may be involved.
Biological factors
There are a number of theories about the type of biological factors that may be involved with panic disorders. These are outlined below.
'Fight or flight' reflex
One theory is panic disorder is closely associated with your body's natural "fight or flight" reflex – its way of protecting you from stressful and dangerous situations.
Anxiety and fear cause your body to release hormones, such as adrenaline, and your breathing and heart rate are increased. This is your body's natural way of preparing itself for a dangerous or stressful situation.
In people with panic disorder, it's thought the fight or flight reflex may be triggered wrongly, resulting in a panic attack.
Neurotransmitters
Another theory is an imbalance in levels of neurotransmitters in the brain can affect mood and behaviour. This can lead to a heightened stress response in certain situations, triggering the feelings of panic.
The fear network
The "fear network" theory suggests the brains of people with panic disorders may be wired differently from most people.
There may be a malfunction in parts of the brain known to generate both the emotion of fear and the corresponding physical effect fear can bring. They may be generating strong emotions of fear that trigger a panic attack.
Spatial awareness
Links have been found between panic disorders and spatial awareness. Spatial awareness is the ability to judge where you are in relation to other objects and people.
Some people with panic disorder have a weakened balance system and awareness of space. This can cause them to feel overwhelmed and disorientated in crowded places, triggering a panic attack.
Psychological factors
Psychological factors that increase your risk of developing agoraphobia include:
- a traumatic childhood experience, such as the death of a parent or being sexually abused
- experiencing a stressful event, such as bereavement, divorce, or losing your job
- a previous history of mental illnesses, such as depression, anorexia nervosa, or bulimia
- alcohol misuse or drug misuse
- being in an unhappy relationship, or in a relationship where your partner is very controlling
Diagnosis
Speak to your GP if you think you have agoraphobia.
If you're unable to visit your GP in person, it should be possible to arrange a telephone consultation.
Your GP will ask you to describe your symptoms, how often they occur, and in what situations. It's very important to tell your GP about how you've been feeling and how your symptoms are affecting you.
They'll also want to know how your symptoms are affecting your daily behaviour. For example, they may ask:
- Do you find it stressful leaving the house?
- Are there certain places or situations you have to avoid?
- Have you adopted any avoidance strategies to help cope with your symptoms, such as relying on others to shop for you?
It can be difficult to talk to someone else about your feelings, emotions and personal life, but try not to feel anxious or embarrassed. Your GP needs to know as much as possible about your symptoms to make the correct diagnosis and recommend the most appropriate treatment.
Physical examination
Your GP may want to do a physical examination, and in some cases they may decide to carry out blood tests to look for signs of any physical conditions that could be causing your symptoms.
For example, an overactive thyroid gland (hyperthyroidism) can sometimes cause symptoms that are similar to the symptoms of a panic attack.
By ruling out any underlying medical conditions, your GP will be able to make the correct diagnosis.
Confirming the diagnosis
A diagnosis of agoraphobia can usually be made if:
- you're anxious about being in a place or situation where escape or help may be difficult if you feel panicky or have a panic attack, such as in a crowd or on a bus
- you avoid situations described above, or endure them with extreme anxiety or the help of a companion
- there's no other underlying condition that may explain your symptoms
If there's any doubt about the diagnosis, you may be referred to a psychiatrist for a more detailed assessment.
Treatment
A stepwise approach is usually recommended for treating agoraphobia and any underlying panic disorder.
The steps are as follows:
- step one – find out more about your condition, the lifestyle changes you can make, and self-help techniques to help relieve symptoms
- step two – enrol yourself on a guided self-help programme
- step three – undertake more intensive treatments, such as cognitive behavioural therapy (CBT), or see if your symptoms can be controlled using medication
The various treatments for agoraphobia are outlined below. You can also read a summary of the pros and cons of the different treatments for agoraphobia, allowing you to compare your treatment options.
Lifestyle changes and self-help techniques
Learning more about agoraphobia and its association with panic disorder and panic attacks may help you control your symptoms better.
For example, there are techniques you can use during a panic attack to bring your emotions under control.
Having more confidence in controlling your emotions may make you more confident coping with previously uncomfortable situations and environments.
These self-help techniques are described below.
- stay where you are – try to resist the urge to run to a place of safety during a panic attack; if you're driving, pull over and park where it's safe to do so
- focus – it's important for you to focus on something non-threatening and visible, such as the time passing on your watch, or items in a supermarket; remind yourself the frightening thoughts and sensations are a sign of panic and will eventually pass
- breathe slowly and deeply – feelings of panic and anxiety can get worse if you breathe too quickly; try to focus on slow, deep breathing while counting slowly to three on each breath in and out
- challenge your fear – try to work out what it is you fear and challenge it; you can achieve this by constantly reminding yourself that what you fear isn't real and will pass
- creative visualisation – during a panic attack, try to resist the urge to think negative thoughts, such as "disaster"; instead, think of a place or situation that makes you feel peaceful, relaxed or at ease: once you have this image in your mind, try to focus your attention on it
- don't fight an attack – trying to fight the symptoms of a panic attack can often make things worse; instead, reassure yourself by accepting that although it may seem embarrassing and your symptoms may be difficult to deal with, the attack isn't life threatening
Making some lifestyle changes can also help. For example, ensure you:
- take regular exercise – exercise can help relieve stress and tension and improve your mood
- have a healthy diet – a poor diet can make the symptoms of panic and anxiety worse
- avoid using drugs and alcohol – they may provide short-term relief, but in the long term they can make symptoms worse
- avoid drinks containing caffeine, such as tea, coffee or cola – caffeine has a stimulant effect and can make your symptoms worse
Guided self-help
If your symptoms don't respond to these self-help techniques and lifestyle changes, your GP may recommend enrolling on a guided self-help programme.
This involves working through self-help manuals that cover the types of issues you might be facing, along with practical advice about how to deal with them.
A number of internet-based programmes are also available. For example, Moodjuice is an online resource designed to help you think about emotional problems and work towards resolving them.
Guided self-help for agoraphobia is based on CBT, which aims to change unhelpful and unrealistic patterns of thinking to bring about positive changes in behaviour.
In turn, CBT uses a type of therapy called exposure therapy, which involves being gradually exposed to the object or situation you fear and using relaxation techniques and breathing exercises to help reduce your anxiety.
As part of the programme, you may have brief sessions with a CBT therapist – around 20 to 30 minutes long – over the telephone or face to face. You may also be invited to take part in group work with other people with a history of agoraphobia and panic disorders.
Most self-help programmes consist of a series of goals to work towards over the course of five to six weeks.
More intensive therapies
If the self-help programme hasn't worked, you may be referred for more intensive therapies. There are three main options:
- CBT with a therapist
- applied relaxation
- medication
Cognitive behavioural therapy (CBT)
Cognitive behavioural therapy (CBT) is based on the idea that unhelpful and unrealistic thinking leads to negative behaviour.
CBT aims to break this cycle and find new ways of thinking that can help you behave more positively. For example, many people with agoraphobia have the unrealistic thought that if they have a panic attack it will kill them.
The CBT therapist will try to encourage a more positive way of thinking – for example, although having a panic attack may be unpleasant, it isn't fatal and will pass.
This shift in thinking can lead to more positive behaviour in terms of a person being more willing to confront situations that previously scared them.
CBT is usually combined with exposure therapy. Your therapist will set relatively modest goals at the start of treatment, such as going to your local corner shop.
As you become more confident, more challenging goals can be set, such as going to a large supermarket or having a meal in a busy restaurant.
A course of CBT usually consists of 12 to 15 weekly sessions, with each session lasting about an hour.
Applied relaxation
Applied relaxation is based on the premise that people with agoraphobia and related panic disorder have lost their ability to relax. The aim of applied relaxation is therefore to teach you how to relax.
This is achieved using a series of exercises designed to teach you how to:
- spot the signs and feelings of tension
- relax your muscles to relieve tension
- use these techniques in stressful or everyday situations to prevent you feeling tense and panicky
As with CBT, a course of applied relaxation therapy consists of 12 to 15 weekly sessions, with each one lasting about an hour.
Medication
In some cases, medication can be used as a sole treatment for agoraphobia. In more severe cases, it can also be used in combination with CBT or applied relaxation therapy.
Selective serotonin reuptake inhibitors (SSRIs)
If medication is recommended for you, you'll usually be prescribed a course of selective serotonin reuptake inhibitors (SSRIs).
SSRIs were originally developed to treat depression, but they've subsequently proved effective for helping treat other mood disorders, such as anxiety, feelings of panic, and obsessional thoughts.
An SSRI called sertraline is usually recommended for people with agoraphobia. Side effects associated with sertraline include:
- feeling sick
- loss of sex drive (libido)
- blurred vision
- diarrhoea or constipation
- feeling agitated or shaky
- excessive sweating
These side effects should improve over time, although some can occasionally persist.
If sertraline fails to improve your symptoms, you may be prescribed an alternative SSRI or a similar type of medication known as serotonin-norepinephrine reuptake inhibitors (SNRIs).
The length of time you'll have to take an SSRI or SNRI for will vary depending on your response to treatment. Some people may have to take SSRIs for 6 to 12 months or more.
When you and your GP decide it's appropriate for you to stop taking SSRIs, you'll be weaned off them by slowly reducing your dosage. You should never stop taking your medication unless your GP specifically advises you to.
Pregabalin
If you're unable to take SSRIs or SNRIs for medical reasons or you experience troublesome side effects, another medication called pregabalin may be recommended. Dizziness and drowsiness are common side effects of pregabalin.
Benzodiazepines
If you experience a particularly severe flare-up of panic-related symptoms, you may be prescribed a short course of benzodiazepines. These are tranquillisers designed to reduce anxiety and promote calmness and relaxation.
Taking benzodiazepines for longer than two weeks in a row isn't usually recommended as they can become addictive.
- Antidepressants
- Antidepressant medicine is used to treat depression. For example Fluoxetine, Paroxetine.
- Benzodiazepines
- Benzodiazepines are a group of medicines used to help sleep, reduce anxiety and as a muscle relaxant. For example, temazepam.
- Panic
- To panic is to be quickly overcome with a feeling of fear or worry.
- Psychotherapy
- Psychotherapy is the treatment of mental and emotional health conditions, using talking and listening.
Case Study
Claire Ledger was diagnosed with agoraphobia after having a panic attack in the street while shopping.
Claire, who was 26 at the time of this interview, was unable to explain the experience. She initially thought it may have had something to do with where she was, so she stopped going there and began to shop elsewhere. When she had a similar panic attack in another location, she stopped going there, too.
Within five months she'd stopped going to so many places she only felt truly safe at home. She left her job as a nurse and spent the next 2.5 years indoors. She read, watched TV, surfed the web and cared for her husband, who is in a wheelchair, and never went outside.
"When I had the first attack, I didn't know what was happening," says Claire, who lives in Bradford, West Yorkshire. "I was in a shop and felt faint all of a sudden, and had to crouch down to avoid collapsing. I was shaking and felt sick."
Claire went to her GP, who initially thought she was suffering from stress. Claire had just started a new job, recently got married, and was having IVF treatment.
"Every time I went out after that I got this feeling again," she says. "Everywhere it happened, I avoided that place. Instead of thinking it was me, I associated the panic attack with the place where it happened. I was such an outgoing person, the idea that it was all in my head never occurred to me."
Claire was eventually diagnosed with agoraphobia. "I got to a point where my stomach dropped as soon as I woke up," she says. "It's like a feeling of grief and despair. You're shaking, tired, and you don't really feel there. It's like you're watching yourself.
"I tried to get through it, but I reached a stage when even the thought of going into my own garden made me panic. It was like coming up against an invisible wall.
"It was hard on my husband. He's a big sports fan and likes going out to watch live events."
The couple's elderly neighbours would help out with getting food and household supplies. "I felt ashamed that someone in their 70s was doing my shopping," says Claire.
Claire became determined to seek treatment and went on a course of cognitive behavioural therapy (CBT). She found the treatment helpful, but it didn't change her thought process.
What made the difference was talking to other people with agoraphobia, who she contacted through online support groups. "You feel like a freak," she says. "Talking to other people in the same position was what helped me the most. We worked on breaking down our boundaries together."
She became friends with a woman in another town and they would make the same trips together in their respective neighbourhoods, slowly increasing the length of their journeys.
"We would call each other before leaving the house and would remain on the phone to each other until we got back in," says Claire. "Even though she wasn't there in person, her voice was really reassuring."
For the next two years, this was how Claire expanded her boundaries from her doorstep. "My husband changed our mobile provider when he saw the monthly bills I was running up!"
Claire has learned to cope with her moods and has now regained enough confidence to go back to work. "It's important for people to know that you can recover," she says. "You may think it's like a death sentence, but the treatments do work. I never thought I'd return to work.
"I still have my down days, but I've learned to accept that you can't feel your best every day."
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