Agoraphobia is an anxiety disorder that will affect an estimated 1.3% of Americans at some point in their lives.5 People with agoraphobia avoid specific public places or situations because they anticipate having anxiety or a panic attack and being unable to escape or get help. In severe cases, these fears cause people to refuse to leave their homes for prolonged periods of time.
What Is Agoraphobia?
Agoraphobia belongs to a cluster of anxiety disorders called specific phobias. A phobia is defined as intense anxiety only in response to very specific places, things, or situations. Agoraphobia is the fear of being in specific public places. These fears usually involve concern about being unable to escape or get help in the event that they become anxious.
While there aren’t any distinct subtypes of agoraphobia, there is variation in the specific places that are feared and avoided. Some people with agoraphobia fear crowded or closed spaces while others fear open and empty spaces, and some fear almost any public place. Many times, the specific places and situations people fear are based on their past experiences. It is common that a person with agoraphobia has had panic attacks in the specific places they are afraid to go.2
Panic attacks (also called anxiety attacks) are sudden and intense symptoms of anxiety which include four or more of the following symptoms1 and usually last ten minutes or less:
- Heart palpitations or racing heart
- Shortness of breath
- Feeling choked
- Tightness or pain in the chest
- Nausea or abdominal distress
- Shaking or trembling
- Dizziness or unsteadiness
- Feeling disconnected from yourself
- Feeling disconnected from your surroundings
- Fear of losing control or dying
- Fear of losing control or going crazy
- Numbness or tingling
- Feeling hot or cold
Because of overlapping symptoms, people commonly confuse panic symptoms with a heart attack and seek emergency medical care. Panic attacks can be very uncomfortable and frightening. People with any anxiety disorder can experience panic attacks, even though many of these individuals do not have or develop panic disorder in the long term.
Panic disorder is described as having a “fear of fear.” The disorder is developed when panic attacks result in significant anxiety about having another panic attack. In people who develop panic disorder, the fear of future attacks becomes debilitating, causing them to avoid places and situations where they fear having another attack.
A strong link exists between panic disorder and agoraphobia. Historically, these two disorders were grouped together in the Diagnostic and Statistical Manual of Mental Disorders (DSM). The DSM is used worldwide by mental health professionals to diagnose mental health conditions.
In 2013, the DSM was revised for the 5th time and agoraphobia and panic disorder were no longer grouped together. Still, most people with agoraphobia have had a previous or current diagnosis of panic disorder or a history of having panic attacks.1 Interestingly, the fear of panic attacks is usually a primary reason why a person with agoraphobia avoids certain public places or situations.
Signs of Agoraphobia
All mental health conditions result in changes in the way a person thinks, feels and behaves. More than other types of anxiety disorders, agoraphobia is most clearly identified by changes in behavior. The most obvious signs of the disorder are avoidance of certain places. People with agoraphobia may begin making excuses, procrastinating, or avoiding going out in public. This avoidance may have a specific pattern (e.g. of places that are crowded or enclosed) or may be more general and include most or all public places.
Agoraphobia usually develops in adulthood, with an average age of onset between 25-30 years old.8 According to the NIH, 2.4% of teens between the ages of 13-18 are diagnosed with agoraphobia and only a very small number of children are diagnosed.5 Regardless of age, the signs of agoraphobia are similar, with fear and avoidance of public places being the primary indicators.
The cited reasons for the fear may differ depending on age. For instance, younger children may share a fear of getting separated from parents while older adults might describe fears of falling. The feared and avoided places can also vary. For example, teens may avoid getting on the school bus, the cafeteria at lunch, or may even try to avoid going to school at all.
Symptoms of Agoraphobia
According to the DSM-5,1 the symptoms of agoraphobia include:
- Intense fear or anxiety prompted by the actual or predicted exposure to 2 or more of the following situations:
- Using public transportation
- Being in open areas
- Being in closed-off areas
- Standing in line or a crowd
- Being alone outside of the house
And all of the following:
- He or she avoids the above situations because the individual believes they may become stuck or help might be unavailable in the event that the individual begins to panic.
- The listed situations almost always cause fear or anxiety.
- The listed situations are avoided, require help from a loved one, or are endured with a lot of anxiety and distress.
- The fear the individual has is out of proportion to the actual possibility of danger.
- The fear or avoidance is persistent, typically lasting for 6 months or longer.
- The fear or avoidance causes the individual significant distress or keeps them from being able to function normally in one or more areas of life.
- The symptoms are not better described by another underlying medical issue.
- The symptoms are not better explained by the symptoms of another mental health condition.
Causes and Triggers of Agoraphobia
No singular cause for agoraphobia exists. Instead, several biological, social, and psychological factors are involved in the development of any mental health disorder, including agoraphobia. These factors are also referred to as risk factors, as they are believed to increase a person’s risk for developing the condition.
Risk factors for agoraphobia include:3,6
- Being diagnosed with another anxiety disorder, especially generalized anxiety disorder, panic disorder, or social phobia
- Being diagnosed with a substance use disorder
- Having a history of physical or sexual abuse or other traumatic events
- Having overly protective parents
- Losing a parent to death or separation
- Having a neurotic personality
- Having a history of panic attacks
- Having a history of panic attacks that occur in public
- Having a family history of anxiety disorders
Certain experiences may also act as precursors to agoraphobia. For example, people may be afraid to leave their homes during a particularly bad flu season or when crime rates are higher than normal. Agoraphobia can also develop after certain stressful or traumatic experiences, like a person getting into a car accident or being the victim of a crime.
In some instances, agoraphobia can develop when people have lifestyle changes that result in fewer outings and social interactions, like transitioning from working in an office to working at home, retiring, or moving to a new city.
Living with Agoraphobia
Living with agoraphobia can be very limiting. People with the condition often describe that their symptoms have impacted their ability to work, maintain relationships, and in some cases even prevented them from being able to live independently. Over time and without treatment, many people with agoraphobia find that their symptoms worsen, and that their list of feared places grows. Sometimes, the condition can progress to the point of not leaving home for several months or longer, depending on other services and people to meet their needs.
Getting help early on when symptoms begin can make treatment easier and faster. Because avoidance makes anxiety worse in the long run, recovery involves intentionally going to places that make them anxious. While doing so will result in temporary increases in anxiety, it will also help to build confidence and prevent their symptoms from disrupting their ability to function.
Some people with mild cases may be able to reverse their symptoms on their own, but most will find that treatment is still helpful and improves the likelihood of a full recovery.
Treatments for Agoraphobia
Agoraphobia is a treatable condition. With therapy, medication, or a combination of the two, it is possible for people with agoraphobia to reduce their symptoms and even make a full recovery. For those with this disorder, a full recovery is indicated by their ability to leave their homes and return to their normal routine and activities.
The most effective form of treatment for agoraphobia is exposure therapy.6 Exposure therapy is a specific form of Cognitive Behavioral Therapy (CBT) that involves gradually facing feared situations that were previously avoided. Before any exposure work begins, therapists help clients learn relaxation skills to help them cope with distress and anxiety. Once these skills have been developed, exposure therapists work collaboratively with the client to develop a plan to begin gradually facing feared situations and places.
In exposure therapy, facing a feared situation is called completing an exposure. Early on, exposures are things or situations that the client identifies as triggering only low or moderate levels of anxiety. These can be done in sessions with the therapist or also sometimes assigned as homework between sessions. Exposures can be either imagined or “in-vivo.” An imagined exposure is one the client imagines in their mind while an in-vivo exposure is one that involves facing the feared situation in real life.
In-vivo exposures are thought to be most effective with people struggling with agoraphobia. Early in treatment, an in-vivo exposure might involve a client being asked to sit by an open window or door if doing so makes them a little anxious. Next, they may be asked to stand on their front porch or in their yard for a few moments.
Eventually, the therapy would progress to exposures like taking walks around the neighborhood or short drives to the store. While exposure therapy is scary and uncomfortable at first, most people experience a drastic reduction in their symptoms if they complete the treatment, gaining the ability to return to their normal life and routine.
Cognitive Behavioral Therapy
Another effective form of therapy for agoraphobia is Cognitive Behavioral Therapy, or CBT.6,7 Exposure therapy is one branch of CBT but other branches of the treatment include ones which can help people challenge irrational thoughts and fears. CBT treatment addresses the link between thoughts, behaviors, and feelings.
When people adjust their ways of thinking and behaving, they often experience a change in the way they feel. For example, a person with agoraphobia can reduce anxiety by interrupting worried thoughts about bad things that might happen, while also putting themselves in the situations they fear.
Medication is sometimes recommended in addition to therapy for people diagnosed with agoraphobia. A medical professional’s decision to prescribe medication depends on the individual symptoms a person is experiencing, how severe these are, and whether they have other mental health issues.
A Person with agoraphobia may be prescribed with one or more of the following medications:4,6,7
- Antidepressant medications which work on serotonin and other brain receptors involved with mood and anxiety
- Anti-anxiety medications which are sometimes prescribed on an as-needed basis for severe situational anxiety or panic attacks and have calming and sedating effects
- Antipsychotic medications which can help to reduce intrusive and worried thoughts experienced by some people with agoraphobia
How to Get Help for Agoraphobia
With treatment, people with agoraphobia can get the support and skills they need to resume their normal lives and routines. Often, the first step is to find a therapist who specializes in treating anxiety and phobias. Meeting with a therapist will help you confirm your diagnosis and also learn more about what treatment options would meet your needs (i.e. therapy, medication, or both).
If you have health insurance, you can call the number on the back of your card or go online to find a list of in-network therapists. You could also conduct an online search using a directory, which allows you to filter results based on location, specialties, and insurance type.
Once you identify a list of options, you may have to call around to find out who has openings. Most of the time, therapists are also willing to offer free phone or in-person consultations in which you can ask questions and learn more about their experience and approach. This can help you make an informed choice, increasing the likelihood that you will be matched with a therapist who is a good fit for your needs.
Because many people with agoraphobia feel unable to leave their homes, online therapy may also be an option. Those interested in online therapy should check with their insurance providers to ensure that telehealth (online video or phone) sessions are covered under their plan.
There are certain trends that have emerged in the research that provide more of an understanding of agoraphobia and those who are more likely to suffer from it.
According to the research:5,6
- 1.3% of American adults will develop agoraphobia in their lifetime
- The average age of onset is between 25-30 years of age
- Older adults ages 65 and up are more likely to develop agoraphobia
- 87% of people diagnosed with agoraphobia also have another mental health condition
- Women are twice as likely as men to develop agoraphobia
- Women with agoraphobia are more likely to be severely impaired by the disorder than men
Agoraphobia vs Social Phobia
Agoraphobia is fear and avoidance of public places, while social phobia involves fear and avoidance of social situations. With agoraphobia, the root fears are generally about not being able to escape or get help in specific situations or places, whereas with social phobias, the root fears are generally about being judged or criticized by other people.
Often, people with social phobias are trying to avoid feeling awkward or embarrassed but people with agoraphobia worry more about feeling afraid or anxious. However, agoraphobia and social phobia sometimes overlap, and it is possible for a person to be diagnosed with both.
Agoraphobia Tests, Quizzes, and Self-diagnosis Tools
Self-diagnosis tools cannot provide an accurate diagnosis of agoraphobia. Only a licensed health or mental health professional (i.e. a licensed counselor, social worker, nurse practitioner, or doctor) can diagnose agoraphobia. This typically occurs during the first scheduled appointment.
Still, understanding some of the signs and symptoms of agoraphobia listed above can be useful in identifying the need for a more formal assessment.
Additional Resources on Agoraphobia
Those wanting additional information about agoraphobia may be interested in these resources: