Agoraphobia is an intense fear of being in public places where you feel escape might be difficult. So you tend to avoid public places and may not even venture out from home. It can greatly affect your life. Treatment can work well in many cases. Treatment options include cognitive behavioural therapy (CBT) and medication, usually with a selective serotonin reuptake inhibitor (SSRI) antidepressant.
What is agoraphobia?
Many people think that agoraphobia means a fear of public places and open spaces. However, this is just part of it. If you have agoraphobia you tend to have a number of fears of various places and situations. So, for example, you may have a fear of:
- Entering shops, crowds and public places.
- Travelling in trains, buses, or planes.
- Being on a bridge.
- Being in a lift.
- Being in a cinema, restaurant, etc, where there is no easy exit.
- Being anywhere far from your home.
However, these all stem from one underlying fear. That is, a fear of being in a place where help will not be available, or where you feel it may be difficult to escape to a safe place (usually to your home).
When you are in a feared place you become very anxious and distressed and you have an intense desire to get out. The anxiety usually causes physical symptoms, such as:
- A fast heart rate.
- A 'thumping heart' (palpitations).
- Shaking (tremor).
- Dry mouth.
- Feeling sick (nauseated).
- Chest pain.
- Stomach pains.
- A 'knot in the stomach'.
- Fast breathing.
You may even have a panic attack.
Even thinking about going to such places can make you anxious. To avoid this anxiety, you tend to avoid feared places.
The severity of agoraphobia can vary greatly. Some people with agoraphobia can cope quite well outside their home by sticking to familiar areas and routines. Some people with agoraphobia can go out from their home and travel on buses, trains, etc, without becoming anxious if they go with a friend or family member. There may be times when they have good spells where they cope better than at other times.
To prevent anxiety, many people with agoraphobia stay inside their homes for most or all of the time. However, by avoiding the feared situations, this can often cause the fear to grow stronger and the problem may then become worse. So, agoraphobia can be disabling and greatly affect your life.
Who has agoraphobia?
Agoraphobia typically develops between the ages of 25 and 35 years and is usually a lifelong problem unless treated. However, it can sometimes develop at a younger or older age than this. Twice as many women as men are affected.
Agoraphobia and panic disorder
Many, but not all, people with agoraphobia also have a condition called panic disorder. Briefly, people with panic disorder have panic attacks that occur suddenly, often without warning. A panic attack is like a sudden and severe attack of anxiety and fear.
If you have panic disorder you may worry about having a panic attack in a public place, which is embarrassing, difficult to get out of, or where help may not be available. Therefore, you may develop agoraphobia - a fear of being in such places - because you have panic disorder. See separate leaflet called Panic Attack and Panic Disorder for more details.
How is agoraphobia diagnosed?
You are likely to have agoraphobia if:
- You avoid situations that cause anxiety, such as going out of the house and being in open spaces.
- Your symptoms are caused by anxiety and not related to some other condition such as depression.
- You feel anxiety in two or more of the following situations: crowds, public places, travelling alone, or away from home.
What are the treatment options for agoraphobia?
Cognitive behavioural therapy (CBT)
CBT helps you to change certain ways that you think, feel and behave. It is a useful treatment for various mental health problems, including phobias.
- Cognitive therapy is based on the idea that certain ways of thinking can trigger, or fuel, certain mental health problems such as anxiety, depression and phobias. The therapist helps you to understand your current thought patterns. In particular, to identify any harmful, unhelpful and false ideas or attitudes which you have that can make you anxious. The aim is then to change your ways of thinking to avoid these ideas. It can help your thought patterns to be more realistic and helpful.
- Behavioural therapy aims to change any behaviours which are harmful or not helpful. For example, with phobias your behaviour (your response to the feared object) is harmful and the therapist aims to help you to change this. Various techniques are used, depending on the condition and circumstances. For example, in agoraphobia, the therapist will usually help you to face up to feared situations, a little bit at a time. A first step may be to go for a very short walk from your home with the therapist who gives support and advice. Over time, a longer walk may be possible, then a walk to the shops, and then a trip on a bus, etc. The therapist teaches you how to control anxiety when you face up to the feared situations and places - for example, by using deep-breathing techniques. This technique of behavioural therapy is called exposure therapy - where you are exposed more and more to feared situations and you learn how to cope.
- Cognitive behavioural therapy (CBT) is a mixture of the two where you may benefit from changing both you thoughts and your behaviours.
CBT is usually done in weekly sessions of about 50 minutes each, for several weeks. You have to take an active part and are given homework between sessions. For example, you may be asked to keep a diary of your thoughts which occur when you become anxious.
Note: unlike other forms of psychotherapy, CBT does not look into the events of the past. CBT aims to deal with (and to change where appropriate) your current thought processes and/or behaviours.
CBT usually works well to treat most phobias; however, it does not suit everyone. Also, it may not be available on the NHS in all areas.
These are commonly used to treat depression; however, they also help to reduce the symptoms of phobias, even if you are not depressed. They work by interfering with brain chemicals (neurotransmitters) - such as serotonin - which may be involved in causing anxiety symptoms.
- Antidepressants do not work straightaway. It takes 2-4 weeks before their effect builds up. A common problem is that some people stop the medicine after a week or so, as they feel that it is doing no good. You need to give it time. It is best to persevere if you are prescribed an antidepressant medicine.
- Antidepressants are not tranquillisers and are not usually addictive.
- There are several types of antidepressants, each with various pros and cons. For example, they differ in their possible side-effects. However, selective serotonin reuptake inhibitor (SSRI) antidepressants (such as sertraline or paroxetine) are the ones most commonly used for anxiety disorders.
Note: after first starting an antidepressant, in some people anxiety symptoms become worse for a few days before they start to improve.
A combination of CBT and an SSRI antidepressant may work better in some cases than either treatment alone.
Further reading and references
Generalised anxiety disorder and panic disorder in adults: management; NICE Clinical Guideline (January 2011)
Katzman MA, Bleau P, Blier P, et al; Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders. BMC Psychiatry. 201414 Suppl 1:S1. doi: 10.1186/1471-244X-14-S1-S1. Epub 2014 Jul 2.
Lewis C, Pearce J, Bisson JI; Efficacy, cost-effectiveness and acceptability of self-help interventions for anxiety disorders: systematic review. Br J Psychiatry. 2012 Jan200(1):15-21. doi: 10.1192/bjp.bp.110.084756.
Bandelow B, Lichte T, Rudolf S, et al; The diagnosis of and treatment recommendations for anxiety disorders. Dtsch Arztebl Int. 2014 Jul 7111(27-28):473-80. doi: 10.3238/arztebl.2014.0473.
Hendriks GJ, Kampman M, Keijsers GP, et al; Cognitive-behavioral therapy for panic disorder with agoraphobia in older people: a comparison with younger patients. Depress Anxiety. 2014 Aug31(8):669-77. doi: 10.1002/da.22274. Epub 2014 May 27.
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