Agoraphobia is an intense fear of being in places or situations where you feel escape might be difficult or help might not be available. So you tend to avoid these situations 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?
Agoraphobia is a type of anxiety disorder. Many people think that agoraphobia means a fear of public places and open spaces, resulting in sufferers being unable to leave their homes. However, that is just part of it. If you have agoraphobia you tend to have intense and excessive fear or anxiety about a range of situations from which escape might be difficult or where help might not be available. So, for example, you may have a fear of:
- Being in shops, crowds and public places.
- Travelling in trains, buses, or planes.
- Being on a bridge.
- Being in enclosed spaces, like a lift.
- Being in a cinema, restaurant, etc, where there is no easy exit.
- Being outside the home on your own.
Agoraphobia is usually a lifelong problem unless treated.
What causes agoraphobia and who gets it?
The exact cause of agoraphobia isn't known, but is likely to be a combination of genes, imbalances in certain brain chemicals, and psychological risk factors such as childhood trauma, stressful events, drug or alcohol use, and having other mental health conditions.
It typically starts in late adolescence and before the age of 35 years. Twice as many women are diagnosed with agoraphobia compared to men.
Many, but not all, people with a separate condition called panic disorder can develop agoraphobia. Briefly, in panic disorder, people have panic attacks that occur suddenly, often without warning. A panic attack is like a sudden and severe attack of anxiety and extreme fear.
Agoraphobia can also be triggered if someone has a panic attack in a specific situation, or if they have a specific phobia (for example, getting infections from being in crowded places).
What are the symptoms of agoraphobia?
Physical agoraphobia symptoms usually present much like panic attacks. They can happen when a person is in the situation or when they anticipate it, and include:
- Rapid heart rate.
- Rapid breathing (hyperventilating).
- Sweating and feeling hot.
- Chest pain.
- Feeling faint.
- Ringing in the ears (tinnitus).
With agoraphobia, you are constantly fearful or anxious because of an underlying fear of specific bad outcomes. These are called cognitive symptoms and the feared bad outcomes include:
- Having a panic attack that leads to embarrassment or humiliation.
- Having a panic attack that leads to death or injury.
- Losing your sanity.
- Losing control in public.
- Being unable to function without the help of someone else.
Read more about anxiety symptoms.
People with agoraphobia develop avoidance behaviours in response to their fear and anxiety. These might include:
- Avoiding situations that may trigger agoraphobia, such as crowded places or public transportation.
- Not leaving the house for long periods of time.
- Needing to be accompanied by someone everywhere they go.
- Avoiding being too far from home.
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.
Many people with agoraphobia stay inside their homes for most or all of the time to avoid situations that may trigger anxiety.
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How to treat agoraphobia
Self-help techniques and lifestyle
There are a number of self-help guides available as booklets or online, which go through techniques such as breathing control, challenging unhelpful thoughts, and confronting the situations.
General lifestyle measures such as exercise, getting plenty of sleep, limiting caffeine and alcohol, and having a healthy diet can also help.
Cognitive behavioural therapy (CBT)
CBT is a type of psychological therapy that 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.
- Behavioural therapy aims to change any behaviours which are harmful or not helpful. 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.
Other psychological therapies are also available.
Antidepressants 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.
- 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. If these do not work, or symptoms are very severe, you can be referred to a specialist mental health service.
Further reading and references
International Classification of Diseases 11th Revision; World Health Organization
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.
Bandelow B, Michaelis S, Wedekind D; Treatment of anxiety disorders. Dialogues Clin Neurosci. 2017 Jun19(2):93-107.
Chawla N, Anothaisintawee T, Charoenrungrueangchai K, et al; Drug treatment for panic disorder with or without agoraphobia: systematic review and network meta-analysis of randomised controlled trials. BMJ. 2022 Jan 19376:e066084. doi: 10.1136/bmj-2021-066084.
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.
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.