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.

Main Signs and 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 apanic 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:

What are the causes?

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.

How common is it?

In the UK, up to 2 people in 100 have panic disorder. It's thought around a third will go on to develop agoraphobia.

Agoraphobia is twice as common in women as men. It usually starts between the ages of 18 and 35.

What are the options for treatment and help?

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), mindfulness, or medication

Lifestyle changes may include taking regular exerciseeating 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.

What could this mean for the future/progress?

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.

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. 

Where can I find further help and advice?

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) and mindfulness, 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 four main options:

  • CBT with a therapist 
  • applied relaxation
  • mindfulness with a class, group or therapist
  • 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.

Mindfulness

Mindfulness involves paying closer attention to the present moment and focusing on your thoughts, feelings, bodily sensations, and the world around you to improve your mental wellbeing.

The aim is to develop a better understanding of your mind and body, and learn how to live with more appreciation and less anxiety.

Mindfulness is recommended by the National Institute for Health and Care Excellence (NICE) as a way of preventing depression in people who've had three or more bouts of depression in the past.

It can also be a useful method for treating other types of mental health conditions, including agoraphobia.

Read more about mindfulness.

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:

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.

Support groups

Charities like Anxiety Alliance and Anxiety Care UK are useful resources for information and advice about how to effectively manage anxiety and phobias. They can also put you in touch with other people who've had similar experiences.

Anxiety Alliance runs a helpline available on 0845 296 7877, every day from 10am to 10pm. Calls are charged at the local rate.

Anxiety Care UK can be contacted by email onrecoveryinfo@anxietycare.org.uk for advice and support.

            

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