Overview

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 that 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 themself 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 will avoid situations that cause anxiety and may only leave the house with a friend or partner. They'll order groceries online rather than go 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 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 such as 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 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

Lifestyle changes may help, 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 see your GP.

You can also refer yourself directly for psychological therapies, including cognitive behavioural therapy (CBT), without seeing your GP.

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 used to treat both anxiety and depression.

In severe cases of agoraphobia, medication can be used in combination other types of treatment, such as CBT and relaxation therapy.

Read more about the treatment of 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.

How common is agoraphobia?

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.

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

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 are not 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 will be unable to breathe
• you would be unable to escape from a place or situation if you were to have a panic attack
• you are 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 not related to panic attacks, including:

• 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

If you think you have the symptoms of agoraphobia, speak to your GP.

You should also seek medical advice if you have any of the following:

• chest pain
• shortness of breath
• headaches
• dizziness
• fainting episodes
• unexplained weakness
• sensation that your heart is beating irregularly (palpitations)
• depression
• thoughts of suicide or self-harm

Who can get it

Most cases of agoraphobia develop as a complication of panic disorders.

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 panic attack returning when they are in a similar situation or environment.

This causes the person to avoid that particular situation or environment.

Panic disorders

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 adrenalin, 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 is 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 overwhelemed 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 the partner is very controlling

Agoraphobia without panic disorder

Occasionally a person can develop symptoms of agoraphobia even though they have no history of having of panic disorder or panic attacks.
 
This type of agoraphobia can be triggered by a range of different phobias (irrational fears), such as the fear of:

• being a victim of violent crime or a terrorist attack if you leave your house
• becoming infected by a serious illness if you visit crowded places
• doing something by accident that will result in you embarrassing or humiliating yourself in front of others

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 carry out a physical examination, and in some cases they may decide to do 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 stepped approach is usually recommended for treating agoraphobia and any underlying panic disorder.

The steps are as follows:

1. Find out more about your condition, the lifestyle changes you can make, and self-help techniques to help relieve symptoms.
2. Enrol yourself on a guided self-help programme.
3. Undertake more intensive treatments, such as cognitive behavioural therapy or see if your symptoms can be controlled using medication.

Self-help techniques, lifestyle changes and apps

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 in coping with previously uncomfortable situations and environments.

• 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 is 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.
• Breath 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 is not 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, your attack is not life threatening.

Making some lifestyle changes can also help. For example, ensure you:

• take regular exercise: exercise can help relieve tension and stress and improve your mood
• have a healthy diet: a poor diet can make 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

Talking therapies

If your symptoms don't respond to self-help techniques and lifestyle changes, your GP may suggest trying a psychological therapy.

If you prefer you can refer yourself directly for psychological therapies, such as cognitive behavioural therapy (CBT), without seeing your GP.

Guided self-help

With guided self-help you work through a CBT-based workbook or computer course with the support of a therapist.

The therapist works with you to understand your problems and make positive changes in your life.

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 the treatment, such as going to your local corner shop.

As you become more confirdent, 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 12-15 weekly sessions, with each session lasting about an hour.

Medicine

Sometimes, medicine 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 will usually be prescribed a course of selective serotonin reuptake inhibitors (SSRIs).

SSRIs were originally developed to treat depression but they've also 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 similar type of medication known as serotonin-norepinephrine reuptake inhibitors (SNRIs).

The length of time you will have to take a 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 is appropriate for you to stop taking SSRIs, you will 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 are 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.

Support groups

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