Causes of Agoraphobia

Agoraphobia is classified as an anxiety disorder. It usually involves a person experiencing intense fear when in situations where escape may be difficult, or they feel it is difficult to access help.

These persistent feelings of anxiety are likely to affect a person’s ability to function in society or everyday life. Those with agoraphobia usually avoid situations that may cause them anxiety, fear or panic, or have caused this in the past. The fear of feeling trapped or helpless, or the knowledge that you may suffer a panic attack, can cause complete avoidance of the anticipated situation.

Many people with agoraphobia develop the condition after suffering one or several panic attacks in public. They may begin to avoid the place or situation where the panic attack occurred. Some people feel they cannot be in any enclosed or public spaces or cannot leave the house.

Agoraphobia comes from the Greek word agora which means “place of assembly” or “open space” and the English word phobia meaning “fear”. Many people assume that those with agoraphobia fear being outside with other people, but agoraphobia is much more complex.

Situations that may trigger agoraphobia or symptoms of agoraphobia include:

• Crowds or busy areas.
• Public transport.
• Enclosed areas such as lifts, tunnels, shops, cinemas and public bathrooms.
• Queues.
• Open spaces such as bridges, car parks and shopping centres.
• Busy areas with high levels of noise such as music and sports events.
• Being too far from home.
• Any place where the individual previously felt anxiety.

If a person with agoraphobia finds themselves in one of these situations, they may begin to experience a panic attack. The anxiety, embarrassment and fear that this may happen again can result in the individual only leaving the house with a trusted family member or friend or refusing to leave the house completely. This is known as avoidance.

Although agoraphobia is closely related to panic attacks and panic disorders, they are considered separate diagnoses. Many people with agoraphobia will also have a diagnosis of panic disorder. This is a type of anxiety disorder where an individual may experience sudden extreme fear that triggers intense physical symptoms – also known as panic attacks.

It is common for someone who is having a panic attack to believe that they are having a heart attack or even dying. The fear of experiencing these symptoms again can result in complete avoidance or increased anxiety.

However, it is possible to experience agoraphobia without experiencing panic disorder or panic attacks. Individuals may feel fear, panic and anxiety without encountering any physical symptoms.

Agoraphobia can develop at any age, with some people being diagnosed in childhood or later in life. However, the majority of people develop the condition between the ages of 18 and 35. Agoraphobia is diagnosed in twice as many women as men. This gender difference has been attributed to several things, including women being more likely to seek professional help than men and men being more likely to deal with their symptoms using alcohol and drugs.

The Priory Group estimates that up to 5 million people in the UK are currently agoraphobic.

If you believe you have agoraphobia, you should schedule an appointment with your GP. If you are unable to leave the house, it is possible to have a telephone consultation instead. In order to diagnose agoraphobia, a doctor or other healthcare professional will interview you and ask for information about your symptoms.

Some of the information they will be interested in includes:

• A description of your symptoms, including how you feel and any physical symptoms you experience.
• How often the symptoms occur.
• The type of situation or place that is likely to trigger the symptoms.
• How it is affecting your day-to-day life.
• If there are any situations or places you avoid.
• Whether there are any underlying health conditions.

To receive a diagnosis, you will likely have been experiencing symptoms for a prolonged period of time. For more information on how to receive a diagnosis, consult the NHS website.

What are the signs and symptoms?

Agoraphobia can have a wide range of symptoms. These can vary hugely from person to person depending on several factors, including the severity of the condition, the triggers and how long you have had the condition.

The symptoms can usually be categorised into three types:

1. Physical Symptoms.
2. Cognitive Symptoms.
3. Behavioural Symptoms.

We will look at each of these in more detail below.

Physical symptoms 

The physical symptoms of agoraphobia can usually be associated with the panic attacks many people experience. Many individuals with agoraphobia do not experience physical symptoms frequently, as they will actively avoid situations or places that they believe will make them anxious or create feelings of fear.

Physical symptoms may include, but are not limited to:

• Rapid heart rate.
• Rapid breathing or difficulty breathing.
• Chest pain or pressure in the chest.
• Difficulty swallowing or feelings of choking.
• Dizziness or light-headedness.
• Feeling hot or excessive sweating.
• Nausea or diarrhoea.
• Ringing in the ears.
• Feeling shaky or numb.
• Fear of dying.

Cognitive symptoms 

Cognitive symptoms include the thoughts and feelings you experience. This may include how you feel in a situation that triggers your agoraphobia or how you feel when you think about being in the situation or place that triggers your agoraphobia.

Cognitive symptoms may include:

• Feeling embarrassed or fear of feeling stupid if you have a panic attack in public.
• Fear that you will be unable to escape or access help in public.
• Thinking that you might die in certain situations.
• Fear that a panic attack will cause a heart attack or stop you from breathing.
• Feelings of anxiety and dread.
• Fear of being alone.
• Feeling unable to leave the house or function without others.
• Fear that you make lose control in public.
• Feeling anxious that people are staring at you or judging you.
• Fear that you are losing your sanity or sense of self.
• Fear that you will be infected with a serious illness, or be a victim of terrorism or a violent crime if you leave the safety of your home.

Behavioural symptoms 

Behavioural symptoms relating to agoraphobia may include:

• Avoiding situations that may cause fear, anxiety or panic attacks.
• Being unable to leave the house, also known as being housebound. The severity of this symptom can vary, with some people unable to leave the house at all, some only able to leave the house for short periods and others only able to leave the house to go to specific places where they feel safe.
• Being unable to leave the house without a trusted family member or friend.
• Avoiding being far away from home or going to places where you may need to use public transport or travel in a car.
• Being unable to overcome feelings of fear and anxiety, no matter how hard you try.
• Isolating yourself from others.

The exact causes of agoraphobia are not known. However, several risk factors increase the likelihood of developing the condition, including:

• Having a panic disorder or experiencing panic attacks – the NHS reports that most instances of agoraphobia occur as a complication of panic disorder.
• Having other mental health difficulties such as depression, anxiety disorder, obsessive compulsive disorder (OCD) or other phobias.
• Experiencing a traumatic childhood experience such as abuse or the death of a parent.
• Experiencing a stressful life event such as a bereavement or divorce.
• Issues with alcohol or drug use.
• Having a family history of agoraphobia.
• Being in an abusive or unhappy relationship.

Prevention

It may not be possible to prevent agoraphobia. However, if you recognise early signs and identify the fear and anxiety as soon as it begins to develop, it may be possible to prevent it from intensifying. This could stop the anxiety you are experiencing from developing into severe agoraphobia.

The more you avoid situations that are causing you to experience cognitive symptoms, the more likely these are to develop into physical and behavioural symptoms, resulting in you becoming agoraphobic.

For example, if you feel anxious about going to a particular place or being in a certain situation, you could practise certain behaviours to prevent the fear from overwhelming you. For example, go to the place repeatedly with a trusted family member or friend and discuss what is it that is making you fearful and why this may be irrational or can be overcome.

Treatment is likely to be much more effective the earlier you access it. If you begin to experience anxiety or panic attacks, consult your GP as soon as possible, before symptoms worsen.

What help is available?

Psychotherapy

Psychotherapy will involve working together with a therapist to set attainable goals and learn skills that may help to reduce your anxiety. You will work on addressing the causes and symptoms of your anxiety and changing the way you think about and respond to situations you currently find difficult.

The most frequently recommended form of psychotherapy is Cognitive Behavioural Therapy (CBT).

You can be referred for CBT by your GP and the sessions may be covered by the NHS.

During CBT sessions, you will learn a number of things, including:

• The factors that may trigger your symptoms or how your symptoms may become exacerbated.
• How to tolerate and manage the symptoms of agoraphobia.
• How to change the thoughts and behaviours that are contributing to, or causing, your anxiety.
• How to address and challenge your fears and concerns to help you return to situations or places you have been avoiding.
• Techniques for managing fear and anxiety.

If agoraphobia prevents you from leaving the house, it is still possible to have CBT sessions. You can initially arrange sessions over the phone or via a video conferencing service, such as Zoom. Alternatively, you may be able to find a therapist who can visit your home or meet with you in an alternative location.

Medication

Medication is often used in conjunction with psychotherapy to treat agoraphobia. Certain medications are prescribed more commonly.

• Antidepressants – Selective Serotonin Reuptake Inhibitors (SSRIs), such as Paroxetine, Fluoxetine and Sertraline, are thought to be the most effective medication for treating agoraphobia. They may take several weeks to begin working so do not expect instant results.
• Other types of antidepressants – This includes tricyclic antidepressants and selective serotonin and norepinephrine reuptake inhibitors.
• Anti-anxiety medication – Benzodiazepines are sedatives that can be used to treat agoraphobia. These are prescribed much less frequently and are usually only available on a limited basis. They can be used to relieve the symptoms of anxiety in the short term. However, they should be closely monitored by your doctor as they are highly addictive.

Medication does not work instantly, and you may need to try several different medications to find the one that is most effective for you. Medication should not be a long-term treatment and an agoraphobic should not expect to take antidepressants or anti-anxiety medication for the rest of their life.

Once your symptoms have improved and you have engaged with psychotherapy sessions, your doctor should begin to reduce your dosage, with the aim to stop taking the medication completely. However, do not stop taking your medication without first seeking the advice and approval of your doctor.

According to the NHS, a Stepwise approach is the best way to treat agoraphobia and any panic disorders or panic attacks you may also be experiencing.

The stepwise approach involves:

• Step 1: Find out more information about the condition, any lifestyle, or behavioural changes you can make and any self-help techniques you can employ to help you manage or overcome the symptoms.
• Step 2: Enrol in a guided self-help programme.
• Step 3: Access any other intensive treatment you may require including medication or Cognitive Behavioural Therapy (CBT).

Other treatments 

Self-help techniques can be extremely helpful strategies to help you better control the symptoms of anxiety or panic attacks. The knowledge that you can control or improve your symptoms can help to improve your agoraphobia, as you may be less afraid of situations that have previously triggered anxiety.

Some self-help techniques include:

• Do not give in to your fight or flight response – Many people experiencing anxiety or panic attacks will try and escape the situation by running away. However, this is likely to exacerbate your anxiety in future situations. Resist the urge to run and instead find a place to sit down and try to manage your emotions.
• Breathe slowly and deeply – Feelings of being unable to breathe are very common with anxiety. Ensure you are getting long deep breaths, as this may help to reduce your symptoms.
• Challenge your fears and consider what is causing your anxiety – Thinking through these fears or talking about them with a trusted family member or friend can help you to understand why they are baseless or unlikely.
• Focus or distract yourself – Find a technique that works for you and stick to it. Some people focus on counting backwards or reciting the times tables in their heads.
• Do not use alcohol or drugs – Although you may feel that they reduce your symptoms in the short term, in the long term your symptoms will worsen.
• Attend a support group – You can find an in-person or online support group where you can talk to other people who are agoraphobic. You can also discuss self-help techniques with experts.

For more self-help techniques, contact Mind who will offer help and support to anyone suffering from a mental health difficulty, including agoraphobia.