Definition of agoraphobia
Agoraphobia falls under the umbrella of anxiety disorders and is marked by extreme fear of being in situations that cause the person to feel trapped, embarrassed, or helpless. Many people think that agoraphobia is simply being afraid of open spaces, but it is much more complex.1
The World Health Organisation (WHO) states that agoraphobia is an “excessive fear and anxiety” over situations that a person might feel unable to get help or escape from. This could be a crowded place, a contained space like a bus, or being outside alone.
Agoraphobia is estimated to affect 1.7% of the population.2
Causes of agoraphobia
Multiple factors may cause agoraphobia to develop, including your mental health, personal experiences, and personality.
Agoraphobia may develop if you have a panic attack in a certain situation. Someone with a panic disorder is then likely to avoid that and similar situations to try and prevent it occurring again.3
Other causes of agoraphobia may include:
- Traumatic experiences, such as being a victim of violence and/or sexual assault
- Highly stressful events, such as bereavement, divorce, and loss of job
- Current mental illness, such as depression, anorexia, and bulimia
- Certain phobias (even without a history of panic disorder or trauma), such as:
- Fear of illness in large crowds, especially following the COVID-19 pandemic
- Fear of a terrorist attack
- Fear that you will do something embarrassing in front of others
Symptoms of agoraphobia
According to the DSM-5, a manual used to diagnose mental disorders, agoraphobia can be diagnosed if you experience disproportionate fear about two or more of the following2:
- Public transport
- Open spaces (e.g. car parks)
- Enclosed spaces (e.g. shopping centres)
- Queues or crowds
- Leaving home alone
These fears are often accompanied by behavioural changes, which may worsen your anxiety over time:
- Avoiding the above situations to prevent panic attacks
- Not leaving home for long periods
- Only going to places with a person you trust
- Not going far from home
The physical symptoms of agoraphobia are similar to those of a panic attack:
- Chest pain or rapid heart rate
- Feeling shaky/trembling
- Hyperventilating or feeling like it’s difficult to breathe properly
- Stomach discomfort
- Feeling hot or sweating
- Feeling dizzy or lightheaded
Cognitive symptoms may relate to these physical symptoms, such as having fears about:
- Being unable to escape if you have a panic attack
- Panic attacks being life threatening (e.g. from being unable to breathe)
- Panic attacks embarrassing you in front of people
- People staring at you
- Losing your sanity or losing control
Seeking professional help
Consult a mental health professional
Later in the article, we will discuss some things you can do yourself to address your agoraphobia, such as anxiety management techniques and positive lifestyle changes. However, if these do not make a difference or you feel your condition is getting worse, then it may be time to seek additional support.
In the first instance, you should speak to your doctor, who can refer you to a mental health service for further assessment. Alternatively, you may be able to self-refer to your local mental health service or psychological therapy team. If it is too difficult for you to leave your home, then a telephone or video appointment may be possible.
A mental health assessment will look at your particular needs, make a diagnosis if necessary, and formulate an effective treatment plan. This may be a referral to a psychological therapy team for ongoing therapy, or, if more severe, you may be taken on by the community mental health team.
Types of therapy available
The National Institute for Clinical Excellence (NICE) doesn’t have recommendations specifically for agoraphobia, but has guidelines for the treatment of panic disorder and generalised anxiety disorder, which are strongly linked to agoraphobia. They suggest that cognitive behavioural therapy (CBT) is the best method for treatment.
CBT is a talking therapy which aims to change the way you think and behave in response to certain problems. When treating agoraphobia, a CBT therapist would help you with implementing graded exposure therapy. You would also explore any underlying causes of the agoraphobia and learn more positive ways to react to the anxiety caused.
Interestingly, NICE has a paper (to be released August 2023) looking at treating agoraphobia using virtual reality.
Medications for agoraphobia
The recommended medications for treating agoraphobia are SSRI antidepressants, most notably sertraline. A 2022 paper in the British Medical Journal (BMJ) found that SSRIs were more effective than benzodiazepines due to having fewer undesirable side effects. It also found that sertraline and escitalopram (another SSRI medication) were more effective than other SSRIs, with higher remission rates and fewer side effects.4
Gradual exposure therapy
This is where you gradually face the fears and anxieties associated with your agoraphobia. You ideally start with something easy (e.g. a short bus ride) and then build it up to facing more difficult situations (e.g. a long-distance train journey).
It is important to repeatly face these situations to maintain those positive changes. To get the most out of graded exposure, you should also prolong your exposure for enough time to experience the anxiety and reduce it using relaxation techniques. This shows you that you can manage the anxiety/panic whilst in a certain situation.
You are less likely to be limited by your agoraphobia if you can effectively manage your anxiety and stress levels. Therefore, learning relaxation techniques is an important part of managing your agoraphobia. You could use yoga, massage, or meditation while at home.
When you are in a stressful situation or place, resisting the urge to leave and using relaxation techniques is crucial. Breathing slowly and deeply, visualisation (picturing something that calms you), and reassuring yourself that the anxiety will pass are some practical choices for public places. You can also practise these at home first.
Cognitive behavioural therapy (CBT)
There are some free online resources that could help you manage agoraphobia without a therapist. For instance, the NHS has a self-help guide about CBT techniques. A controlled trial also found that app-based CBT is effective at reducing agoraphobia symptoms.1
Exercising regularly can boost your confidence and self-esteem, thus creating a resilience to events that would normally impact your mood. It can also distract you from something that has been worrying you. Moving your body also helps your muscles to relax, making you less tense. So, in short, exercise is good at managing stress and anxiety, which influence agoraphobia.
Eating a healthy and balanced diet can help you to optimise your mental wellbeing. For example, eating the right foods regularly can help maintain stable blood sugar levels, reducing lethargy and irritability. Staying hydrated will help with concentration and alertness.
Be mindful of how you are feeling before consuming caffeinated drinks. Drinking caffeine while anxious will likely increase your heart rate, making you feel more anxious.
Stress reduction techniques
Techniques that reduce stress could be different from one person to another. The first step is to identify the source of your stress, then find a way to reduce it that works for you. For some people, it is exercise, for others, organising their lives will help to reduce stress. Some people find massage, yoga, or meditation helpful. Anything that can reduce your stress levels will aid in reducing the impact of agoraphobia on your life.
Building a support system
Join a support group
Support groups are a useful resource because you can meet people who have, or have had, similar experiences. This may help you understand your current situation a little better. In addition, others in the group might be further along in their recovery and be able to offer advice on what helped them. Alternatively, you may be in a position to help others with their recovery, which in turn will boost your sense of self esteem and worth.
Reach out to family and friends
Family and friends are invaluable in managing agoraphobia. Part of managing this condition is exposure to the place or situation that causes you to feel panic. This may be difficult to do alone at first, and a friend or family member keeping you company initially would be helpful with this exposure.
Seek help from a mental health professional
If self-help does not lead to positive changes, or your agoraphobia gets worse, then it is time to seek help from a mental health professional. Your doctor can refer you to a mental health team. Alternatively, in the UK, you can refer yourself to a mental health team or talking therapies team for ongoing support.
A community mental health team would be able to provide further assessment and prescribe medication. A talking therapies team would use CBT to treat your agoraphobia.
Identifying triggers is vital for managing anxiety and panic moving forward. This can be done alone or through exploration work with a mental health professional.
You could keep a journal to record events (e.g. panic attacks) that occur and what possible triggers are. Reflect on what your body is telling you; is your heart racing because you’ve had too much caffeine, for example?
Exploring and reflecting on life events can also help identify triggers; this can also be done alone or with a professional.
Breathing techniques are useful in reducing your heart rate and controlling hyperventilation. They can be done anywhere, and practised anytime. See the NHS breathing exercises guide for tips.
Also known as positive affirmations, these can help calm you down and reinforce that you can get through the situation that is causing you distress.
Agoraphobia is an anxiety disorder which can be life limiting if left untreated. The associated fear and anxiety may lead to you rarely, or never, leaving your home and can make you extremely isolated. Agoraphobia can be caused by certain mental health conditions, but can also exacerbate or cause depression, anxiety, or other conditions.
Fortunately, there are things you can do to make it easier to live with agoraphobia, such as making positive changes to your lifestyle and practising self-help techniques. If these do not work, there is the option of professional support using medication and therapy, with sertraline being the best option for medication and CBT being the recommended psychological therapy.
There may be alternative or supplementary treatment options in the future, with research taking place on virtual reality and computer/mobile based treatments.
With agoraphobia, as with many mental health conditions, it is important to build a good support network to optimise recovery and reduce the chances of relapsing.
- Christoforou M, Fonseca JAS, Tsakanikos E. Two novel cognitive behavioral therapy–based mobile apps for agoraphobia: randomized controlled trial. Journal of Medical Internet Research [Internet]. 2017 Nov 24 [cited 2023 May 11];19(11):e7747. Available from: https://www.jmir.org/2017/11/e398
- Balaram K, Marwaha R. Agoraphobia. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 [cited 2023 May 11]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK554387/
- Hara N, Nishimura Y, Yokoyama C, Inoue K, Nishida A, Tanii H, et al. The development of agoraphobia is associated with the symptoms and location of a patient’s first panic attack. BioPsychoSocial Medicine [Internet]. 2012 Apr 11 [cited 2023 May 11];6(1):12. Available from: https://doi.org/10.1186/1751-0759-6-12
- Chawla N, Anothaisintawee T, Charoenrungrueangchai K, Thaipisuttikul P, McKay GJ, Attia J, et al. Drug treatment for panic disorder with or without agoraphobia: systematic review and network meta-analysis of randomised controlled trials. BMJ [Internet]. 2022 Jan 19 [cited 2023 May 11];376:e066084. Available from: https://www.bmj.com/content/376/bmj-2021-066084