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 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

Title
Agoraphobia

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 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 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:

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

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

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

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

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 your partner is very controlling

Agoraphobia without panic disorder

Occasionally, a person can develop symptoms of agoraphobia even though they don't have a history of panic disorder or panic attacks.

This type of agoraphobia can be triggered by a number of different irrational fears (phobias), 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
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 adrenaline, 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's 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 overwhelmed and disorientated in crowded places, triggering a panic attack.

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 do a physical examination, and in some cases they may decide to carry out 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 stepwise 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 (CBT), or see if your symptoms can be controlled using medication.
Self-help
  • 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 anxietycan 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