Agoraphobia

Agoraphobia is worrying about being in places or situations where escape might be difficult or embarrassing. Common examples are fear of using public transit, being in open spaces, being in enclosed spaces, standing in line, or being in a crowd.

Agoraphobia is treatable. You can get better. A good place to begin is with an overview of anxiety including the symptoms, causes, and treatment.

Symptoms and Diagnosis of Agoraphobia (DSM-F40.0)

Agoraphobia diagnostic criteria based on the DSM-5.[1]

  • Are you very worried or afraid about two or more of the following situations?
    • Using public transportation
    • Being in open spaces
    • Being outside alone
    • Being in enclosed spaces (eg, shops, malls, theaters)
    • Standing in line or being in a crowd
  • Do you worry about these situations because of one or more of the following reasons:
    • You think it might be difficult to escape
    • Help might not be available if you start to panic
    • It will be difficult to leave if you are incapacitated (eg, fall or have a heart attack)
    •  Something embarrassing will happen to you (eg, incontinence)
  • Do other people consider your fear to be out of proportion to the actual danger?
  • Have your symptoms lasted for at least six months?
  • Has your fear had a significant negative impact on your life (relationships, work, social, or emotional life.)?
  • Your symptoms are not due to medication, substance abuse, or any other medical condition (e.g., hyperthyroidism).
  • Your symptoms are not due to another mental health condition such as social anxiety disorder, obsessive-compulsive disorder, post-traumatic stress disorder, or depression.

If you answered yes to all of the above criteria, you may meet the DSM definition of agoraphobia.

Related Conditions

Specific phobias can trigger agoraphobic symptoms if your phobia relates to a specific situation, such as public transport or spiders. But if your symptoms are triggered by only one situation, then this does not meet the criteria of agoraphobia.

Panic disorder and agoraphobia can coexist, but only if your panic attacks happen in two or more of the agoraphobic situations described above.

Social anxiety disorder is worrying about social situations and the possibility of being criticized or judged. But agoraphobia is not a fear of being judged, but a fear of difficulty escaping or getting help.

Post-traumatic stress disorder can trigger agoraphobic symptoms, such as avoiding crowds. But if your anxiety and fear are only triggered by the traumatic event or traumatic reminders, this does not meet the criteria of agoraphobia.

Depression can make it difficult to leave home because of low energy or the anxiety that can be part of depression. But if your fear of leaving home is not related to difficulty escaping or getting help, then this does not meet the criteria of agoraphobia.

Tests

Medical Tests

Your health care provider can determine if your agoraphobia is caused by an underlying medical condition, such as heart disease or thyroid problems. This may require blood tests and an electrocardiogram (ECG). A complete assessment should also include questions about your caffeine and alcohol consumption, and any substance use, which can contribute to an anxiety disorder.

Standardized Screening Tests for Agoraphobia

There is no screening test for agoraphobia. But for monitoring agoraphobia symptoms as part of treatment, the Panic and Agoraphobia Scale (PAS) has been proven effective.[2] There are also a number of screening tests for anxiety in general.[3]

Here is an online version of the Generalized Anxiety Disorder Test – GAD7 (pdf).

Causes of Agoraphobia

Before looking at the treatment of agoraphobia, it helps to understand the causes because they can help guide the treatment. Agoraphobia can often occur in combination with panic disorder, and both disorders share several similarities.

Avoidance Behavior

If you suffer from agoraphobia you probably tend to avoid anxiety-provoking situations. But avoiding them gives them power. You’re saying that they are stronger than you. You’re telling yourself that you can’t handle everyday situations. This sets up an avoidance-anxiety cycle. The more you try to avoid your anxious feelings, the more convinced you are that you can’t handle everyday situations, which makes you more anxious.

The negative thinking behind avoidance behavior is taking an all-or-nothing approach to your strengths. Maybe you had a bad experience with one agoraphobic situation, such as being in a crowd or being in an enclosed space. From that you project that you won’t be able to handle all similar situations. When you combine that with the fact that being anxious makes your less effective in dealing with difficult situations, and your agoraphobia can spiral out of control.

Cognitive behavioral therapy (CBT) helps you take a more realistic view of your abilities so that you won’t take an all-or-nothing approach. It helps you see alternative solutions besides just avoidance, and helps you rebuild your confidence.

Substance Use

Tobacco, caffeine, drugs, and alcohol can all increase anxiety and the risk of developing agoraphobia. Billionaire, Howard Hughes, suffered from agoraphobia that many people believe was caused or made worse by his prescription pill abuse.

Medical Causes

A number of medical conditions can cause anxiety symptoms. These include an overactive thyroid, hypoglycemia, mitral valve prolapse, anemia, asthma, COPD, inflammatory bowel disease, Parkinson's disease, and dementia among others. Your physician may perform certain tests to rule out these conditions. But it is important to remember that anxiety is more often due to poor coping skills or substance abuse than any medical condition.

Treatment of Agoraphobia

The three main treatments for agoraphobia are cognitive behavioral therapy, stress management-meditation, and anti-anxiety medications.

Five Things You Can Do About Your Agoraphobia

  • Quit smoking, reduce your alcohol and caffeine use. These can all cause or worsen anxiety symptoms.
  • Review your over-the-counter medications such as diet pills and cold medications that can contain stimulants, which may trigger anxiety.
  • Learn relaxation and stress-management techniques and make them part of your life. Develop healthy coping skills.
  • Rule out any medical causes for your symptoms.
  • Ask for help. Talk with a health professional about your anxiety. Review your thought patterns, and identify any negative thinking that can contribute to your anxiety.

Cognitive Behavioral Therapy for Agoraphobia

The main negative thinking behind agoraphobia is that your fears are exaggerated and not based on facts. Cognitive behavioral therapy (CBT) helps you overcome your agoraphobia, by changing your thinking. You will learn how to challenge your thinking, consider the consequences of your thinking, and find alternative and healthier ways of thinking.

MRI studies have shown that cognitive behavioral therapy changes brain pathways and results in a more permanent change in thinking and behavior.[4, 5]

Cognitive behavioral therapy also has a behavioral component. The idea is to take small steps into your anxiety-provoking situations as you develop healthier thinking patterns. In this way you get to exercise your coping skills and see that you can safely negotiate everyday situations.

Stress Management, Mindfulness and Meditation for Anxiety

Stress management methods such as meditation and mindfulness have been proven effective in reducing and treating anxiety disorders and are being incorporated into standard medical treatment.[6, 7] There are a number of techniques to choose from. All are effective, and which one works for you is largely a matter of personal choice. Start slowly with ten minutes a day, and see how you will reduce your anxiety and change your life.

Find Help

Agoraphobia is treatable. Visit www.IWantToChangeMyLife.org/findhelp for a list of resources including, crisis phonelines, counselors, therapists, psychologists, psychiatrists, and support groups. You can change your life.

References

  1. American Psychiatric Association, DSM-5 The Diagnostic and Statistical Manual of Mental Disorders. 5 ed, ed. D. Kupfer: American Psychiatric Association.
  2. Bandelow, B., Broocks, A., Pekrun, G., George, A., et al., The use of the Panic and Agoraphobia Scale (P & A) in a controlled clinical trial. Pharmacopsychiatry, 2000. 33(5): p. 174-81.
  3. Beidas, R. S., Stewart, R. E., Walsh, L., Lucas, S., et al., Free, brief, and validated: Standardized instruments for low-resource mental health settings. Cogn Behav Pract, 2015. 22(1): p. 5-19. PMC4310476.
  4. Beutel, M. E., Stark, R., Pan, H., Silbersweig, D., et al., Changes of brain activation pre- post short-term psychodynamic inpatient psychotherapy: an fMRI study of panic disorder patients. Psychiatry Res, 2010. 184(2): p. 96-104.
  5. Linden, D. E., How psychotherapy changes the brain--the contribution of functional neuroimaging. Mol Psychiatry, 2006. 11(6): p. 528-38.
  6. Manzoni, G. M., Pagnini, F., Castelnuovo, G., & Molinari, E., Relaxation training for anxiety: a ten-years systematic review with meta-analysis. BMC Psychiatry, 2008. 8: p. 41. PMC2427027.
  7. Vollestad, J., Nielsen, M. B., & Nielsen, G. H., Mindfulness- and acceptance-based interventions for anxiety disorders: a systematic review and meta-analysis. Br J Clin Psychol, 2012. 51(3): p. 239-60.
Last Modified: September 10, 2018