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Introduction

Agoraphobia is a fear of being in situations where escape might be difficult, or help wouldn't be available if things go wrong.

Many people assume that agoraphobia is simply a fear of open spaces but it's more complex than this. A person with agoraphobia may be scared of:

  • travelling on public transport

  • visiting a shopping centre

  • leaving home

If someone with agoraphobia finds themselves in a stressful situation they'll usually experience 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 will order groceries online rather than go to the supermarket. This change in behaviour is known as "avoidance".

What causes agoraphobia?

Agoraphobia usually develops as a complication of panic disorder (an anxiety disorder involving panic attacks and moments of intense fear). It may arise as a result of associating panic attacks with the 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 that are inherited from your parents.

 

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. However, 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.

 

Treating agoraphobia

A stepwise approach is usually recommended for treating agoraphobia and any underlying panic disorder. These are usually:

  • Step one: educate yourself about your condition, possible lifestyle changes you can make, and self-help techniques to help relieve symptoms.

  • Step two: enrol yourself on a guided self-help programme (see below).

  • Step three: more intensive treatments, such as cognitive behavioural therapy (CBT) or medication.

Lifestyle changes may include taking regular exercise, eating more healthily, and avoiding alcohol, drugs and drinks containing 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 the above treatment methods, your GP may suggest that you try a guided self-help programme. This involves working through self-help manuals that cover the types of issues you might be facing, along with practical advice about how to deal with them.

Medication may be recommended if self-help techniques and lifestyle changes aren't effective in controlling your symptoms of agoraphobia. You'll usually be prescribed a course of selective serotonin reuptake inhibitors (SSRIs) which are used to treat both anxiety and depression.

 

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. 

Symptoms of agoraphobia

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 (symptoms associated with the way we think)

  • 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 apanic attack and may include:

  • rapid heartbeat

  • rapid breathing (hyperventilating)

  • feeling hot and sweaty

  • feeling sick

  • upset stomach

  • 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 embarrassed in front of other people

  • a panic attack will be life-threatening – for example, you may be worried that 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

  • you may be stared at

There are also psychological symptoms that aren't related to panic attacks, such as:

  • feeling that 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

  • not being able to leave the house for long periods of time (being housebound)

  • 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 spells

  • unexplained weakness

  • sensation that your heart is beating irregularly (palpitations)

  • depression

  • thoughts of suicide or self-harm

 

Causes of agoraphobia 

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

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

Panic disorder

As with many mental health conditions, the exact cause of panic disorder isn't fully understood.

However, most experts think that a combination of biological and psychological factors may be involved.

Biological factors

A number of theories about what type of biological factors may be involved with panic disorders are outlined below:

‘Fight or flight’ reflex

One theory is that 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's thought that the fight or flight reflex may be triggered wrongly, resulting in a panic attack.

Neurotransmitters

Another theory is that there is an imbalance in levels of neurotransmitters in the brain which 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 that 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.

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 asdepression, anorexia nervosa or bulimia

  • alcohol misuse or drug misuse

  • being in an unhappy relationship, or in a relationship where your partner is very controlling

Diagnosing agoraphobia

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, such as in a crowd or on a bus, where escape or help may be difficult if you feel panicky or develop a panic attack.

  • You avoid situations described above, or endure them with extreme anxiety, or with 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.

Treating agoraphobia 

A stepwise approach is usually recommended for treating agoraphobia and any underlying panic disorder.

The steps are usually:

  • Step one: educate yourself about your condition, possible lifestyle changes you can make, and self-help techniques to help relieve symptoms.

  • Step two: enrol yourself on a guided self-help programme.

  • Step three: undertake more intensive treatments, such as cognitive behavioural therapy (CBT), or see if your symptoms can be controlled using medication.

 

Lifestyle changes and self-help techniques

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.

These self-help techniques are described below.

  • Stay where you are and try to resist the urge to run to a place of safety during a panic attack. If 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  that the frightening thoughts and sensations are a sign of panic and will eventually pass.

  • Breathe 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 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 it worse. Instead, reassure yourself by accepting that although it may seem embarrassing, and your symptoms may be difficult to deal with, your attack isn't life-threatening.

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

  • take regular exercise – exercise can relieve stress and tension and improve your mood

  • eat 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

 

Guided self-help

If your symptoms fail to respond to the above self-help techniques and lifestyle changes, your GP may recommend enrolling on a guided-self help programme.

This involves working through self-help manuals that cover the types of issues you might be facing along with practical advice about how to deal with them.

A number of internet-based programmes are also available. For example, Moodjuice is an online resource designed to help you think about emotional problems and work towards solving them.

Guided self-help for agoraphobia is based on CBT, which aims to change unhelpful and unrealistic patterns of thinking to bring about positive changes in behaviour (see below).

In turn, CBT uses a type of therapy called exposure therapy, which involves being gradually exposed to the object or situation you fear and using relaxation techniques to help reduce anxiety.

As part of the programme you may have brief sessions with a CBT therapist (around 20-30 minutes) over the telephone or face-to-face.

You may also be invited to take part in group work with other people with a history of agoraphobia and panic disorders.

Most self-help programmes consist of a series of goals to work towards over the course of five to six weeks.

More intensive therapies

If the self-help programme described above hasn't worked, you may be referred for more intensive therapies.

There are three main options:

  • CBT with a therapist 

  • applied relaxation

  • medication

 

Cognitive behavioural therapy

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 it 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 treatment, such as going to your local corner shop. As you become more confident, 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 12-15 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.

Therefore, the aim of applied relaxation is 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 from feeling tense and panicky

As with CBT, a course of applied relaxation therapy consists of 12-15 weekly sessions lasting an hour.

Medication

In some cases, medication 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

If medication is recommended for you, you'll usually be prescribed a course of selective serotonin reuptake inhibitors (SSRIs).

SSRIs were originally developed to treat depression, but they've subsequently proved effective in 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 libido (sex drive)

  • blurred vision

  • diarrhoea or constipation

  • feeling agitated or shaky

  • excessive sweating

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 a similar type of medication known as serotonin-norepinephrine reuptake inhibitors (SNRIs).

The length of time you'll have to take an SSRI (or SNRI) for will vary depending on your response to treatment. Some people may have to take SSRIs for six to 12 months or more.

When you and your GP decide it's appropriate for you to stop taking SSRIs, you'll 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're unable to take SSRIs or SNRIs for medical reasons, or you experience troublesome side effects, another medication calledpregabalin may be recommended.

Dizziness and drowsiness are common side effects of pregabalin.

Benzodiazepines

If you experience a particularly severe flare-up of panic-related symtoms, you may be prescribed a short course of benzodiazepines. These are tranquillisers that are designed to reduce anxiety and promote calmness and relaxation.

Taking benzodiazepines for longer than two weeks in a row isn't usually recommended because it can become addictive if taken for longer.