Health A to Z
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:
If someone with agoraphobia finds themselves in a stressful situation, they'll usually experience the symptoms of a panic attack, such as:
They'll avoid situations that cause anxiety and may only leave the house with a friend or partner. They'll order groceries online rather than going to the supermarket. This change in behaviour is known as avoidance.
Read more about the symptoms of agoraphobia.
Agoraphobia usually develops as a complication of panic disorder, an anxiety disorder involving panic attacks and moments of intense fear. It can arise by 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 like 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 inherited from your parents.
Read more about the possible causes of 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:
It can sometimes be difficult to talk 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.
Read more about diagnosing agoraphobia.
With psychological treatment (talking therapies), most people with agoraphobia will make significant improvements, particularly if the three steps described below are followed.
A stepwise approach is usually recommended for treating agoraphobia and any underlying panic disorder:
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 these treatment methods, your GP may suggest trying 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. You'll usually be prescribed a course of selective serotonin reuptake inhibitors (SSRIs), which are also used to treat anxiety and depression.
In severe cases of agoraphobia, medication can be used in combination with other types of treatment, such as CBT and relaxation therapy.
Read more about treating agoraphobia.
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.
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:
These are explained in more detail below.
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:
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:
There are also psychological symptoms that aren't related to panic attacks, such as:
Symptoms of agoraphobia relating to behaviour include:
Some people are able to force themselves to confront uncomfortable situations, but they feel considerable fear and anxiety while doing so.
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:
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.
As with many mental health conditions, the exact cause of panic disorder isn't fully understood.
However, most experts think a combination of biological and psychological factors may be involved.
There are a number of theories about the type of biological factors that may be involved with panic disorders. These are outlined below.
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.
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" 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.
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 that increase your risk of developing agoraphobia include:
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:
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.
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.
By ruling out any underlying medical conditions, your GP will be able to make the correct diagnosis.
A diagnosis of agoraphobia can usually be made if:
If there's any doubt about the diagnosis, you may be referred to a psychiatrist for a more detailed assessment.
A stepwise approach is usually recommended for treating agoraphobia and any underlying panic disorder.
The steps are as follows:
The various treatments for agoraphobia are outlined below. You can also read a summary of the pros and cons of the different treatments for agoraphobia, allowing you to compare your treatment options.
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 coping with previously uncomfortable situations and environments.
These self-help techniques are described below.
Making some lifestyle changes can also help. For example, ensure you:
If your symptoms don't respond to these 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 resolving 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.
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 and breathing exercises to help reduce your anxiety.
As part of the programme, you may have brief sessions with a CBT therapist – around 20 to 30 minutes long – 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.
If the self-help programme hasn't worked, you may be referred for more intensive therapies. There are three main options:
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 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 to 15 weekly sessions, with each session lasting about an hour.
Applied relaxation is based on the premise that people with agoraphobia and related panic disorder have lost their ability to relax. The aim of applied relaxation is therefore to teach you how to relax.
This is achieved using a series of exercises designed to teach you how to:
As with CBT, a course of applied relaxation therapy consists of 12 to 15 weekly sessions, with each one lasting about an hour.
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.
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 for 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:
These 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 6 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.
If you're unable to take SSRIs or SNRIs for medical reasons or you experience troublesome side effects, another medication called pregabalin may be recommended. Dizziness and drowsiness are common side effects of pregabalin.
If you experience a particularly severe flare-up of panic-related symptoms, you may be prescribed a short course of benzodiazepines. These are tranquillisers designed to reduce anxiety and promote calmness and relaxation.
Taking benzodiazepines for longer than two weeks in a row isn't usually recommended as they can become addictive.
Claire Ledger was diagnosed with agoraphobia after having a panic attack in the street while shopping.
Claire, who was 26 at the time of this interview, was unable to explain the experience. She initially thought it may have had something to do with where she was, so she stopped going there and began to shop elsewhere. When she had a similar panic attack in another location, she stopped going there, too.
Within five months she'd stopped going to so many places she only felt truly safe at home. She left her job as a nurse and spent the next 2.5 years indoors. She read, watched TV, surfed the web and cared for her husband, who is in a wheelchair, and never went outside.
"When I had the first attack, I didn't know what was happening," says Claire, who lives in Bradford, West Yorkshire. "I was in a shop and felt faint all of a sudden, and had to crouch down to avoid collapsing. I was shaking and felt sick."
Claire went to her GP, who initially thought she was suffering from stress. Claire had just started a new job, recently got married, and was having IVF treatment.
"Every time I went out after that I got this feeling again," she says. "Everywhere it happened, I avoided that place. Instead of thinking it was me, I associated the panic attack with the place where it happened. I was such an outgoing person, the idea that it was all in my head never occurred to me."
Claire was eventually diagnosed with agoraphobia. "I got to a point where my stomach dropped as soon as I woke up," she says. "It's like a feeling of grief and despair. You're shaking, tired, and you don't really feel there. It's like you're watching yourself.
"I tried to get through it, but I reached a stage when even the thought of going into my own garden made me panic. It was like coming up against an invisible wall.
"It was hard on my husband. He's a big sports fan and likes going out to watch live events."
The couple's elderly neighbours would help out with getting food and household supplies. "I felt ashamed that someone in their 70s was doing my shopping," says Claire.
Claire became determined to seek treatment and went on a course of cognitive behavioural therapy (CBT). She found the treatment helpful, but it didn't change her thought process.
What made the difference was talking to other people with agoraphobia, who she contacted through online support groups. "You feel like a freak," she says. "Talking to other people in the same position was what helped me the most. We worked on breaking down our boundaries together."
She became friends with a woman in another town and they would make the same trips together in their respective neighbourhoods, slowly increasing the length of their journeys.
"We would call each other before leaving the house and would remain on the phone to each other until we got back in," says Claire. "Even though she wasn't there in person, her voice was really reassuring."
For the next two years, this was how Claire expanded her boundaries from her doorstep. "My husband changed our mobile provider when he saw the monthly bills I was running up!"
Claire has learned to cope with her moods and has now regained enough confidence to go back to work. "It's important for people to know that you can recover," she says. "You may think it's like a death sentence, but the treatments do work. I never thought I'd return to work.
"I still have my down days, but I've learned to accept that you can't feel your best every day."