- Risk Factors
- When to Call a Doctor
- More Information
What is the definition of agoraphobia?
A phobia is usually defined as the severe, unrelenting fear of a situation, activity, or thing that makes one want to avoid it. The definition of agoraphobia is the severe anxiety about being outside or otherwise being in a situation from which one either cannot escape or from which escaping would be difficult or embarrassing.
Phobias are often underreported and underdiagnosed, likely because many phobia sufferers find ways to avoid the situations they have a phobia about. The fact that agoraphobia often co-occurs with panic disorder makes it even more difficult to determine how often it occurs. Other statistics about agoraphobia include that researchers estimate it occurs in less than 1% to nearly 7% of the population. The age of onset for this condition is most often during the mid to late 20s.
What causes agoraphobia?
There are a number of theories about what can cause agoraphobia. One hypothesis is that agoraphobia develops in response to repeated exposure to anxiety-provoking events. Mental health theory that focuses on how people react to internal emotional conflicts (psychoanalytic theory) describes agoraphobia as being the result of a feeling of emptiness that comes from an unresolved Oedipal conflict, which is a tension between the feelings the person has toward the opposite-sex parent and a sense of competition with the same-sex parent.
Although agoraphobia, like other mental disorders, is related to a number of psychological and environmental risk factors, it also tends to run in families, and for some individuals, may have a clear contributing genetic component. Girls and women are more likely to develop agoraphobia compared to boys and men. For ethnic minorities in the U.S., a number of factors influence the likelihood of developing agoraphobia or any other anxiety disorder, like immigration from another country, language proficiency, feeling discriminated against, as well as the specific ethnicity of the individual.
What are the risk factors for agoraphobia?
Agoraphobia tends to begin in adolescence or early adulthood. Those who are at increased risk of developing agoraphobia include the following:
- Girls and women
- Native Americans
- Middle-aged individuals
- Low-income populations
- Individuals who are widowed or separated or divorced
- Individuals with a history of panic attacks
Individuals who are Asian, Hispanic, or of African/African-American descent tend to have a lower risk of developing this disorder. However, people who have felt discriminated against are thought to be at higher risk of suffering from a number of anxiety disorders, including agoraphobia.
Agoraphobic individuals are at increased risk of developing panic attacks, as well. Other anxiety disorders that tend to co-occur with agoraphobia include social anxiety disorder (social phobia) and generalized anxiety disorder. Even the use of alcohol can result in severe, albeit temporary anxiety.
What are agoraphobia symptoms?
Symptoms of agoraphobia include the anxiety that one will have a panic attack when in a situation from which escape is not possible or is difficult or humiliating. Examples of such situations include using public transportation, being in open or confined places, or being in crowds.
The apprehension or panic attacks that can be associated with agoraphobia, like all panic attacks, may involve symptoms and signs like:
Agoraphobic individuals often begin to avoid the situations that provoke these reactions. Interestingly, the situations that people with agoraphobia avoid and the environments that cause people with balance disorders to feel disoriented are quite similar. This leads some cases of agoraphobia to be considered vestibular function (related to balance disorders) agoraphobia.
When should you seek medical care for agoraphobia?
Call a doctor if your signs and symptoms of anxiety are not easily, quickly, and clearly relieved:
- Symptoms are so severe that medication may be needed
- Symptoms are interfering with someone's personal, social, or professional life
- You have chest pain, shortness of breath, headaches, palpitations, dizziness, fainting spells, or unexplained weakness
- You are experiencing depression or feeling suicidal or homicidal
When the signs and symptoms suggest that anxiety may have been present for a prolonged period (more than a few days) and appear to be stable (not getting significantly worse), it's advisable to make an appointment with a doctor for evaluation. But when the signs and symptoms are severe and come on suddenly, they may indicate a serious medical illness that needs immediate evaluation and treatment in a hospital's emergency department.
How is agoraphobia diagnosed?
Interestingly, physicians often diagnose and treat agoraphobia, like other phobias, when patients seek treatment for other medical or emotional problems rather than as the primary reason that care is sought. As with other mental disorders, there is no single, specific test for agoraphobia.
The primary care doctor or psychiatrist will take a careful history, perform or refer to another doctor for a physical examination, and order laboratory tests as needed. If someone has another medical condition that he or she knows about or there has been exposure to a medication, drug of abuse, or other substance, there may be an overlap of signs and symptoms between the old and the new conditions. Just determining that anxiety does not have a physical cause does not immediately identify the ultimate cause. Often, determining the cause requires the involvement of a psychiatrist, clinical psychologist, and/or other mental health professional.
In order to establish the diagnosis of agoraphobia, the professional will likely ask questions to ensure that the anxiety of the sufferer is truly the result of a fear of being in situations that make it impossible, difficult, or embarrassing to escape rather than the context of another emotional problem (for example, fear of being near people that remind one of an abuser in the case of posttraumatic stress disorder or the fear of hearing voices that have no basis in reality as occurs in schizophrenia). The evaluator will also seek to determine if the symptoms of agoraphobia have occurred most times that the sufferer has been exposed to the previously described anxiety-provoking situations over at least a 6-month period.
What is the treatment for agoraphobia?
There are many treatments available for overcoming agoraphobia, including specific kinds of psychotherapy as well as several effective medications.
Cognitive behavioral therapy
A specific form of psychotherapy that focuses on decreasing negative, anxiety-provoking, or other self-defeating thoughts and behaviors (called cognitive behavioral therapy) has been found to be highly effective in treating agoraphobia. In fact, when agoraphobia occurs along with panic disorder, cognitive behavioral therapy, with or without treatment with medication, is considered to be the most effective way to both relieve symptoms and prevent their return. Sometimes patients respond equally as well when treated with group cognitive behavioral therapy or a brief course of that kind of therapy, as they do when treated with traditional cognitive behavioral therapy. Psychotherapy for agoraphobia is also effective for many people when they receive it over the Internet, which is optimistic news for people who live in areas that are hundreds of miles from the nearest mental health professional.
Another form of therapy that has been found effective in managing agoraphobia includes self-exposure. In that intervention, people either imagine or put themselves into situations that cause increased levels of agoraphobic anxiety, using relaxation techniques in each situation (systematic desensitization) in order to master their anxiety. When avoiding the cause of the anxiety is gradually, and thoughtfully presented as part of this mode of therapy, it is often referred to as exposure and response prevention. As people gain access to the Internet, there is increasing evidence that exposure therapy can also be done effectively through that medium.
Regarding medication therapy, agoraphobia is usually treated in connection with panic disorder. Commonly, members of the selective serotonin reuptake inhibitor (SSRI) and the minor tranquilizer (benzodiazepine) groups of medications are used in treatment. Examples of SSRI medications include:
- Vortioxetine (Brintellix)
- Vilazodone (Viibryd)
- Escitalopram (Lexapro)
- Citalopram (Celexa)
- Fluvoxamine (Luvox)
- Sertraline (Zoloft)
- Paroxetine (Paxil)
- Fluoxetine (Prozac)
The possible side effects of SSRI medications can vary greatly from person to person and depend on which of the drugs is being used. Common side effects of this group of medications include dry mouth, sexual dysfunction, nausea or other stomach upset, tremors, trouble sleeping, blurred vision, constipation or soft stools, and dizziness. In rare cases, some people have been thought to become acutely more anxious or depressed once on the medication, even trying to or completing suicide or homicide. Children and teens are thought to be particularly vulnerable to this rare possibility. Phobias are also sometimes treated using beta-blocker medications, which block the effects of adrenaline (like rapid heartbeat, stomach upset, and shortness of breath) on the body. An example of a beta-blocker medication is propranolol.
Panic disorder and phobias are sometimes treated with drugs in a medication class known as benzodiazepines, also sometimes referred to as anxiolytics or sedatives. This class of medications causes relaxation but is used less often these days to treat anxiety due to the possibility of addiction, increasing need for higher doses, and overdose. The risk of overdose is especially heightened if taken when alcohol is also being consumed. Examples of medications from that group include
As anything that is ingested carries the risk of possible side effects, it is important to work closely with a doctor to decide whether medication is appropriate, and if so, which medication would be best. Further, the treating doctor will likely closely monitor for the possibility of side effects that can vary from minor to severe and in rare cases may even be life-threatening.
A variety of mental health specialists treat agoraphobia. In this age of managed care (involvement of insurance companies in determining payment for treatment), psychiatrists are often relegated to managing medication treatment for this condition despite the training these professionals receive in conducting therapy. Other mental health prescribers, like nurse practitioners and physician assistants, may also provide medication management for this condition. Psychoanalysts of a variety of disciplines, as well as psychologists, social workers, and psychiatric nurses, are some of the specialists that may conduct psychotherapy to treat agoraphobia.
Are there home remedies for agoraphobia?
While people often explore and attempt to address anxiety with alternative treatments, sometimes described as home remedies, there remains a lack of large-scale, controlled scientific research to indicate a clear benefit of such interventions. Examples of oral alternative treatments include:
Another challenge with these remedies is that there is little regulation of the doses and other ingredients for such substances. Lifestyle interventions that may help decrease anxiety include:
What are the complications of agoraphobia?
Agoraphobia increases the likelihood that the person will also suffer from another anxiety disorder, like social or other phobias, panic disorder, or anxiety associated with posttraumatic stress disorder. Agoraphobia also predisposes sufferers to have more severe and difficult-to-treat anxiety disorders of any kind.
People with agoraphobia are more at risk for developing alcohol or other drug use disorders. Also, agoraphobia tends to occur more often in individuals who have a number of different physical conditions, like irritable bowel syndrome (IBS) and asthma.
If not treated, agoraphobia may worsen to the point at which the person's life is seriously impacted by the disease itself and/or by attempts to avoid or hide it. In fact, some people have had problems with loved ones, failed in school, and/or lost jobs while trying to cope with severe agoraphobia or another severe phobia.
What is the prognosis for agoraphobia?
While there may be periods of spontaneous improvement of symptoms for people with agoraphobia, it does not usually go away unless the person receives treatment specifically for agoraphobia sufferers. Some research has indicated a more chronic and debilitating course of agoraphobia in African-American individuals compared to Caucasians.
One significant challenge of agoraphobia is revealed by the statistics related to treatment. Specifically, less than half of individuals with this condition in the United States are receiving treatment at any one time. Further, alcoholics can be up to 10 times more likely to suffer from a phobia than those who do not have alcohol use disorder, and phobic individuals can be twice as likely to be addicted to alcohol as people who have never been phobic.
Is it possible to prevent agoraphobia?
As agoraphobia often develops as a fearful reaction to having panic attacks, prevention of agoraphobia usually focuses on developing ways to cope with the anxiety about the possibility of another panic attack without avoiding leaving one's home. The treatments for agoraphobia previously described are usually used to prevent its development, as well.
Where can I find more information about agoraphobia?
The following organizations can provide information, self-help tips, and/or support for individuals experiencing agoraphobia as well as their families.
ABIL (Agoraphobics Building Independent Lives), Inc.
3805 Cutshaw Ave., Suite 415
Richmond, VA 23230
Agoraphobics in Motion
Royal Oak, MI 48067-1306
American Academy of Child and Adolescent Psychiatry
American Counseling Association
American Psychiatric Association
American Psychological Association
Anxiety Disorders Association of America
8730 Georgia Ave., Ste. 600
Silver Spring, MD 20910
Council on Anxiety Disorders
Route 1, Box 1364
Clarkesville, GA 30523
Freedom From Fear
National Anxiety Foundation
3135 Custer Dr.
Lexington, KY 40517-4001
National Association of Social Workers
National Mental Health Association
National Panic/Anxiety Disorder News, Inc.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Washington, D.C.: American Psychiatric Association, 2013.
Bienvenu, O.J., Onyike, C.U., Stein, M.B., Chen, L., Samuels, J., Nestadt, G., and Eaton, W.W. Agoraphobia in adults: incidence and longitudinal relationship with panic. The British Journal of Psychiatry 188: 432-438, 2006.
Biondi, M. and Picardi, A. Increased probability of remaining in remission from panic disorder with agoraphobia after drug treatment in patients who received concurrent cognitive-behavioural therapy: a follow-up study. Psychotherapeutic Psychosomatics 72(1): 34-42, 2003.
Bruce, S.E., Vasile, R.G., Goisman, R.M., Salzman, C., Spencer, M., Machan, J.T., Keller, and M.B. Are benzodiazepines still the medication of choice for patients with panic disorder with our without agoraphobia? American Journal of Psychiatry 160: 1432-1438, August 2003.
Bruce, S.E., Yonkers, K.A., Otto, M.W., Eisen, J.L., Weisberg, R.B., Pagano, M., Shea, T., and Keller, M.B. Influence of psychiatric comorbidity on recovery and recurrence in generalized anxiety disorder, social phobia and panic disorder: a 12-year prospective study. American Journal of Psychiatry 162: 1179-1187, 2005.
Chou, T., A. Asnaani, and S.G. Hofmann. "Perception of racial discrimination and psychopathology across three U.S. ethnic minority groups." Cultural Diversity and Ethnic Minority Psychology 18.1 (2012): 74-81.
Collier, D.A. FISH, flexible joints and panic: are anxiety disorders really expressions of instability in the human genome? The British Journal of Psychiatry 181: 457-459, 2002.
Fava, G.A., Ruini, C., Rafanelli, C., and Grandi, S. Cognitive behavior approach to loss of clinical effect during long-term antidepressant treatment: A pilot study. American Journal of Psychiatry 159: 2094-2095, December 2002.
Furukawa, T.A. and Watanabe, N. Psychotherapy plus antidepressant for panic disorder with or without agoraphobia. The British Journal of Psychiatry 188: 305-312, 2006.
Gersley, E. Phobias: Causes and treatments. All Psych Journal, 11/17/01.
Godemann, F., Ahrens, B., Behrens, S., Berthold, R., Gandor, C., Lampe, F., and Linden, M. Classic conditioning and dysfunctional cognitions in patients with panic disorder and agoraphobia treated with an implantable cardioverter/defibrillator. Psychosomatic Medicine 63: 231-238, 2001.
Goodwin, R., Faravelli, C., Rosi, S., Cosci, F., Truglia, E., de Graaf, R., and Wittchen, H.U. The epidemiology of panic disorder and agoraphobia in Europe. European Neuropsychopharmacology 15(4): 435-443, 2003.
Grant, B.F. The epidemiology of DSM-IV panic disorder and agoraphobia in the United States: results from the national epidemiologic survey on alcohol and related conditions. Journal of Clinical Psychiatry 67(3): 363-374, 2006.
Hofmann, S.G., and D.E. Hinton. "Cross-cultural aspects of anxiety disorders." Current Psychiatry Reports 16.6 June 2014: 450.
Ito, L.M., de Araujo, L.A., Tess, V.L.C., de Barros-Neto, T.P., Asbahr, F.R., and Marks, I. Self-exposure therapy for panic disorder with agoraphobia: randomized controlled study of external v. interoceptive self-exposure. The British Journal of Psychiatry 178: 331-336, 2001.
Kenwright, M., Liness, S., and Marks, I. Reducing demands on clinicians by offering computer-aided self-help for phobia/panic. The British Journal of Psychiatry 179: 456-459, 2001.
Kessler, R.C. The epidemiology of panic attacks, panic disorder and agoraphobia in the National Comorbidity Survey Replication. Archives of General Psychiatry 63(4): 415-424, 2006.
Kikuchi, M., Komuro, R., Oka, H., Kidani, T., Hanaoka, A., and Koshino, Y. Panic disorder with and without agoraphobia: comorbidity within a half-year of the onset of panic disorder. Psychiatry and Clinical Neurosciences 59(6): 639-643, 2005.
Kumano, H., Kaiya, H., Yoshiuchi, K., Yamanaka, G., Sasaki, T., and Kuboki, T. Comorbidity of irritable bowel syndrome, panic disorder and agoraphobia in a Japanese representative sample. The American Journal of Gastroenterology 99(2): 370-376, 2004.
Leinonen, E., Lepola, U., Koponen, H., Turtonen, J., Wade, A., and Lehto, H. Citalopram controls phobic symptoms in patients with panic disorder: randomized controlled trial. Journal of Psychiatry Neuroscience, 25(1): 25-32, 2000.
Magee, W.J., Eaton, W.W., Wittchen, H.U., McGonagle, K.A., and Kessler, R.C. Agoraphobia, simple phobia and social phobia in the National Comorbidity Survey. Archives of General Psychiatry 53(2): 159-168, 1996.
McLean, C.P., and E.R. Anderson. "Brave men and timid women? A review of the genter differences in fear and anxiety." Clinical Psychology Review 29 (2009): 496-505.
Mental Health America. Mental Health and Complementary and Alternative Medicine. April 2016.
Milrod, B. Emptiness in agoraphobia patients. Journal of the American Psychoanalytic Association 55(3): 1007-1026, 2007.
Nascimento, I. Psychiatric disorders in asthmatic outpatients. Psychiatry Research 110(1): 73-80, 2002.
Roberge, P., Marchand, A., Reinharz, D., and Savard, P. Cognitive-behavioral treatment for panic disorder with agoraphobia: A randomized, controlled trial and cost-effectiveness analysis. Behavior Modification 32(3): 333-351, 2008.
Rosenberg, F. "Treating panic disorder with exposure response prvention (ER/P) therapy." Anxiety.org. July 2014.
Schuckit, M.A., and Hesselbrock, V. Alcohol dependence and anxiety disorders: what is the relationship? Focus 2: 440-453, 2004.
Shandley, K., Austin, D.W., Klein, B., Pier, C., Schattner, P., Pierce, D., and Wade, V. Therapist-assisted, internet-based treatment for panic disorder: can general practitioners achieve comparable patient outcomes to psychologists? Journal of Medical Internet Research 10(2), 2008.
Sibrava, N.J., C. Beard, A.S. Bjornsson, et al. "Two-year course of generalized anxiety disorder, social anxiety disorder and panic disorder in a longitudinal sample of African American adults." Journal of Consulting and Clinical Psychology 81.6 (2013): 1052-1062.
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Thomas, S.E., Thevos, A.K., and Randall, C.L. Alcoholics with and without social phobia: a comparison of substance use and psychiatric variables. Journal of Studies on Alcohol (60) 1999.
Wittchen, H.U., Nocon, A., Beesdo, K., Pine, D.S., Hofler, M., Lieb, R., and Gloster, A.T. Agoraphobia and panic: Prospective-longitudinal relations suggest a rethinking of diagnostic concepts. Psychotherapy and Psychosomatics 77(3), 2008.
Yardley, L., Britton, J., Lear, S., Bird, J., and Luxon, L.M. Relationship between balance system function and agoraphobic avoidance. Behavior Research Theory 33(4): 435-439, 1995.
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