- Agoraphobia is an anxiety disorder that occurs when a person shows extreme forms of fear response while leaving their houses, being in a crowded place from where escape would be difficult.
- It involves feeling shaky and uncomfortable while in shopping centers, elevators, trains, theatres, and other public places where help would not be available easily.
- Agoraphobia can be caused by stressful life events, biological factors, and a person’s innate nature to respond with fear and anxiety in unknown and uncertain conditions.
- Cognitive behavior therapy and exposure therapy remain the first line of treatment for agoraphobia. Other supportive therapies facilitate good coping and adaptation during the fearful state.
Many times you must have experienced disgust and apathy while traveling in an overcrowded bus or navigating a busy marketplace.
Too many people in a public place may make you feel irritable and out of place. This is absolutely normal.
However, there are a few of them who experience extreme fear while being in enclosed or crowded public spaces.
They feel escape would be difficult and thus feel helpless, embarrassed, and pinned down. This condition is known as Agoraphobia.
The fear can come out of a real situation or an anticipated one. People with agoraphobia experience a state of panic. The fear gets out of control and impacts day to day functioning of the person.
Let us elaborate more on this condition here.
What is Agoraphobia?
Agoraphobia causes irrational and intense fear of public places, crowded spaces that are unknown such as market places, standing in a queue, availing a public transportation, etc where the person feels that escape would be difficult if their fear gets worse.
The term agoraphobia was coined in 1871 to describe the condition of patients who were afraid to venture alone into public places.
The term is derived from the Greek words ‘Agora’ and ‘Phobos’, meaning ‘fear of the marketplace’
It can be the most disabling of phobias because it can significantly interfere with a person’s ability to function in work and social situations outside the home.
The fear of crowded places makes the person feel that they will not be able to get out of the confined space if the discomfort intensifies.
People diagnosed with agoraphobia feel stuck and helpless. They suffer from bouts of panic attacks which can bring a number of physical symptoms and emotional problems.
Most of the time, agoraphobia is a perceived state of mind without any real physical threat. It is a type of anxiety disorder in which the patient anticipates harm that is not genuine, rather an idea that is baseless.
They never feel safe in enclosed spaces where a lot of crowds have already gathered. Thus, these people fear stepping out of their house.
In extreme forms of the disease, the person will avoid going out completely and prefers to remain in a safe place for days, weeks, and even months.
In the United States, most researchers believe that agoraphobia almost always develops as a complication in patients with panic disorder.
That is, the fear of having a panic attack in a public place from which escape would be formidable is thought to cause agoraphobia.
Although agoraphobia often coexists with panic disorder, DSM-5 classifies agoraphobia as a separate condition that may or may not be co-morbid with panic disorder.
If you are suffering from agoraphobia, you must have noticed that you never feel secure being alone in a public place.
You always feel threatened even if there is no immediate danger lurking around. There is a tendency to avoid places or situations that are unknown and the probability of receiving help is not present.
You always wish to have a companion or friend to escort you in such places. The fear response to crowded places can make you feel completely helpless and insecure.
Sometimes, you may experience the fear only by thinking about a crowded place and the way it can affect you.
As such, the condition can stop you from visiting public places such as grocery shops, banks, hospitals, religious places, etc.
The fear is intense and consuming. You may not feel comfortable leaving your home at all.
When we talk about mental health conditions, it is obvious that we refer to how the condition can change and alter the way you think, feel, and act in everyday life.
Agoraphobia can be identified by the typical signs that it brings in the early course of its onset. You may find yourself avoiding certain places by giving excuses, or procrastinating, etc.
Sometimes you may try hard to explain rationally to someone why you really want to avoid such visits.
You will try to avoid all public gatherings or crowded, enclosed spaces that make you feel trapped and powerless. Feelings of mental weakness, dependability, can start to kick off soon.
In most cases, it has been found that agoraphobia starts in adolescence and early adulthood. The average age given is 20 – 30 years.
The study findings of NIH show that about 2.4% of teenagers between the age group of 13 -18 years suffer from agoraphobia.
The signs are avoiding public places and extreme forms of fear and anxiousness, if at all exposed to crowded or overfilled spaces from where getaway would be an uphill task.
The DSM-5 handbook, published by the American Psychiatric Association gave diagnostic criteria for agoraphobia.
It involves a marked fear or anxiety about at least one situation from two or more of five situation groups:
- using public transportation (e.g., bus, train, cars, planes)
- in an open space (e.g., park, shopping center, parking lot)
- alone outside of the home / leaving their home comfortably
- in an enclosed space (e.g., stores, elevators, theaters)
- in a crowd or standing in line
The fear or anxiety must be persistent and last at least 6 months for the clinical diagnosis of agoraphobia.
The symptoms of agoraphobia include the following:
- A constant need to avoid places of extreme discomfort because the person thinks that they may be stuck in one place and may not get out of it. No help may be available at that time when the anxiety gets bad.
- All the above situations mentioned above are avoided at all costs
- The perceived fear is much higher and out of proportion than the real threat
- The crowded places are endured with a lot of fear and physical reactions such as sweating, dry mouth, and pounding heart, etc.
- The fear response is overwhelming and it stops the person from doing regular activities such as shopping, going to parks, and banks, etc.
- Your symptoms are not getting better in any other way
- The fear and avoidance have become critical ones with a lot of anxiety that has consumed your thoughts and feelings completely.
- Fear and shaky feeling in the body
- Sudden chills and excessive sweating when confronted in danger
- Troubles in breathing and feeling dizzy and imbalanced
- Any unfamiliar places feel unstable and insecure. You may develop anxiety and panic symptoms instantly.
Impact of Agoraphobia
Patients with agoraphobia rigidly avoid situations in which it would be difficult to obtain help.
They prefer to be accompanied by a friend or a family member in busy streets, crowded stores, closed-in spaces (e.g., tunnels, bridges, and elevators), and closed-in vehicles (e.g., subways, buses, and airplanes).
Patients may insist that they be accompanied every time they leave the house. The behavior can result in marital discord, which may be misdiagnosed as the primary problem.
Severely affected patients may simply refuse to leave the house.
Particularly before a correct diagnosis is made, patients may be terrified that something is badly wrong with them and they are going crazy day by day.
Though it is not clear what actually causes agoraphobia, there are many theories that hint towards an existing condition of panic attacks that may lead to this condition.
As this is an anxiety disorder, there are several risk factors associated with it. Some of the major factors that lead to the development of agoraphobia are as follows:
- Agoraphobia develops with other existing types of phobias
- Stressful situations in life
- Death of someone in a closed space or crowded setups
- You were attacked in a crowded place sometime earlier
- If you are an anxious and nervous person, it may lead to agoraphobia
- Your response to anxiety is always with fear and insecurity. Maybe this is your nature
- Family history of panic and agoraphobia
Many theories have pointed towards the combination of biological and psychological factors in the causation of agoraphobia.
One theory says that agoraphobia is caused by the body’s natural tendency to avoid stimuli and situations that are perceived as harmful and dangerous.
This is known as the fight and flight response. If you are suffering from agoraphobia, you’ll tend to avoid all such crowded places because you feel unsafe and helpless.
As you do not know the escape route, your body reflexes start responding in a negative way, saying that something bad might happen. Thus, fear and anxiety set in and condition you to avoid such places in the future as well.
Another biological cause hints towards the imbalance of neurotransmitters in the causation of anxiety disorders.
The fear network theory points out that certain people are more prone to fear than others. It means they are wired to think negatively and feel unsafe in unknown situations than other people.
There could be certain malfunctioning in certain parts of the brain that elicits a fear response and many other physical reactions in times of stress.
People who ate wired with fear and anxiousness may lose the ability to judge things rationally.
The fear is so overwhelming that they feel that avoiding the situation is the best possible way to safeguard them from the agony.
The psychological theories state that agoraphobia may be caused by some traumatic incident that left a deep-seated mark in the person’s psyche. It could be the death of a loved one, sexual abuse, etc.
If you have experienced a bad event recently while in a crowded place, you may develop an aversion to the same. You may be unable to leave your house.
Any other persistent psychological problem such as anxiety disorder, depression, can aggravate agoraphobia symptoms as well.
If you feel confined in space and feel helpless about how to come out of the situation, it can result in symptoms of agoraphobia.
Certain examples of agoraphobic responses are:
- Feelings of helplessness when anxiety strikes in
- Fear of leaving the house or a space of comfort
- When you are not comfortable going to a shopping mall, a small store, or other public places such as museums and zoo
- If you see crowded queues, you may not feel comfortable to line up in the same
- Travelling in public transportation can be very disturbing for you
- Meeting unknown people is not your choice at all
- You may feel uncomfortable in a movie hall or circus show. The closed space may feel emotionally overwhelming
Agoraphobia vs. Social anxiety
Agoraphobia is fear of leaving one’s own home or comfort space. It also means avoiding crowded places from where escape or moving out would be difficult.
However, social anxiety disorder or social phobia is the fear of being with others in a public situation.
Social anxiety is a form of psychological discomfort that arises when a person fears being judged, evaluated, or criticized by others in some way or the other.
Though they may sound alike, the symptoms of these two disorders are different and don’t match with one another.
The table shown below shows the major differences between agoraphobia and social anxiety.
|Fear of being alone in a public place
|Fear of being judged by others in public places or social gatherings
|Avoidance of crowded spaces where a lot of people have gathered
|Fear of public places where there is a chance to talk, mingle, and interact with other people
|The root fear is not being able to escape
|The root fear is feeling awkward or embarrassed
|May feel better if accompanied by a friend or family member
|A socially anxious person will not feel comfortable even if accompanied by loved ones
|Spontaneous panic attacks may occur
|Feels ashamed but no panic attacks happen publicly
|Avoids unfamiliar places and situations
|Avoid any place where they are required to interact and talk to others
|There is a fear of leaving one’s own home
|No fear of leaving one’s own home
Types of agoraphobia
Agoraphobia involves fear of crowded and uncomfortable spaces where the person feels embarrassed and confined in some way. Some of them may fear going alone in an elevator, car, subway, or airplane.
There is a strong desire to avoid or escape the situation because it creates a lot of emotional discomfort and agony.
In DSM 5, there are two types of agoraphobia that are discussed. They are
- Panic disorder with agoraphobia
- Agoraphobia without a history of panic disorder
Panic disorder with agoraphobia
In the first one, the feeling of anxiousness will be enormous. People suffering from this disorder often get sudden anxiety attacks that are intense and overwhelming.
The anxiety attacks may come without a warning, and even in a non-threatening circumstance.
The patient may start avoiding those places that elicited a panic response before. Thus, avoidance response may be seen while being a theatre, shopping malls, train, airports, etc.
Panic attacks that accompany agoraphobia can keep someone at home for a longer time. They fear going out even if there is no imminent threat in real-life.
Some of the crucial symptoms of a panic attack with agoraphobia are –
- Feeling threatened without being exposed to the feared situation
- A need to flee or avoid the situation
- Choking sensation
- Fear of losing control
Agoraphobia without panic attacks
When agoraphobia symptoms appear without a panic attack, it involves avoidance of crowded places and a strong need to feel safe and secure from within.
The person never wants to go out of a comfort zone. It includes all the symptoms of general agoraphobia, just without the occurrence of sudden and unexpected anxiety attacks.
If you have agoraphobia without panic disorder, it means that you must have been a victim of some crime in a public place, or been infected with a community disease in the past and thus you’re scared of such places in general.
The fear may aggravate if you have a negative experience attached to the place before. Agoraphobia without panic attacks can also happen if you had faced any embarrassment in public places before.
Now, you fear being humiliated gin and thus want to avoid the situation.
Apart from these two broad categories of agoraphobia, we have some other types of this disorder as well. They are as follows:
1. Paranoid agoraphobia
This type of agoraphobia involves a combination of paranoia and phobia. The person suffers from some false beliefs and irrational fear about a situation that is true, and if the condition involves agoraphobia, the false beliefs can induce a lot of fear as well.
The person will be reluctant to come out of their comfort zone.
This condition involves fear of very small, confined, and ill-fitted spaces. The person may feel trapped in a situation. Feelings of extreme anxiety may lead to avoiding the trapped spaces at all costs.
3. Disorganized agoraphobia
This type of agoraphobia shows intense anxiety if placed in a situation that the person resists. Sometimes it may lead to distortions about the reality of the threat.
It means that though there is no real danger around, the person feels the fear and tries to avoid the situation.
For example – being in a marketplace where there is no real threat but the person may think that they may be harmed in some way.
4. Catatonic agoraphobia
This condition involves a state of overwhelming fear that may lead to an inability to move when the person is in the face of fear.
For example – entering a room filled with many people may make the person stand still for long a long time without moving. It can be marked by several physical reactions of agoraphobia as well.
This condition is common agoraphobia where the person fears being in a crowded place. They may avoid marketplaces, movie halls, sporting events, etc.
How to overcome agoraphobia? (Self-help tips)
Since there is no one size fits all method to prevent agoraphobia, you can use some self-help tips to manage your symptoms and feel better.
Along with medications and psychotherapy, you can bring some desirable changes in your lifestyle that will help you to become symptom-free as soon as possible.
- Do not avoid going to crowded or public places consciously. It will increase your fear response than reduce it.
- Eat a well-balanced diet
- Sleep well and keep stress far away from your daily life
- Practice deep breathing and grounding techniques such as 54321 technique to reduce your anxiousness
- Take medicines on time
- Joining a support group of people suffering from agoraphobia can help you to learn new coping skills
- Avoid caffeine, alcohol, drugs, and other toxic drinks that can affect sleep and healthy living
- Be in touch with your therapist regularly because consistency is important
- Visit places that appears frightening to you. Take help from friends and family. The more you visit the places of fear and discomfort, the less the fear becomes
- Yoga, meditation, calming exercises can reduce the instant fear responses
- Stay physically active because remember that a healthy mind stays in a healthy body
- Take enough self-care to boost your confidence
- Try to affirm your efforts positively and make sure that you do not criticize yourself if you cannot do anything right
Treatment of Agoraphobia
If you are suffering from agoraphobia, you might not be comfortable visiting a therapist in the first go. You may feel shy and awkward.
Thus, it is advisable that whenever you feel the need to visit a mental health professional, you take a trusted friend or a caring family member with you.
During your first visit, the therapist will ask you many questions regarding your problem and the ways you use to cope with it.
This is a part of the mental status examination that you will undergo in your first clinic visits.
Some of the probable questions in your first visit could be like this –
- Your symptoms and the duration of your suffering
- The various things that you are avoiding because of your fear
- They may ask you about your immediate fear response
- Some personal information about your general lifestyle and other stress factors
- Your coping style and stress management methods
- Medical history of you and your family members, just to rule out whether the condition runs in family
- Medications, if any that you may be taking to feel better
After this, the therapist will prepare an individualized treatment plan that will meet your requirements.
You will be put in a definite regime and would be supported in all possible ways. Some of the best ways for treating agoraphobia are as follows:
This treatment method involves the use of various ways to promote adaptive coping. Adaptive defenses are encouraged and strengthened, and maladaptive ones are discouraged.
The person is helped by the therapist to confront fearful situations boldly. This is done by praising the person when they accomplish facing the feared situation successfully.
This motivates the patient to take a step-wise plan towards reducing the fear response. The therapist assists in reality testing and may offer advice regarding behavior.
In insight-oriented psychotherapy, the goal is to increase the patient’s development of insight into psychological conflicts that, if unresolved, can manifest as symptomatic behavior.
The patient is asked to delve deeper into their unconscious and find out the reasons for their fear. Here, the role of past experience plays an important role.
If the patient has suffered a setback while being in a crowded place that may have given rise to the fear, then this method can help in removing the past fear element.
In behavior therapy, the basic assumption is that change can occur without the development of psychological insight into underlying causes.
Techniques include positive and negative reinforcement, systematic desensitization, flooding, implosion, graded exposure, response prevention, stop thought, relaxation techniques, panic control therapy, self-monitoring, and hypnosis.
This is based on the premise that maladaptive behavior results from distortions in how people perceive themselves and in how others perceive them.
Treatment is short-term and interactive, with assigned homework and tasks to be performed between sessions. The therapy aims to correct the distorted assumptions and cognitions.
The emphasis is on confronting and examining situations that elicit interpersonal anxiety and associated mild depression.
In CBT sessions, you may be asked to imagine a situation that is crowded and you’ll have to walk through the busy place confidently.
The therapist records your anxiety responses and notes down the treatment plan that you will have to follow.
You will be taught to manage your emotions without getting overwhelmed.
The method aims to expose you to situations that evoke fear so that you can manage the reactions as aptly as possible and treat anxiety issues at the earliest.
Computer programs have been developed that allow patients to see themselves as avatars who are then placed in open or crowded spaces (e.g., a supermarket).
As they identify with the avatars in repeated computer sessions, they are able to master their anxiety through the process of de-conditioning.
This treatment method is intended to be a substitute for real exposure. It is a mild form of treatment that helps the patient to face the feared situation slowly without the real threat.
Agoraphobia symptoms can be managed with the use of anti-anxiety drugs, anti-depressives, selective serotonin reuptake inhibitors, etc.
They can be used along with psychotherapy as a second line of treatment. Medication can reduce anxiety attacks and keep the person calm and relaxed.
It is obvious that coping with agoraphobia is not one-night magic. Most patients recover well and can become symptom-free in the course of time.
The trick to be followed is to treat yourself well, have a balanced lifestyle, stay positive, and learn to keep yourself relaxed in some best possible ways.
The aim of this treatment procedure is to expose the patient to feared situations slowly and gradually. Your therapist may ask you to visit a local shop to buy things or pay a visit to a nearby park for a walk.
You will be asked to record your feelings while these visits. The aim of this technique is to boost your confidence till you are ready to face more threatening situations.
the therapist will encourage and motivate you to go out of the house alone to nearby places. moreover, you will be able to think positively and alter your negative thoughts easily.
Exposure therapy is used with CBT and the duration of the treatment varies from 12 – 15 weeks depending upon the severity of symptoms and the patient’s ability to cope with it.
Slowly, you will find yourself more capable of confronting those situations and public spaces that you earlier avoided.
it will improve your willingness to participate and confront situations that are challenging and fearful. maybe your fear will gradually come down in a few weeks’ time.
Applied relaxation technique
if you are suffering from agoraphobia, you must have noticed that your ability to relax has decreased a lot. You are always in the grip of anxiety and fear and it has clouded your perception of reality.
The mundane and less complicated situations are perceived as fearful and dangerous. Thus, it doesn’t allow you to be cool and relaxed.
In applied relaxation techniques, you will be taught how to relax and take things easy.
The procedure is simple where simple mind exercises are conducted and you will be asked to record your thoughts and feelings.
- You will have to spot the signs of fear and describe why you think that the situation is fearful
- Relax your body muscles slowly by breathing exercises
- Use these exercises in daily life wherever you are in the grip of fear and doubt
- The method can last for 12 weeks till you feel better
Agoraphobia tests and diagnostic tools
For the proper diagnosis of agoraphobia, you will have to visit your doctor. They will evaluate your condition and may tell you to take a self-report anxiety scale to assess the intensity of fear response.
The Panic and Agoraphobia scale, commonly known as PAS is used widely to check the efficacy of the treatment plan followed by the patient.
It is a clinical tool that has a self-rated and clinician-rated version.
The test has 13 questions that are used to assess the severity of the illness. There are five categories of agoraphobia symptoms that are tested with this test. They are
- Panic attacks
- Agoraphobic avoidance
- Anticipatory anxiety
- Worries about health
In some severe cases of the illness, a psychotherapist may also use another test known as the Panic Disorder Severity Scale (PDSS).
How common is agoraphobia?
Agoraphobia is a common type of specific phobia. In the United States, about 1% to 2% of the population suffers from agoraphobia. Women suffer from agoraphobia more often than men.
The research findings suggest various trends in the disorder and the more number of people who might suffer from this disorder.
- 1.3% of adults develop agoraphobia at some point in their life
- The onset of the disease is between 20 -30 years
- The older population has more chances of developing the disorder
- 87% of those who suffer from agoraphobia have a higher chance of developing other mental health problems such as panic disorder or depression
- Women suffer more from this disorder than men
There are many good books on agoraphobia that describe the symptoms and how one can manage the symptoms and start accepting their condition.
The more accepting you are, the better you’ll be able to adapt the coping skills well. It will also help to bring some desirable changes in your daily life.
Summing Up from ‘ThePleasantMind’
To finish off, it can be said that if agoraphobia affects your mental health and overall lifestyle, you need to do something to keep your symptoms in check.
Sometimes, your anxiety levels may be overwhelming and can affect your relationships and work habits on a day-to-day basis.
Thus, it is important that you learn more about the disorder and feel free to seek professional help from an expert if the need arises.
With timely treatment, you will experience fewer panic attacks, and more control over your feelings and behavior if exposed to crowds and other open spaces.
Meanwhile, there will be less avoidance and more active joining in public places.
The overall quality of life will improve and you will feel in control of your thoughts, feelings, and behavior.
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A Psychologist with a master's degree in Psychology, a former school psychologist, and a teacher by profession Chandrani loves to live life simply and happily. She is an avid reader and a keen observer. Writing has always been a passion for her, since her school days. It helps to de-stress and keeps her mentally agile. Pursuing a career in writing was a chance occurrence when she started to pen down her thoughts and experiences for a few childcare and parenting websites. Her lovable niche includes mental health, parenting, childcare, and self-improvement. She is here to share her thoughts and experiences and enrich the lives of few if not many.