Agoraphobia

Overview

Agoraphobia (ag-uh-ruh-FOE-be-uh) is a type of anxiety disorder. Agoraphobia involves fearing and avoiding places or situations that might cause panic and feelings of being trapped, helpless or embarrassed. You may fear an actual or upcoming situation. For example, you may fear using public transportation, being in open or enclosed spaces, standing in line, or being in a crowd.

The anxiety is caused by fear that there's no easy way to escape or get help if the anxiety gets overwhelming. You may avoid situations because of fears such as getting lost, falling, or having diarrhea and not being able to get to a bathroom. Most people who have agoraphobia develop it after having one or more panic attacks, causing them to worry about having another attack. They then avoid the places where it may happen again.

Agoraphobia often results in having a hard time feeling safe in any public place, especially where crowds gather and in locations that are not familiar. You may feel that you need a companion, such as a family member or friend, to go with you to public places. The fear can be so overwhelming that you may feel you can't leave your home.

Agoraphobia treatment can be challenging because it means confronting your fears. But with proper treatment — usually a form of therapy called cognitive behavioral therapy and medicines — you can escape the trap of agoraphobia and live a more enjoyable life.

Symptoms

Typical agoraphobia symptoms include fear of:

• Leaving home alone.
• Crowds or waiting in line.
• Enclosed spaces, such as movie theaters, elevators or small stores.
• Open spaces, such as parking lots, bridges or malls.
• Using public transportation, such as a bus, plane or train.

These situations cause anxiety because you fear you won't be able to escape or find help if you start to feel panicked. Or you may fear having other disabling or embarrassing symptoms, such as dizziness, fainting, falling or diarrhea.

In addition:

• Your fear or anxiety is out of proportion to the actual danger of the situation.
• You avoid the situation, you need a companion to go with you, or you endure the situation but are extremely upset.
• You have major distress or problems with social situations, work or other areas in your life because of the fear, anxiety or avoidance.
• Your fear and avoidance usually lasts six months or longer.

Panic disorder and agoraphobia

Some people have panic disorder in addition to agoraphobia. Panic disorder is a type of anxiety disorder that includes panic attacks. A panic attack is a sudden feeling of extreme fear that reaches a peak within a few minutes and triggers a variety of intense physical symptoms. You might think that you're totally losing control, having a heart attack or even dying.

Fear of another panic attack can lead to avoiding similar situations or the place where it happened in an attempt to prevent future panic attacks.

Symptoms of a panic attack can include:

• Rapid heart rate.
• Trouble breathing or a feeling of choking.
• Chest pain or pressure.
• Lightheadedness or dizziness.
• Feeling shaky, numb or tingling.
• Sweating too much.
• Sudden flushing or chills.
• Upset stomach or diarrhea.
• Feeling a loss of control.
• Fear of dying.

When to see a doctor

Agoraphobia can severely limit your ability to socialize, work, attend important events and even manage the details of daily life, such as running errands.

Don't let agoraphobia make your world smaller. Call your health care provider or a mental health professional if you have symptoms of agoraphobia or panic attacks.

Causes

Biology — including health conditions and genetics — personality, stress and learning experiences may all play a role in the development of agoraphobia.

Risk factors

Agoraphobia can begin in childhood, but usually starts in the late teen or early adult years — usually before age 35. But older adults also can develop it. Females are diagnosed with agoraphobia more often than males are.

Risk factors for agoraphobia include:

• Having panic disorder or other excessive fear reactions, called phobias.
• Responding to panic attacks with too much fear and avoidance.
• Experiencing stressful life events, such as abuse, the death of a parent or being attacked.
• Having an anxious or nervous personality.
• Having a blood relative with agoraphobia.

Complications

Agoraphobia can greatly limit your life's activities. If your agoraphobia is severe, you may not even be able to leave your home. Without treatment, some people become housebound for years. If this happens to you, you may not be able to visit with family and friends, go to school or work, run errands, or take part in other routine daily activities. You may become dependent on others for help.

Agoraphobia also can lead to:

• Depression.
• Alcohol or drug misuse.
• Suicidal thoughts and behavior.

Prevention

There's no sure way to prevent agoraphobia. But anxiety tends to increase the more you avoid situations that you fear. If you start to have mild fears about going places that are safe, try to practice going to those places over and over again. This can help you feel more comfortable in those places. If this is too hard to do on your own, ask a family member or friend to go with you, or seek professional help.

If you experience anxiety going places or have panic attacks, get treatment as soon as possible. Get help early to keep symptoms from getting worse. Anxiety, like many other mental health conditions, can be harder to treat if you wait.

Diagnosis

Agoraphobia is diagnosed based on:

• Symptoms.
• In-depth interview with your health care provider or a mental health provider.
• Physical exam to rule out other conditions that could be causing your symptoms.

Treatment

Agoraphobia treatment usually includes both psychotherapy — also called talk therapy — and medicine. It may take some time, but treatment can help you get better.

Talk therapy

Talk therapy involves working with a therapist to set goals and learn practical skills to reduce your anxiety symptoms. Cognitive behavioral therapy is the most effective form of talk therapy for anxiety disorders, including agoraphobia.

Cognitive behavioral therapy focuses on teaching you specific skills to better tolerate anxiety, directly challenge your worries and gradually return to the activities you've avoided because of anxiety. Cognitive behavioral therapy is usually a short-term treatment. Through this process, your symptoms improve as you build on your initial success.

You can learn:

• What factors may trigger a panic attack or panic-like symptoms and what makes them worse.
• How to cope with and tolerate symptoms of anxiety.
• Ways to directly challenge your worries, such as whether bad things are actually likely to happen in social situations.
• That anxiety gradually decreases and that feared outcomes tend not to happen if you remain in situations long enough to learn from them.
• How to approach feared and avoided situations in a gradual, predictable, controllable and repetitive manner. Also known as exposure therapy, this is the most important part of treatment for agoraphobia.

If you have trouble leaving your home, you may wonder how you could possibly go to a therapist's office. Therapists who treat agoraphobia are aware of this problem.

If you feel homebound due to agoraphobia, look for a therapist who can help you find alternatives to office appointments, at least in the early part of treatment. The therapist may offer to see you first in your home or meet you in what you consider a safe place. Some therapists also may offer some sessions by video, over the phone or through email.

If the agoraphobia is so severe that you cannot access care, you might benefit from a more intensive hospital program that specializes in the treatment of anxiety. An intensive outpatient program usually involves going to a clinic or hospital for either a half or full day over a period of at least two weeks to work on skills to better manage your anxiety. In some cases, a residential program may be needed. This includes a stay in the hospital for a period of time while receiving treatment for severe anxiety.

You may want to take a trusted relative or friend to your appointment who can offer comfort, help and coaching, if needed.

Medicines

Certain types of antidepressants are often used to treat agoraphobia. Sometimes anti-anxiety medicines are used on a limited basis. Antidepressants are more effective than anti-anxiety medicines in the treatment of agoraphobia.

• Antidepressants. Certain antidepressants called selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine (Prozac) and sertraline (Zoloft), are used for the treatment of panic disorder with agoraphobia. Other types of antidepressants also may effectively treat agoraphobia. Antidepressants also are used for other mental health conditions, such as depression.
• Anti-anxiety medicine. Anti-anxiety medicines called benzodiazepines are sedatives that, in limited situations, your health care provider may prescribe to relieve anxiety symptoms. Benzodiazepines are generally used only on a short-term basis for relieving anxiety that happens suddenly, also called acute anxiety. Because they can be habit-forming, these medicines are not a good choice if you've had long-term problems with anxiety or problems with alcohol or drug misuse.

It may take weeks for medicine to help manage symptoms. And you may have to try several different medicines before you find one that works best for you.

Both starting and ending a course of antidepressants can cause side effects that create uncomfortable physical sensations or even panic attack symptoms. For this reason, your health care provider likely will gradually increase your dose during treatment, and slowly decrease your dose when you're ready to stop taking medicine.

Alternative medicine

Certain dietary and herbal supplements claim to have calming benefits that reduce anxiety. Before you take any of these for agoraphobia, talk with your health care provider. Although these supplements are available without a prescription, they still pose possible health risks.

For example, the herbal supplement kava, also called kava kava, appeared to be a promising treatment for anxiety. But there have been reports of serious liver damage, even with short-term use. The Food and Drug Administration (FDA) has issued warnings but not banned sales in the United States. Avoid any product that contains kava until more-thorough safety studies are done, especially if you have liver problems or take medicines that affect your liver.

Coping and support

Living with agoraphobia can make life difficult and very limiting. Professional treatment can help you overcome this condition or manage it well so that you don't become a prisoner to your fears.

You also can take these steps to cope and care for yourself:

• Follow your treatment plan. Keep therapy appointments. Talk regularly with your therapist. Practice and use skills learned in therapy. And take any medicines as directed.
• Try not to avoid feared situations. It can be hard to go to places or be in situations that make you uncomfortable or that bring on symptoms of anxiety. But routinely practicing going to more and more places can make them less frightening and lower your anxiety. Family, friends and your therapist can help you work on this.
• Learn calming skills. Working with your therapist, you can learn how to calm and soothe yourself. Meditation, yoga, massage and visualization are simple relaxation techniques that also may help. Practice these techniques when you aren't anxious or worried, and then put them into action during stressful situations.
• Avoid alcohol and recreational drugs. Also limit or don't have caffeine. These substances can worsen your panic or anxiety symptoms.
• Take care of yourself. Get enough sleep, be physically active every day, and eat a healthy diet, including lots of vegetables and fruits.
• Join a support group. Joining a support group for people with anxiety disorders can help you connect with others facing similar challenges and share experiences.

Preparing for your appointment

If you have agoraphobia, you may be too afraid or embarrassed to go to your health care provider's office. Consider starting with a video visit or phone call, and then work out a plan to try to meet in person. You also can ask a trusted family member or friend to go with you to your appointment.

What you can do

To get ready for your appointment, make a list of:

• Any symptoms you've been experiencing, and for how long.
• Things you have stopped doing or are avoiding because of your fears.
• Key personal information, especially any major stress or life changes that you had around the time your symptoms first started.
• Medical information, including other physical or mental health conditions that you have.
• All medicines, vitamins, herbs or other supplements you're taking, and the doses.
• Questions to ask your health care provider or mental health provider so that you can make the most of your appointment.

Some basic questions to ask include:

• What do you believe is causing my symptoms?
• Are there any other possible causes?
• How will you decide on my diagnosis?
• Is my condition likely temporary or long term?
• What type of treatment do you recommend?
• I have other health problems. How best can I manage these together?
• What is the risk of side effects from the medicine that you're recommending?
• Are there options other than taking medicines?
• How soon do you expect my symptoms to improve?
• Should I see a mental health professional?
• Are there any printed materials that I can have? What websites do you suggest?

Feel free to ask other questions during your appointment.

What to expect from your doctor

Your health care provider or mental health provider will likely ask you a number of questions, such as:

• What symptoms do you have that concern you?
• When did you first notice these symptoms?
• When are your symptoms most likely to occur?
• Does anything seem to make your symptoms better or worse?
• Do you avoid any situations or places because you fear they'll cause symptoms?
• How are your symptoms affecting your life and the people closest to you?
• Have you been diagnosed with any medical conditions?
• Have you been treated for other mental health conditions in the past? If yes, what treatment was most helpful?
• Have you ever thought about harming yourself?
• Do you drink alcohol or use recreational drugs? How often?

Be ready to answer questions so that you'll have time to talk about what's most important to you.