Fear of being in a place or situation from which escape is difficult or impossible

During the pandemic, we’ve spent a lot more time at home. The fear of spreading and possibly getting COVID-19 has had many people understandably more cautious and anxious when being out in public. But, could growing less accustomed to feeling safe in public or leaving your home feed an anxiety disorder known as agoraphobia?

We spoke with Gagandeep Singh, MD, a psychiatrist at Banner Behavioral Health Hospital to learn more about agoraphobia, the potential impact COVID-19 is having on this disorder and ways to get help.

What is agoraphobia?

Many people believe that agoraphobia is the fear of leaving one’s home, thanks in part to its portrayal in media, but it is much more complex.

“The hallmark of agoraphobia is anxiety about or avoidance of places or situations from which escape might be difficult,” Dr. Singh said. “Someone with agoraphobia avoids places or situations where they believe escape or access to help may be impossible, very difficult or very embarrassing if they develop panic attacks, panic-like symptoms or some other incapacitating loss of control.”

These irrational or disproportionate fears are so intense that people go to great lengths to avoid situations, such as using public transportation, being in open or enclosed spaces or standing in a line or being in a crowd. As time passes, they may consider more public places “unsafe” until they eventually are confined to their homes.

While there is no definite cause for agoraphobia, it is likely related to a number of contributing factors that may put someone at greater risk. You may be at greater risk of developing agoraphobia if you live with other phobias or anxiety disorders, have a parent who also had the disorder or experienced a traumatic event or stressful situation.

“Events like the pandemic can set in motion neurobiological changes that make our anxiety worse, for others this may be related to dysfunctional learned behaviors ” Dr. Singh said. “Some, but not all, people may develop it after experiencing a panic attack. Since panic attacks are so unpleasant, they may avoid situations or places that might trigger them. As a result, worry about having a panic attack and attempts to control or avoid it can self-perpetuate their condition.”

How does the pandemic play a role in agoraphobia?

While the mental health impact of the pandemic is still being evaluated, Americans are experiencing an uptick in mental health issues, such as anxiety, stress and depression. However, it’s unclear how the pandemic impacts the development of agoraphobia. Dr. Singh said this may start with rational fears of COVID-19 that over time become exacerbated.

“Agoraphobia is different from fears of leaving home due to COVID-19, because there are very real, rational elements to the fear, such as going out in public can increase our risk of disease,” he said. “These fears are also likely not incapacitating either, meaning we choose not to go out but, when needed, we can, and it hopefully won’t result in panic or a profound loss of control.”

How is agoraphobia clinically diagnosed?

Agoraphobia is diagnosed based on symptoms and signs. Your doctor will ask you a series of questions about your symptoms, medical history and family history and may perform a blood test to rule out other physical causes for your symptoms. For a proper diagnosis, symptoms must meet certain criteria listed by the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders.

What treatment options are available?

“Treatment options are definitely available for agoraphobia,” Dr. Singh said. “These treatments can help with abnormal learned behaviors and the neurobiological changes that go with them.”

Treatment options include psychotherapy, especially cognitive behavioral therapy, and medications, such as SSRIs. Although, long-term outcomes are best done in combination.

Don’t wait to get help

While it may seem like you can handle this all on your own, therapy and/or medication can successfully help you manage your condition.

The main reason to get treatment is that agoraphobia is disabling. “It prevents us from being able to do normal activities for living and causes lots of distress,” Dr. Singh said. “Additionally, the longer it goes untreated the more difficult it is to treat.”

If you or a loved one are struggling with agoraphobia or another anxiety disorder, seek professional help. A mental health professional can help you get your life back on track.

Related articles:

• Do I Have Anxiety, Depression or Both? Here’s How to Tell
• Think the World Is Out to Get You? It Could Be Victim Mentality
• How to Choose the Right Therapist for You or Your Child

Join the Conversation

Agoraphobia is not, as many people believe, just about open spaces.

It is really a fear of being in any place or situation where the sufferer does not feel safe, where they feel trapped, or where escape may be difficult or embarrassing. A person with agoraphobia may avoid a range of situations, e.g. queues, public transport, large crowded shops, supermarkets, shopping centers. In these situations, the person feels anxious with panic feelings (butterflies in the stomach, palpitations i.e. increased heart rate, hyperventilation etc.). The sufferer feels that when they panic something ‘bad’ will happen. These fears are usually about a fear of illness and harm (e.g. having a heart attack, dying, stopping breathing) or a fear of public scrutiny and embarrassment (e.g. falling and “making a fool” of oneself). Panic-like symptoms might include typical symptoms of panic (e.g. dizziness, faintness, and fear of dying), or “other intrusive, uncomfortable or embarrassing symptoms” such as vomiting, fainting, sweating, falling, or, in children, a sense of disorientation, getting lost, or being kidnapped are more common.

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

A patient articulated agoraphobia well: “It’s a fear that’s vague enough that it can apply to anything, anywhere – any situation or location. It can dictate where you go, demand control of every tiny detail, and it steals the fun out of life under the pretense of protecting you. I’ve been living with agoraphobia for seven years now. It started with panic attacks and evolved into a constant fear of having a panic attack away from the only place I knew I wouldn’t; my home. The intense and relentless stress had a rapid effect on my brain and body, and over time I felt I’d be only safe if I stayed inside my house. I became terrified, and sometimes completely unable, to step out of my front door. The simplest of tasks, everything I once took for granted, became impossible.”

When experiencing fear and anxiety cued by such situations, individuals typically experience thoughts that something terrible might happen, and believe that escape from such situations might be difficult. Individuals will likely experience acute anxiety, and thus avoid using public transportation, such as automobiles, buses, trains, ships, or planes being in open spaces such as parking lots, marketplaces, or bridges; an enclosed space such as shops, theaters, or cinemas, standing in line or being in a crowd, getting their haircut, being outside of the home alone.

Agoraphobia makes sufferers behave in ways to intentionally prevent or minimize contact with agoraphobic situations or symptoms of panic.

Avoidance can be behavioral (e.g., changing daily routines, choosing a school closer to home, arranging for food delivery to avoid entering a grocery store) as well as cognitive in nature (e.g., using distraction to get through agoraphobic situations). Often, an individual is better able to confront a feared situation when accompanied by a companion, such as a partner, friend, or health professional, and if left untreated the sufferer can become completely housebound.

Prevalence of Agoraphobia

The lifetime prevalence of Agoraphobia is estimated at 5%-12%. The average age of onset is 20 years old, typically occurring between age 15 and age 35. The prevalence of agoraphobia is higher for females than for males.

Overcoming agoraphobia is possible, but it requires a deliberate, goal orientated CBT approach with a heavy focus on exposure therapy.

Exposure means gradually facing your fear until anxiety decreases enough to make the situation, at a minimum, tolerable. The treatment of agoraphobia, graded exposure therapy is the most effective intervention. Graded refers to the pace at which the feared situation is confronted which is done is a gradual, deliberate manner.

The Anxiety Institute developed and utilizes a treatment approach termed Exposure-Focused CBT, which is a model designed to make the process more gradual, where treatment begins by deliberate discussion of the anxiety provoking situation (Conversational Exposure), followed by imagining the situation vividly (Guided Imaginal Exposure), prior to exposing oneself to the situations virtually (Virtual Reality Exposure), and in real life (In-Vivo Exposure). The Anxiety Institute’s 4 step process is expanded across social, family, and school domains to assure that the scope of recovery matches the scope of impairment.

There are four essential rules in making EfCBT effective, each of which should be maintained until the anxiety is tolerable.

Rule 1: Repeated Exposures

It is important to practice the exposure in same situation multiple times until the anxiety level (SUDS score) consistently diminishes with repetition. Once mastered, practice the same exposure in a different situation or location. Practice a minimum of 30-60 minutes each day.

Rule 2: Prolonged Exposures

It is important to stay in the anxiety provoking situation long-enough until the fear decreases, typically 30-60 minutes. Allow enough time during each exposure for you to habituate to the situation or the sensation.

Rule 3: Focused Exposures

It is important that the person in the exposure focus

on the situation and sensation as fully as possible. They should not distract, avoid or use safety cues to avoid the discomfort nor should another person “rescue” them from the anxiety as this will interfere with the effectiveness of the intervention.

Rule 4: Monitored Exposures

After each exposure write down your anxiety level during the exposure. Pay attention to patterns. If anxiety has not decreased over a number of repetitions, ask yourself if you are using any of the maintaining factors or distractions. If your anxiety has decreased congratulate yourself.

Is fear of being in a place or situation from which escape is difficult or impossible?

What is the term for an intense fear of being in a situation where immediate escape is not possible or help is not immediately available in case of incapacitating anxiety?

What's agoraphobia meaning?

Why is it called agoraphobia?