Agoraphobia is one of the most misunderstood mental health conditions. While most people will have heard of it, they will tend to believe it’s a fear of crowds or a fear of open spaces, or even a fear of leaving the house at all. The actual condition, however, is much more complex.

What is agoraphobia?

The term, like many medical terms, derives from Ancient Greek. The ‘agora’ was a central public square or meeting place, so the literal definition of agoraphobia would be a fear of public spaces. This, combined with the fact that agoraphobia tends to be experienced when outside, has resulted in the common misconceptions about the condition¹Hara, Naomi, et al. “The Development of Agoraphobia Is Associated With the Symptoms and Location of a Patient’s First Panic Attack – PMC.” PubMed Central (PMC), 11 Apr. 2012, www.ncbi.nlm.nih.gov/pmc/articles/PMC3349583..

In fact, it is more accurate a fear of situations in which a person does not feel safe and fears that escape will be difficult or even impossible, when, for most people, those situations would be perfectly normal. Crowds might trigger agoraphobia because an individual feels constrained, and the volume of people leaves them feeling trapped. Likewise, public transport can trigger attacks because the person does not feel in control and cannot easily escape if the vehicle is moving. And wide-open spaces can cause attacks because they lack obvious places of safety or help should anything happen.

What causes agoraphobia?

It is not clear what causes agoraphobia, although there are several theories.

There appears to be a genetic component to the condition. People are more likely to develop agoraphobia if there is a family history of agoraphobia. Some research has found that people with agoraphobia tend to have a slightly weaker vestibular system than the general, non-agoraphobic, population, which might have a genetic component²Shin, Jin, et al. “Clinical Implications of Agoraphobia in Patients With Panic Disorder – PMC.” PubMed Central (PMC), 24 July 2020, www.ncbi.nlm.nih.gov/pmc/articles/PMC7387026..

The vestibular system is the series of canals in the inner ear that, along with senses like sight, help us maintain balance and position. The hypothesis is that a weaker vestibular system means more reliance is placed on visual cues for balance. When these are removed, for example in a packed crowd, it can trigger disorientation and anxiety and in some this has a runaway effect that triggers panic attacks and agoraphobia.

There also seems to be a link with substance abuse, with depressant medications, like tranquillizers and alcohol, linked with the onset of agoraphobia. In these cases, the agoraphobic symptoms ended when use of the drug ended. Again, it’s unclear why this might be a cause, although it is speculated that the changes in brain chemistry may result in anxiety being triggered more easily in some circumstances³Kuch, Klaus. “Agoraphobia: What Westphal Really Said.” Agoraphobia: What Westphal Really Said, journals.sagepub.com/doi/10.1177/070674379203700212. Accessed 12 Oct. 2022..

There is some speculation that agoraphobia has an evolutionary explanation. There is a clear evolutionary advantage to being cautious in unfamiliar environments; a species’ survival, after all, depends on it being able to identify and react to threats. Agoraphobia may be a result of that fight-or-flight instinct being triggered unnecessarily when in unfamiliar surroundings, or even familiar surroundings where there are uncontrolled factors.

Finally, although anyone can suffer from agoraphobia, it tends to affect women more than men. But, whatever the causes, it is remarkably common, around 1.8 million Americans are affected by the condition.

What are the symptoms of agoraphobia?

The Diagnostic and Statistical Manual of Mental Health Disorders, DSM-5, lists several symptoms, all of which need to be present for a formal diagnosis of agoraphobia. While many may believe they are agoraphobic, for example not liking crowds or preferring familiar places, actual agoraphobia can be a debilitating condition.

The diagnostic criteria include a marked, and disproportionate, fear or at least two different situations, for example crowds and public transport, and an immediate anxiety response when faced with these situations. For most people this will be a panic attack, and for some agoraphobics an unexpected panic attack will be the first symptom they experience.

The person should recognize that the fear is disproportionate. However, despite their rational understanding, they will still exhibit avoidance behavior or anxiety that disrupts their normal lives. These symptoms need to have been present for at least six months.

Finally, there should not be any other underlying condition that can explain the symptoms. However, this does not mean that agoraphobia should, or will, be the only diagnosable condition. It commonly co-occurs with other disorders, most often with panic disorders: around one-third of people diagnosed with a panic disorder will also have agoraphobia. It is also frequently seen with depression, anxiety, obsessive-compulsive disorders and other social phobias.

What is it like to have agoraphobia?

The most common symptom of agoraphobia is a panic or anxiety attack. These are intense, often frightening episodes. Although agoraphobia is a mental health condition, a panic attack is a very real physical response.

During a panic attack, the body will release large amounts of epinephrine, the flight-or-fight chemical. This will rapidly trigger several physical responses, including an elevated heart rate, sweating and shivering or trembling. In extreme cases, it might prompt nausea and vomiting, as well as dizziness and shortness of breath. Those who have experienced them will report fearing loss of control, either of their emotions, body, or behaviors; many agoraphobics fear vomiting or defecating during an attack. Some panic attacks are so severe they will leave the person afraid they are dying.

Panic attacks are intense, but usually relatively short. Starting abruptly, they will typically have reached their maximum intensity within ten minutes and be over within thirty minutes, although the psychological distress they cause will last much longer.

Like other mental health conditions, agoraphobia will affect someone’s entire lifestyle, not just when they are in difficult situations, either because of the avoidance behaviors they adopt, or the anxiety they have in anticipation of the stimulus. For example, someone who would ordinarily commute on public transport may be faced with choosing between dreading a trauma twice a day or finding an alternative, and possibly much less convenient, way to undertake the journey.

Agoraphobics will exhibit their avoidance behaviors differently, depending on their presentation. However, they will frequently avoid situations like driving, being alone when outside the home, shopping at busy places, or using public transport.

The advent of the internet means the effects of this might not seem so profound. The internet means people can shop, work and even socialize from home. However, it also means that agoraphobics can miss out on many of the usual social interactions that enrich human life, as well as creating risks to their physical health from what can become a hermit-like existence.

Some have even suggested that the internet might actually be increasing the incidence of agoraphobia, since people are not receiving the natural exposure therapy they would otherwise get. In other words, those with mild symptoms can find it easier to normalize agoraphobic behaviors and, therefore, develop a more severe presentation of the condition.

Can agoraphobia be treated?

Agoraphobia can be treated effectively. However, because it commonly co-occurs with other mental health conditions, it is advisable to seek professional support to ensure that recovery is complete.

Medication might be prescribed to assist with treatment. Antidepressants, which can also have an anti-anxiety effect, can help in stabilizing symptoms in some situations. Although these will mean that the client can now go to places that previously triggered the condition, medication alone is usually not enough. Since agoraphobia is specific to places or situations, and medication cannot be so specific, it will tend to be used when there are co-occuring conditions, like a generalized anxiety disorder, or in conjunction with therapy.

Therapy is effective in treating agoraphobia. Cognitive behavioral therapy can help by challenging the thought processes, but exposure therapy, or systematic desensitization, is the most commonly used and effective approach.

Exposure therapy will build a tolerance to the triggering situations. It will do this by exposing the individual to their phobia in controlled situations, and increasing amounts. Using an example of someone who is unable to use public transport, they might start in their therapist’s office watching videos of a train station and journey. During this, they can discuss the feelings and reactions they are experiencing. From this, they may build up to visiting a train station, and over a period of time, increase their exposure. The next visit might spend some time inside the station, then getting on a train, and traveling a short distance in following visits.

They will also be taught self-help techniques that would also benefit those who experience mild agoraphobic symptoms, which perhaps don’t meet the DSM threshold for an agoraphobia diagnosis. These will include learning more about agoraphobia and how the mental and physical responses work to create the anxiety, using visualization to prepare for situations and techniques like deep breathing to manage any anxiety they do experience.

Finally, more general stress management techniques will assist with agoraphobic symptoms, and will help most people regardless of their mental health. These will include lifestyle changes, like minimizing intake of drugs like caffeine, nicotine and alcohol, taking regular exercise and practicing mindfulness and relaxation.

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