Agoraphobia

Agoraphobia (ag-uh-ruh-FOE-be-uh) is a type of anxiety disorder in which you fear and often avoid places or situations that might cause you to panic and make you feel trapped, helpless or embarrassed.

With agoraphobia, you fear an actual or anticipated situation, such as 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 seek help if intense anxiety develops. Most people who have agoraphobia develop it after having one or more panic attacks, causing them to fear another attack and avoid the place where it occurred.

People with agoraphobia often have a hard time feeling safe in any public place, especially where crowds gather. You may feel that you need a companion, such as a relative or friend, to go with you to public places. The fears can be so overwhelming that you may feel unable to leave your home.

Agoraphobia treatment can be challenging because it usually means confronting your fears. But with talk therapy (psychotherapy) and medications, you can escape the trap of agoraphobia and live a more enjoyable life.

Typical agoraphobia symptoms include:

• Fear of being alone in any situation
• Fear of being in crowded places
• Fear of losing control in a public place
• Fear of being in places where it may be hard to leave, such as an elevator or train
• Inability to leave your home (housebound) or only able to leave it if someone else goes with you
• Sense of helplessness
• Overdependence on others

In addition, you may have signs and symptoms of a panic attack, such as:

• Rapid heart rate
• Excessive sweating
• Trouble breathing
• Feeling shaky, numb or tingling
• Chest pain or pressure
• Lightheadedness or dizziness
• Sudden flushing or chills
• Upset stomach or diarrhea
• Feeling a loss of control
• Fear of dying

Panic disorder and agoraphobia

Some people have a panic disorder in addition to agoraphobia. Panic disorder is a type of anxiety disorder in which you experience sudden attacks of extreme fear that reach a peak within a few minutes and trigger intense physical symptoms (panic attacks). 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 circumstances or the place where it occurred in an attempt to prevent future panic attacks.

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 if you have symptoms.

Having panic disorder or other phobias, or experiencing stressful life events, may play a major role in the development of agoraphobia.

Agoraphobia usually starts before age 35, but older adults also can develop it. Women are diagnosed with agoraphobia more often than men are.

In addition to having panic disorder or other phobias, agoraphobia risk factors include:

• Having a tendency to be nervous or anxious
• Experiencing stressful life events, such as abuse, the death of a parent or being attacked
• Having a blood relative with agoraphobia

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. You may not be able to visit with family and friends, go to school or work, run errands, or take part in other normal daily activities. You may become dependent on others for help.

Agoraphobia can also lead to or be associated with:

• Depression
• Other mental health disorders, including other phobias and other anxiety disorders
• Alcohol or drug misuse to try to cope with the fear, guilt, hopelessness, isolation and loneliness

If you have agoraphobia, you may be too afraid or embarrassed to go to your health care provider’s office. Consider starting, instead, with a phone call to your provider. Some health care providers, particularly mental health experts who specialize in agoraphobia and anxiety disorders, may be able to offer you options that are less stressful than meeting in an office.

What you can do

To prepare for your appointment, make a list of:

• Any symptoms you’ve been experiencing, and for how long.
• Your key personal information, especially any significant stress or life changes that you experienced around the time your symptoms first developed.
• Your medical information, including other physical or mental health conditions that you have. Also write down the names and dosages of any medications and supplements you’re taking.

Ask a trusted family member or friend to go with you to your appointment, if possible, to help you remember information.

Prepare questions to ask your health care provider so that you can make the most of your appointment. For agoraphobia, some basic questions include:

• What do you believe is causing my symptoms?
• Are there any other possible causes?
• How will you determine my diagnosis?
• Should I be tested for any underlying medical problems?
• Is my condition likely temporary or long term (chronic)?
• What type of treatment do you recommend?
• I have other health problems. How best can I manage these together with agoraphobia?
• What is the risk of side effects from the medication you’re recommending?
• Are there options other than taking medications?
• How soon do you expect my symptoms to improve?
• With treatment, will I eventually be comfortable in the situations that currently scare me?
• Does agoraphobia increase my risk of other mental health problems?
• Should I see a mental health specialist?
• Are there any printed materials that I can have? What websites do you recommend?

Don’t hesitate to ask questions during your appointment.

What to expect from your doctor

Being ready to answer your health care provider’s questions may leave time to go over any points you want to talk about in-depth. Be prepared to answer the following questions from your provider:

• Have you recently had a spell or an attack when all of a sudden you felt frightened, anxious or very uneasy?
• Have you recently been feeling nervous, anxious or on edge?
• During these attacks of fear and anxiety, have you ever felt like you couldn’t breathe or like you were having a heart attack?
• What other symptoms do you have?
• 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 trigger your symptoms?
• What do you think is causing your 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 psychiatric symptoms or mental illness in the past? If yes, what treatment was most helpful?
• Have you ever thought about harming yourself or others?
• Do you drink alcohol or use illegal drugs? How often?

Agoraphobia is diagnosed based on signs and symptoms, as well as an in-depth interview with your health care provider. You may also have a physical exam to rule out other conditions that could be causing your symptoms.

To be diagnosed with agoraphobia, you must meet criteria listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) published by the American Psychiatric Association. This manual is used by mental health providers to diagnose mental conditions and by insurance companies to reimburse for treatment.

Diagnostic criteria for agoraphobia include severe fear or anxiety about two or more of the following situations:

• Using public transportation, such as a bus or plane
• Being in an open space, such as a parking lot, bridge or large mall
• Being in an enclosed space, such as a movie theater, meeting room or small store
• Waiting in a line or being in a crowd
• Being out of your home alone

These situations cause anxiety because you fear you won’t be able to escape or find help if you develop panic-like symptoms or other disabling or embarrassing symptoms.

In addition, diagnostic criteria for agoraphobia include:

• Fear or anxiety that almost always results from exposure to a situation
• Avoidance of the situation, needing a companion to go with you or endurance of this situation with extreme distress
• Fear or anxiety that’s out of proportion to the actual danger posed by the situation
• Significant distress or problems with social situations, work or other areas in your life caused by the fear, anxiety or avoidance
• Persistent phobia and avoidance, usually lasting six months or longer

Agoraphobia treatment usually includes both psychotherapy and medication. It may take some time, but treatment can help you get better.

Psychotherapy

Also known as talk therapy or psychological counseling, psychotherapy involves working with a therapist to reduce your anxiety symptoms. Cognitive behavioral therapy is one of the most effective forms of psychotherapy for anxiety disorders, including agoraphobia.

Generally a short-term treatment, cognitive behavioral therapy focuses on teaching you specific skills to gradually return to the activities you’ve avoided because of anxiety. Through this process, your symptoms improve as you build upon your initial success.

You can learn:

• That your fears are unlikely to come true
• That your anxiety gradually decreases if you remain in public and you can manage those symptoms until they do
• What factors may trigger a panic attack or panic-like symptoms and what makes them worse
• How to cope with these symptoms
• How to change unwanted or unhealthy behaviors through desensitization, also called exposure therapy, to safely face the places and situations that cause fear and anxiety

If you have trouble leaving your home, you may wonder how you could possibly go to a therapist’s office. Therapists who treat agoraphobia will be well aware of this problem. They may offer to see you first in your home, or they may meet you in what you consider a safe place (safe zones). They may also offer some sessions over the phone, through email, or using computer programs or other media.

Look for a therapist who can help you find alternatives to in-office appointments, at least in the early part of your treatment. You may also want to take a trusted relative or friend to your appointment who can offer comfort and help, if needed.

Medications

Antidepressant and anti-anxiety medications are often used to treat agoraphobia and panic symptoms that frequently accompany agoraphobia. You may have to try several different medications before you find one that works best for you.

Your doctor is likely to prescribe one or both of the following:

• Antidepressants. Certain antidepressants called selective serotonin reuptake inhibitors (SSRIs), such as paroxetine (Paxil, Pexeva) and fluoxetine (Prozac), are used for the treatment of panic disorder with agoraphobia. Other types of antidepressants, such as tricyclic antidepressants or monoamine oxidase inhibitors, may effectively treat agoraphobia, although they’re associated with more side effects than SSRIs.
• Anti-anxiety medication. Also called benzodiazepines, anti-anxiety medications are sedatives that, in limited circumstances, your doctor may prescribe to relieve anxiety symptoms. Drugs in this category that are used for the treatment of panic disorder with agoraphobia include alprazolam (Niravam, Xanax) and clonazepam (Klonopin). Benzodiazepines are generally used only for relieving acute anxiety on a short-term basis. Because they can be habit-forming, these medications aren’t a good choice if you’ve had problems with alcohol or drug abuse.

Both starting and ending a course of antidepressants can cause side effects that seem like a panic attack. For this reason, your health care provider likely will gradually increase your dose during treatment, and slowly decrease your dose when he or she feels you’re ready to stop taking medication.

Certain dietary and herbal supplements claim to have calming and anti-anxiety benefits. 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 in some people.

For example, the herbal supplement called kava appeared to be a promising treatment for anxiety, but reports of serious liver damage — even with short-term use — caused several European countries and Canada to pull it off the market. The Food and Drug Administration has issued warnings but not banned sales in the United States. Avoid using kava until more rigorous safety studies are done, especially if you have liver problems or take medications that affect your liver.

Living with agoraphobia can make life difficult. Professional treatment can help you overcome this disorder or manage it effectively so you don’t become a prisoner to your fears.

You can also take these steps to cope and care for yourself when you have agoraphobia:

• Stick to your treatment plan. Take medications as directed. Keep therapy appointments. Consistency can make a big difference, especially when it comes to taking your medication.
• Try not to avoid feared situations. It’s hard to go to places or be in situations that make you uncomfortable or that bring on symptoms of anxiety. But practicing going to more and more places can make them less frightening and anxiety provoking. Family, friends and your therapist can help you work on this.
• Learn calming skills. Working with your health care professional, you can learn how to calm and soothe yourself. You can practice these skills on your own, especially at the first hint of anxiety.
• Practice relaxation techniques. Meditation, yoga and imagery are simple relaxation techniques that may help — and you can do them in the comfort of your own home. Practice these techniques when you aren’t anxious or worried, and then put them into action during stressful situations.
• Avoid alcohol and illegal drugs. 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.

There’s no sure way to prevent agoraphobia. However, 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 before your fear becomes overwhelming. 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.

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