Defining Fear in Agoraphobia

Sarah Bence
·8 min read

Medically reviewed by Michael MacIntyre, MD

Agoraphobia is an anxiety disorder in which a person is afraid of and avoids situations that they perceive as difficult to escape. This disorder may stem from fears of being trapped, experiencing a panic attack in public, being unable to get help if something goes wrong, and more.

In the United States, an estimated 1.3% of adults experience agoraphobia in their lifetime, with 0.9% having agoraphobia in the past year. Agoraphobia affects men and women nearly equally.

The two main treatments for agoraphobia are cognitive behavioral therapy (CBT) and antidepressants.

In this article, learn about agoraphobia diagnosis, coping, and treatment.

Agoraphobia Definition: What Exactly Do People Fear?

Agoraphobia is a real mental illness, which falls under the umbrella of anxiety disorders.

People with agoraphobia fear and avoid certain situations that they believe will be difficult to escape, or where something "bad" might happen. As with other anxiety disorders, this fear is intense and disproportionate to the actual situation.

Agoraphobia may include fear or avoidance of the following situations:

  • Open spaces, like fields or parking lots

  • Crowded spaces, like malls or parades

  • Enclosed spaces, like elevators or subway cars

  • Public transportation

  • Leaving home

  • Going outside

The exact reason for avoidance differs from person to person. It may be related to fears and catastrophizing (jumping to the worst possible outcome and believing that it's likely to occur) about what may happen in that situation or anticipatory anxiety related to generalizing something that happened in the past.



Examples of Agoraphobia

Examples of agoraphobia include:

  • Being afraid of getting into elevators due to having a panic attack while in an elevator last year, and instead climbing 12 flights of stairs to work for the past year

  • Developing an intense fear and avoidance of public transportation and not being able to see your friends or go to school as a result

  • Refusing to go into supermarkets, movie theaters, and schools to prevent developing a panic attack when in those settings after witnessing a shooting

  • Fear of leaving your house alone because you fear you may experience a panic attack or do something embarrassing in front of many people, with nobody around to help



How to Tell If You Have Agoraphobia

It's essential to seek prompt diagnosis and treatment if you have agoraphobia. When left untreated, it can worsen and affect your quality of life.

You may be worried about having agoraphobia if you've noticed yourself:

  • Worrying about having a panic attack if you're in a specific situation

  • Developing new fears of certain places

  • Avoiding certain situations

  • Leaving your home alone less frequently

  • Restricting travel and limiting your transportation options

  • Relying on strategies to help you avoid the feared situations, like grocery delivery or remote work

  • Experiencing panic attacks when in the feared situation (rapid heartbeat, nausea, sweating, hyperventilating)

It is essential to receive a proper agoraphobia diagnosis from a mental health provider. If visiting a clinic or medical office contributes to your symptoms, consider telehealth options like virtual conferences with your provider.

Agoraphobia Diagnosis

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) is the guidebook clinicians use to diagnose psychiatric conditions, including agoraphobia.



Agoraphobia Definition

According to the DSM-5, the definition of agoraphobia is, “Marked fear or anxiety about actual or anticipated exposure of public spaces, with the symptoms of fear or anxiety occurring most of the time in at least two of five common, different situations.”



According to the DSM-5, the diagnostic criteria for agoraphobia include a marked fear and/or anxiety of in least two of the following five situations:

  • Being alone outside the home

  • Being in a crowd or standing in line

  • Being in open spaces

  • Being in enclosed spaces

  • Using public transportation

Additional diagnostic criteria include:

  • The feared situations are avoided, highly restricted, or endured with severe distress or requiring a companion for support.

  • The agoraphobic situations almost always incite fear and anxiety.

  • The fear and anxiety are disproportionate to the situation and its sociocultural context.

  • Fear, anxiety, or avoidance causes significant distress and impairment.

  • The situation is avoided because of thoughts that it might be challenging to escape, or help might not be available in the instance of panic or embarrassing or incapacitating symptoms.

  • The above diagnostic criteria must be met for at least six months and can't be attributed to another condition.



Agoraphobia and the COVID-19 Pandemic

Much discussion has surrounded the COVID-19 pandemic and its relationship with agoraphobia, including people's fear and avoidance of public places due to the threat of being exposed to the virus.

Some experts argue that the sociocultural context of the COVID-19 pandemic and the real dangers (i.e., avoidance would not be disproportionate to the situation) meant that agoraphobic behaviors were a natural reaction. It is unclear how the pandemic affected people with clinical agoraphobia, however.



Addressing Agoraphobia in Therapy

There is no established treatment protocol for agoraphobia since it is a newly recognized mental health condition. Studies are still underway to determine standardized evaluations, measurements, and treatments for agoraphobia.

Healthcare providers often recommend cognitive behavioral therapy as a first-line treatment for agoraphobia. CBT is used to treat many mental health conditions and is considered the "gold standard" of psychotherapy.

The basis of CBT is that our thoughts influence our behavior, and by changing our thinking into more positive and helpful thoughts, we can alter our behaviors. For those with agoraphobia, CBT can help alleviate symptoms and improve quality of life by teaching you how to overcome your fear and avoidance.

In severe cases of agoraphobia that do not respond to CBT, a healthcare provider may recommend antidepressants.



Supporting Someone With Agoraphobia

If someone you love is experiencing symptoms of agoraphobia, such as fearing certain situations or refusing to leave home, encourage them to speak to a trusted mental health professional.



What Usually Happens in Agoraphobia Treatment

Most therapists who work with people with agoraphobia understand that it can feel overwhelming to consider leaving the house to see a therapist. They may offer in-home services or telehealth options when necessary.

CBT is a structured, time-limited therapy. You may have around six to 20 sessions, depending on your needs.

At your first meeting, you will get to know your therapist and discuss your feared situations, concerns, past experiences, and how it impacts your daily life.

Next, your therapist will help you recognize any negative thought cycles. For example, if you got stuck in an elevator last year, and since then, you've been terrified to go in any elevator.

Some things your therapist may comment on or discuss include:

  • Helping you realize that just because you got stuck in one elevator doesn't mean it's likely to happen again

  • Helping you think reasonably about what would happen if you got stuck in an elevator again

  • Teaching awareness of negative thought patterns such as catastrophizing, rumination, and anticipatory anxiety

By challenging your negative thoughts, you learn to change them into more productive ones and eventually change your behaviors.

Supplemental Agoraphobia Therapy Treatments

A therapist may also use other strategies during therapy to help you work through your agoraphobia. These are often used in combination with CBT.

Supplemental agoraphobia therapies include:

  • Neurofeedback therapy

  • Exposure therapy, either in vivo (in real life) or virtual reality

  • Systematic desensitization (exposure to a buildup of anxiety-provoking stimuli and learning relaxation techniques to cope)

  • Eye movement desensitization and reprocessing therapy (EMDR; encourages patients to focus on a traumatic memory while undergoing bilateral stimulation, usually in the form of eye movements)

Self-Help to Cope Through Agoraphobia

First, if you are in CBT, you likely were given homework to complete outside therapy. Do your best to stick with this and your medication schedule.

Other ways to cope with life with agoraphobia include:

  • Exercising regularly

  • Joining a support group online, on social media, or in person

  • Journaling

  • Practicing mindfulness, breathing techniques, progressive relaxation, and other stress management techniques

  • Maintaining a healthy diet

  • Limiting or eliminating substances, including caffeine, alcohol, and drugs

  • Finding and keeping a meaningful hobby

Related: Best Mental Health Apps

Where Do Agoraphobia Tendencies Come From?

Experts don't know the exact causes of agoraphobia, but certain factors can increase your risk of developing it.

Agoraphobia risk factors include:

  • Genetic predisposition

  • Grief or bereavement in childhood

  • Adverse or traumatic events in childhood

  • Parental overprotectiveness

  • Childhood night terrors or intense fears

  • Co-occurring anxiety disorders, including panic disorder and post-traumatic stress disorder (PTSD)

  • Co-occurring major depressive disorder

  • Low self-esteem



Agoraphobia and Panic Disorder

Agoraphobia frequently occurs with panic disorder. In one study of 35 people with agoraphobia, the majority (26) also had a panic disorder diagnosis. Although agoraphobia and panic disorder are closely related, you don't need a panic disorder diagnosis to have agoraphobia and vice versa.



Summary

Agoraphobia is not as simple as a fear of open spaces or leaving the house. It is a type of anxiety disorder in which a person develops an intense fear and avoidance of certain situations. Specifically, they fear these situations because they believe they may be trapped, unable to seek help if they are incapacitated, or embarass themselves, or experience a panic attack. It's important to treat agoraphobia promptly for the best outcomes.