agoraphobia symptoms

Agoraphobia Symptoms and Treatment

Overview and Definition

Agoraphobia symptoms manifest whenever feelings of entrapment, helplessness, or embarrassment arise. Agoraphobia is defined by the Diagnostic and Statistical Manual of Mental Disorders as a fear of situations where escape might be difficult or impossible, or where help might be unavailable if something went wrong. In contrast, agoraphobia has usually meant simply a fear of open spaces, but this usage is now obsolete.

Examples of Agoraphobia

Examples of agoraphobia include anxiety about traveling on bus, plane, subway, or other public transportation. Even being a passenger in a car can be difficult, simply because the person is not driving. Agoraphobia symptoms can surge in crowded spaces, like bars, restaurants, shopping centers and grocery stores, concerts, movie theaters, or any gathering of people. Simply waiting with others and standing in line can be hard.

Avoidance in Agoraphobia

All the agoraphobic situations listed above are actively avoided, unless the person can be absolutely sure an escape route is available. They may, for example, sit only at the edge of the row in a movie theater closest to the exit door. The agoraphobic person may eventually refuse to leave the safety of their own home unless accompanied by a friend, parents, or other support person, who might provide help and assistance should something go wrong. The internet makes agoraphobia somewhat easier, since subject can order groceries online, have food and other supplies delivered, even work remotely.

If someone with agoraphobia encounters a stressful situation outside their home, they can experience panic symptoms, like rapid heartbeat, choking, sweating, trembling, or nausea.

Agoraphobia and Panic Disorder

What causes agoraphobia? How do agoraphobia symptoms develop?

Agoraphobia tends to develop secondary to panic disorder. Panic attacks typically occur suddenly and may occur without any warning whatsoever. The anxiety of a panic attack onsets and peaks without about ten minutes. The attack peaks with full-blown activation of the fight or flight response. Panic attacks are subjectively experienced as terror, like the terror you feel in the worst nightmare that you’ve ever had. Panic attacks onset and peak in about ten minutes and often less. You begin to feel the panic symptoms and you immediately begin looking for an escape. Perhaps you fear having the panic attack in the presence of others. Perhaps you fear going crazy and knocking people down as you flee the triggering situation. Once the symptoms start, ten minutes or less gives you a very narrow windows to escape the triggering situation.

Whether you manage to escape or not, you make up your mind not to return to that situation. This is called generalization, and it’s a major mechanism by which anxiety expands and takes over one’s life. If the panic attack symptoms happened on a bus, then you start to avoid all buses. If the panic attack happened in a grocery store, you start to avoid grocery stores. Eventually, you may refuse to leave your home at all. Why? Because you feel safe inside your home. Whenever your leave, you begin to fear having panic attack symptoms and actual panic attacks.

Some people, however, experience agoraphobia symptoms with no history of panic attacks. In such cases, the avoidance is related to fear of crime, terrorism, disease, accidents, or just fear of the occurrence of random catastrophic events. A history of trauma may well predispose subjects to the development of agoraphobia, since trauma is often induced by random catastrophic events, like automobile accidents.

Agoraphobia Diagnosis

Agoraphobia is typically diagnosed by a mental health professional or physician. You will be asked specific questions about your agoraphobia symptoms, such as how frequently they occur and how intense these symptoms are. Here are some examples:

  • Are there some situations that you avoid because they make you feel anxious? What are they?
  • What do you do to cope with these situations?
  • Is there someone that you feel safer with, who makes it easier to go into these situations?
  • Have you ever experienced a panic attack? How did your avoidance get started?

By asking these questions, your mental health professional or physician is looking for the essential features of an agoraphobia diagnosis, namely the anxious avoidance of situations where escape might be difficult or impossible. All anxiety disorders tend to shrink life down to a narrow safety zone. Be as forthcoming and honest as possible. This interview is your chance for better life.  

Agoraphobia Treatment

Agoraphobia is rarely treated in any single way. Fortunately, there are many ways to treat agoraphobia and agoraphobia symptoms.

Lifestyle Changes and Self-Care

Effective agoraphobia treatment may include lifestyle changes like healthy eating, regular exercise, and avoidance of drugs and alcohol. Healthy eating increases feelings of general well-being. Some subjects report positive effects to magnesium and zinc as dietary supplements. Exercise burns away stress hormones and promotes a feeling of relaxation throughout the day. Foods and drinks that contain caffeine and other stimulants, like coffee, tea, and soda, can be reduced or eliminated. Stimulants raise the level of background arousal in the body, which makes anxiety symptoms, like muscle tension, more likely. Meditation, dance, deep breathing, or any calming activity that reduces anxiety provides an opportunity for self-care. Finally, in-person and online support groups can provide reassurance and practical advice.

Exposure Therapy

If your agoraphobia symptoms developed due to a history of panic attack symptoms, then it makes sense to treat panic disorder as a means of treating your agoraphobia. Panic attack treatment may involve medications, but also frequently involves graded exposure to the situations that provoke anxiety. You agree to put yourself in situations that evoke moderate anxiety and remain in the situation until the anxiety subsides. For example, if you have a fear of parking lots because of all the cars circulating through, you might go to a mostly vacant parking lot that causes moderate to moderately high anxiety. You would do this over and over again, until your anxiety is greatly diminished. Next, you try another parking lot, one where there are somewhat more cars. You visit and remain in this parking lot until the anxiety is greatly diminished. Avoidance prevents your nervous system from learning that situations you experience as dangerous are, in fact, safe. Eventually, your nervous system learns that parking lots are mostly safe, and you’re able to enter, park, and leave with minimal or no anxiety or panic symptoms.

If your agoraphobia symptoms are so intense that exposure to actual situations is impossible, then you can use guided imagery. This is exposure in imagination, which typically results in less intense anxiety symptoms than exposure to real life situations. Once the agoraphobia symptoms have diminished somewhat, guided imagery can be followed by graded exposure to real life situations. The fundamental idea is to take “baby steps” that build confidence and don’t evoke so much anxiety and panic that the person drops out of therapy.

Cognitive Therapy

Cognitive means thought, so cognitive therapy is about modifying the thoughts that accompany anxiety and the situations that trigger anxiety. Cognitive therapy can be used to provide more focus to exposure therapy. The common thread to all agoraphobia symptoms is fear that escape will be difficult or impossible, but the exact reasons may be different. Maybe one person fears going crazy during a panic attack and having to be restrained or hospitalized, while another person fears that they’ll be too nervous to drive out of the parking lot. Fears of being trapped, helpless, and embarrassed are commonly reported. Knowing the exact catastrophic thoughts is necessary to effective exposure therapy for agoraphobia, panic attacks, and other anxiety disorders.

Medications

Medications for agoraphobia symptoms are prescribed by your general practitioner or psychiatrist. These may be used as the sole intervention for agoraphobia symptoms or in combination with psychotherapy. No drugs are specifically FDA-approved to treat agoraphobia or panic, but certain medications have been found to be effective and can be used off-label, meaning with the approval of a physician. Three main classes of medication are prescribed: SSRI and SNRI antidepressants, anxiolytics, and sedatives.

Despite their name, antidepressants often treat the symptoms of both anxiety and depression. Since anxiety is what the anxiety disorders have in common, SSRI’s can treat both agoraphobia symptoms and panic symptoms. Commonly used SSRI medications for agoraphobia and panic include Fluoxetine (Prozac), Citalopram (Celexa), and Escitalopram (Lexapro). Every cell in the nervous system relies on a certain kind of neurotransmitter to transmit signals between neurons. SSRI means Selective Serotonin Reuptake Inhibitor, meaning that these drugs make more serotonin available for brain neurons which use that neurotransmitter. SNRIs make more norepinephrine available in the synapse between neurons. They are Selective Norepinephrine Reuptake Inhibitors. Commonly prescribed SNRIs include Duloxetine (Cymbalta) and Venlafaxine (Effexor).

Benzodiazepines like Alprazolam (Xanax) and Lorazepam (Ativan) can be used with panic attack symptoms. Benzodiazepines are fast acting and can be very effective at reducing or even eliminating anxiety. Benzodiazepines work by increasing the effect of GABA, the principal inhibitory neurotransmitter in the brain. Unfortunately, they can interact with alcohol, may cause dependency and withdrawal, and have a long-term risk of dementia. As such, benzodiazepines are prescribed mainly for short-term use.

Finally, Buspirone (Buspar) is a commonly prescribed anxiolytic drug that has almost no side-effects.

Agoraphobia Treatment Effectiveness

Approximately one-third of subjects with agoraphobia are completely cured by some combination of treatments and remain symptom-free. Another one-half experience improvement but have periods when agoraphobia symptoms exacerbate to become more problematic, perhaps during periods of substantial life stress. The final approximately 20 percent do not respond well to treatment and continue to meet diagnostic criteria for an agoraphobia diagnosis.