What Is Agoraphobia the Fear Of?

The Diagnostic and Statistical Manual of Mental Disorders 5th Edition (DSM-5) of the American Psychiatric Association lists symptoms of agoraphobia as: 

• Fear or anxiety about:
  • Being outside the home alone
  • Use of public transportation
  • Being in enclosed places (such as inside stores or movie theaters)
  • Standing in line 
  • Being in a crowd
  • Being in open spaces (such as open-air markets or parking lots)
  • Being in places where escape might be difficult
  • Active avoidance of all situations that provoke fear and anxiety
  • Becoming housebound for prolonged periods
  • Feelings of detachment or estrangement from others
  • Feelings of helplessness
  • Dependence upon others
  • Panic symptoms (in some patients)
  • Anxiety or panic attack (acute severe anxiety)
  • Alcohol and sedative medication abuse (as a way of coping with stress)

The cause of agoraphobia is not known, but it is believed to be due to an interaction of biological, psychological, and environmental factors.

Risk factors that may predispose a person to develop agoraphobia include: 

• Genetic factors: the disorder often runs in families
• Neurobiological factors: there may be certain brain changes that occur in people with agoraphobia 
• Personality factors: people who have neurotic tendencies may be more likely to develop agoraphobia
  • Introversion: extreme introversion is associated with increased odds of an agoraphobia diagnosis
  • Anxiety sensitivity: a belief that physical symptoms of anxiety are dangerous has been shown to predict panic disorder as well as agoraphobia without panic attacks 
  • Dependency: people with avoidant, dependent, and related personality traits may be more likely to develop agoraphobia 
  • Other
    • Lack of perceived control 
    • Lack of assertiveness
    • Low self-efficacy (belief they will be unable to cope in the feared situation)
• Cognitive factors: fear of having panic attacks or panic symptoms combined with expectations of the harmfulness of a panic attack and coping mechanisms play a role in influencing and maintaining avoidant behavior  
  • Other types of fear-related beliefs 
    • Fear of having an illness
    • Bodily preoccupation
    • Fear they will be trapped or unable to cope due to a physical limitation 
• Social/environmental factors: learning processes in which avoidance behaviors are reinforced because they reduce anxiety and stressful emotional states 

Agoraphobia is diagnosed with a comprehensive psychiatric assessment.

The DSM-5 criteria for a diagnosis of agoraphobia include: 

• Marked fear or anxiety about two or more of the following situations: 
  • Using public transportation 
  • Being in open spaces 
  • Being in enclosed places 
  • Standing in line or being in a crowd
  • Being outside the home alone
• Fear or avoidance of these situations because of thoughts that escape might be difficult or help might not be available of they develop panic-like symptoms or other incapacitating or embarrassing symptoms (e.g., fear of falling in the elderly or fear of incontinence). 
• The situations almost always provoke fear or anxiety. 
• The situations are actively avoided, require the presence of a companion, or are endured with intense fear or anxiety. 
• The fear or anxiety is out of proportion to the actual danger posed by the situations and the sociocultural context. 
• The fear, anxiety, or avoidance is persistent, lasting six months or more. 
• The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. 
• If another medical condition (e.g., inflammatory bowel disease, Parkinson's disease) is present, the fear, anxiety, or avoidance is clearly excessive.
• The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder and are not related exclusively to:
  • A specific situation, as in specific phobia, situational type
  • Social situations, as in social anxiety disorder
  • Obsessions, as in obsessive-compulsive disorder (OCD)
  • Perceived defects or flaws in physical appearance, as in body dysmorphic disorder
  • Reminders of traumatic events, as in posttraumatic stress disorder (PTSD)
  • Fear of separation, as in separation anxiety disorder

Agoraphobia is a separate diagnosis from panic disorder. If a patient meets the criteria for panic disorder and agoraphobia, they would be diagnosed with both conditions. 

Treatment for agoraphobia, as with many other phobias, often involves what is called desensitization or exposure therapy. The patient is supervised and gradually exposed to the feared situation to learn that the outcomes they fear do not happen. 

Techniques used to treat agoraphobia include: 

• Graded real-life exposure 
  • Involves exposure to real situations that progressing from less to more extreme aversion
  • The patient works with a therapist to develop coping strategies 
• Cognitive behavioral therapy (CBT) 
  • Helps patients change or eliminate negative thought patterns that influence their symptoms and help them change behavior
  • Takes at least 8 to 12 weeks or more
  • Can also reduce anticipatory anxiety and avoidance of feared situations 
• Biofeedback
• Hypnosis
• Meditation
• Relaxation
• Couples therapy 
• Self-help or support groups 
• Stress management techniques 
• Aerobic exercise 
• Avoiding caffeine, some illegal drugs, and certain over-the-counter cold medications that can aggravate symptoms of anxiety disorders

Patients who experience panic attacks as part of their agoraphobia may be prescribed medication to help prevent or reduce panic attacks. Medications used to treat panic attacks associated with agoraphobia include: 

• Tricyclic antidepressants
• Selective serotonin reuptake inhibitors (SSRIs) antidepressants, such as fluoxetine (Prozac), sertraline (Zoloft), escitalopram (Lexapro), paroxetine (Paxil), and citalopram (Celexa)
  • Often used to treat panic disorder when it occurs in combination with obsessive-compulsive disorder (OCD), social phobia, or depression
• High-potency benzodiazepines, such as alprazolam, clonazepam, and lorazepam
• Monoamine oxidase inhibitors (MAOIs)