Agoraphobia: Fear of public places and situations
Agoraphobia can make you feel trapped and feel like you are not able to get out. It’s a mental disorder that causes you to worry over time and excessively. Worrying and stressing is an everyday, normal occurrence that is quite common in a general population. Due to the society that we live in, we move at a very fast pace, always surrounding ourselves with a million of to-do lists and stressors. Nowadays, stress is on everybody’s mind and everybody is playing a catch-up game.
There are certain times, however, when stress and worrying become intense and impossible to handle without professional help. Agoraphobia is one of those cases. If you are experiencing agoraphobia you might be afraid of open and public places. You might feel unsafe when you find yourself in an open space. It doesn’t necessarily mean that you have to be at a wide square with nobody there. No, people with agoraphobia can experience anxiety anywhere outside of the safety of their house, be it a movie theater, a shopping mall or a square.
The main fear that characterizes agoraphobia is the potential inability for escape in case something happens. The world that we know today is filled with political tensions and conflicts. One can imagine how fast agoraphobia can develop and how strong it will become as a result of the unsettling situations happening all over the world. In order to understand the disorder better, we need to first talk about what is an anxiety disorder and how agoraphobia fits under its big umbrella.
What is agoraphobia?
In the world that we live in today, anxiety disorders are quite common. As mentioned before, feeling anxious is okay when it happens for a particular reason. Everybody feels nervous before an interview, an important test or before going on a first date. Anxiety disorders take that feeling to a whole different level. Anxiety disorders are a hat that encompasses a variety of different mental conditions.
All of the mental illnesses that fall under this hat have a few things in common. They all cause you severe anxiety and distress and prevent you from living your life in a normal adaptive way. They can do so at a variety of different aspects, including your personal feelings, your family life, your school/work life and your social life. Anxiety disorders also tend to be highly comorbid with one another. It is quite common to have a diagnosis of two or more anxiety disorders together. Apart from that, anxiety disorders also have a high comorbidity with other mental illnesses, like OCD, depression and personality disorders like, for example, borderline personality disorder.
Anxiety disorders make you feel constant and excessive fear and worry and these feelings prevent you from doing activities that were once enjoyable. Fortunately, with a combination of professional help, pharmacotherapy, and psychotherapy, many are able to come back to carry on with their lives in a fulfilling way.
Types of anxiety disorders
The most common types of anxiety disorders include:
- Social anxiety disorder: this particular disorder is also called a social phobia. People with the disorder worry and fear social situations that happen every day. They often suffer from low self-esteem, self-consciousness. The anxiety can either be focused on one particular activity (e.g. public speaking)
- Generalized anxiety disorder: people who suffer from a generalized anxiety disorder will feel overwhelming anxiety, stress and worry over everything for no apparent reason.
- Panic disorder: this disorder causes panic attacks to happen suddenly and at random moments. You will experience all of the symptoms of a panic attack that will be described later. Your heart might feel like it is about to pop out of your chest; you might have a heart attack.
- Specific phobias: phobias are quite common and there is a big variety of them. People will irrationally fear a certain thing or a situation (spiders, snakes, flying). This fear and worry will make you avoid the situations where you might encounter the reason for your anxiety.
Agoraphobia falls under the sub-type of phobias where a person is afraid of open, public spaces. In order to understand it, we need to make a clear distinction between fear and phobia; fear and anxiety.
Fear vs. Anxiety
It is quite normal to feel fear. If there is a lion running after you, by no means do not worry about the fact that you are afraid. Anybody else in your situation would be scared as well. Fear and anxiety often happen together and sometimes it’s hard to distinguish them. It is important to do so for the sake of diagnosing and treating anxiety disorders.
Fear happens when there is a real, known threat (e.g. that lion). When we see a lion running after us, our sympathetic nervous system activates what is known to be fight or flight response that involves the activation of the hypothalamus and one of the main structures of the limbic system – the amygdala.
Anxiety, on the other hand, forms from something in the future; a threat that doesn’t make sense; something that might or might not happen.
Both fear and anxiety produce similar symptoms. Those symptoms are common throughout all of the anxiety disorders, agoraphobia included.
Fear vs. Phobia
Phobia falls under that umbrella of unnecessary worry, anxiety and fear over some future situation. That is why phobias are a part of anxiety disorders. You cannot help the worry that appears when you face or even think about the phobia producing object or situation. These feelings might make you flee or freeze you in the spot and you might not be able to help them at all.
Some common phobias
- Social phobia (social anxiety disorder)
- Acrophobia: fear of heights
- Claustrophobia: fear of closed spaced
- Arachnophobia: fear of spiders
- Ophidiophobia: fear of snakes
- Aerophobia: fear of flying
- Blood-injection-injury phobias: fear of things that involve needs, blood or some type of injury.
Speaking of agoraphobia, it is indeed a fear of open spaces. It prevents people from going outside of their house and when they do end up in a place they are not comfortable in, they might experience some very unpleasant feelings.
Some places and situations that might induce the feelings of anxiety in those that suffer from agoraphobia are:
- Movie theaters
- Parking lots
- Elevators (similar to claustrophobia)
- Public transportation
- Standing in the line
- Being outside of the house, in general
These are just some examples that may bring anxiety for somebody who has agoraphobia, but there are many other places that will bring fear and worry and, even sometimes, panic attacks. In fact, these panic attacks and bouts of terror happen involuntarily and that’s what can cause anxiety of the open places in the future. The person will feel trapped and helpless, unable to escape. A fully formed agoraphobia usually will appear after a panic attack or two. Due to the fact that they person is scared of more panic attacks, he or she will avoid the places and situation where the original panic attacks happen. It gets so bad at times that these people are afraid of leaving their own house.
People who suffer from agoraphobia feel a variety of feelings, fears and physical symptoms. They do not like showing embarrassment but often feel it. On the other hand, they do not like being by themselves. They hate it when people stare at them, may feel like they are going crazy. These people are scared that they will lose themselves and act out in a public space. They are also afraid that the panic attacks might cause them to have a heart attack and death.
Apart from these emotions, people with agoraphobia often experience feelings of helplessness; feel like they do or they have to avoid others. They often feel agitated and detached from their close friends and family. In certain extreme agoraphobia cases, people will stop coming out of the house, leaving them completely dependent upon their family or friends.
Certain physical symptoms occur as well.
Agoraphobia physical symptoms
- Upset stomach: person may experience nausea, diarrhea etc.
- Chest pain
- Shortness of breath
- Shaking and trembling
- Heart racing
- Feeling dizzy
- Hot flashes
- Sudden chills
- Panic attacks
Agoraphobia panic attacks
Before agoraphobia fully develops or after it happens, panic attacks can become a common occurrence. Certain physical symptoms surround a panic attack that help understand why a person would develop a fear or severe anxiety of entering into a situation where a panic attack can occur.
Panic attacks are characterized by sudden feelings of terror. They happen so suddenly that a person cannot prepare for them. During these panic attacks people often think their heart will pop out of their chest and they will die from a heart attack. Often times they will also think they are going crazy.
Some symptoms include:
- Sudden feeling of terror
- Feeling that you are going to die or something horrible will happen
- Difficulty breathing
- Feeling like you are going crazy or losing control
- Your heart starts to race and pound against your chest
- Chest pains
- You feel really sweaty or the opposite, feeling very cold
- Your hands and fingers are feeling very tingly and numb
- You feel weak
Because of all of these physiological and emotional symptoms, it becomes really hard for a person to escape the vicious cycle of agoraphobia and other anxiety disorders. The combination of physiological symptoms that include muscle tension, dizziness and chest pain and cognitive symptoms of what will happen if you go to this place are agonizing. They cause fear, panic, sadness and lead to avoidance and escape behaviors.
These escape behaviors make you feel better due to the fact that you are safe and at home and you are not experiencing all the symptoms. Because of this, you have successfully managed to negatively reinforce yourself to escape situations that might cause you fear and anxiety. And that’s how the loop of anxiety disorders and agoraphobia is formed and sometimes it is very hard to break out of it. Fortunately, certain treatments exist but before that it’s important to talk about certain predispositions that might help in the development and further progression of agoraphobia.
Agoraphobia causes & risk factors
There are different causes that play together in the development of agoraphobia, neurological, genetic and environmental. Situational factors play a big role in the development of any anxiety disorders. Certain traumatic experiencing including an attack, emotional or physical abuse can certainly contribute to the feelings of being helpless and fear of public places.
Scientists believe that many times agoraphobia develops as a result of a panic disorder. This disorder is characterized by moments of terror and sudden panic attacks. Those who later develop agoraphobia learn to associate panic attacks with certain situations or places and end up escaping them and avoiding going there. Not only the avoiding behavior is important for developing agoraphobia. It seems that those with the disorder cling on to their ‘safe zone’ – a place where they feel safe and know that a panic attack won’t occur.
They start believing that outside of the safe zone that they have created, danger waits for them. This leads people with agoraphobia to avoid situations where it’s hard or virtually impossible to escape from and easy to become trapped – escape back to their safe zone. In very severe cases, as mentioned before, the person may become housebound and not leave the house for fear of leaving their ‘safe zone.’
Agoraphobia genetic risk factors
Recently, scientists have come to see that environmental factors are not the only cause for agoraphobia and associated anxiety disorders. In fact, it seems that there is a familial trait in the development of anxiety disorders.
Stein MB, Jang KL and Livesley WJ in their 1999 twin study, found that heritability of sensitivity of anxiety was 45% for the development of panic disorder. Mosing and colleagues in their 2009 study found that panic disorder and agoraphobia have a high genetic correlation. They mention that it is more common in siblings to have both, agoraphobia and panic disorder than agoraphobia without the panic disorder. Finally, in Kendler KS, Karkowski LM and Prescott CA 1999 study studied the familial factors for a variety of different phobias. They found that in comparison with other phobias, the twin resemblance that is associated only with genetic factors was the highest in agoraphobia with 67% while other phobias had a lower percentage and only blood/injury and social phobia coming close to agoraphobia at 59 and 51% respectively.
Neurological underpinnings in agoraphobia
Apart from certain genetic factors, there are certain areas in the brain along with their neural activity that cannot be forgotten. Due to the recent development of a variety of neuroimaging methods, it possible to look deeper into variations in anxiety disorders, to look for treatment possibilities and prevention.
According to Engel and colleagues in their 2009 “Neuroimaging in anxiety disorders” report the anterior cingulate cortex showed neural activity during elicitation and association of fear in healthy individuals. Interestingly enough, the neural activity didn’t hold which showed that the individuals were not scared of the stimuli permanently and quickly habituated to it, not eliciting the fear response. They say that many different studies implicate not only the anterior cingulate cortex, but also insula (known for its response to disgust and aversion) and, of course, amygdala (fear and aggression) are all involved in this fear network. These areas not only show activity during response to fear, but also in anxiety disorders.
Eser and colleagues in their 2009 study induced panic attacks in healthy volunteers with a help of a panic inducing substance. Not surprisingly, the anterior cingulate cortex showed activity, specific its ventral part. Apart from it, the substance also showed anxiety patterns in other areas. These areas included the occipital lobe, the brainstem, cerebellum, precuneus, middle and superior frontal and temporal gyri and the sublobar area.
Fear network in anxiety disorders and agoraphobia
Apart from doing studies with healthy individuals to see the response in the fear network, many scientists also used neuroimaging tools for figuring out the anxiety disorders themselves. They usually do so by pairing the anxiety-provoking stimuli to a person who has that phobia (e.g. showing snake photos to a person who has ophidiophobia). The most common region that shows activity always comes out to be the amygdala, followed, not surprisingly by the anterior cingulate cortex and the insula.
According to Kim, Dager and Lyoo from 2012, the amygdala shows a considerable reduction in volume in those diagnosed with panic disorder. If we think about the high correlation between the panic disorder and agoraphobia, we can speculate that the brains of those affected with agoraphobia will have a similar pattern in their brain. Interestingly enough, they also mention the fact that the right amygdala appears to be smaller in size than the left one in those with panic disorder. It is interesting due to the fact that the right hemisphere is believed to influence the left hemisphere when it comes to emotional processing and specifically, fear.
Due to such a high involvement of amygdala in the processing of fear and anxiety, certain neurotransmitters must play a role in the development and progression of anxiety disorders. According to Nuss, in the 2015 report the involvement of the GABA neurotransmitter. Targeting this particular neurotransmitter with pharmacotherapy may prove fruitful in the fight against agoraphobia and other anxiety disorders.
Agoraphobia is highly associated with the panic disorder, but it is not always the case. Sometimes a person displays the symptoms of agoraphobia, however, without the panic symptoms and can still be diagnosed with agoraphobia.
In order to diagnose somebody with agoraphobia, they need to display the symptoms mentioned above. They should display the level of anxiety that is excessive and extreme compared to the danger that the person might believe in. The symptoms must be prevalent for at least 6 months for all ages. Displaying two or more agoraphobia associated fears is required for its differentiated diagnosis from specific phobias.
Agoraphobia in children and adolescents
Usually agoraphobia does not develop until 18 or older, however, there are cases of it appearing during childhood and adolescence. Panic attacks are more common in adolescents, however, not all of them might qualify for the diagnosis of agoraphobia. Despite agoraphobia, kids will also often have other mental disorders, usually other anxiety disorders or depression, or both. They display similar symptoms as adults do. What can you do if your child has symptoms of agoraphobia? Give your full support and understanding to your child. Listen to his or her problems and try to identify the traumatic experience that might have caused the development of agoraphobia. Seek professional help and together with your doctor come up with a full individualized treatment plan.
There are a lot of treatments available for someone who suffers from anxiety disorders and from agoraphobia. Usually it involves a combination of pharmacotherapy and psychotherapy for the best possible outcome.
A psychologist or a psychiatrist will practice therapy that will decrease negative thoughts that usually leave to decreased self-esteem and shame.
They will usually do so with the help of cognitive-behavioral therapy. Doctors will try to minimize the anxiety and cognitive-behavioral therapy has been found to be quite promising with regards to agoraphobia. It is so effective that even without the help of medications, it is very helpful and can decrease the symptoms or eliminate them completely.
Apart from cognitive-behavioral therapy, specialists also use exposure therapy where they can expose the patient to the anxiety-provoking stimuli. In order to do that, they build a ladder of anxiety provoking objects/situations. This is called systematic desensitization. Psychologists will, therefore, start with the very lowest to facing the object/situation of anxiety. Therefore, they will slowly guide the patient through the ladder. They do so in an attempt to show the patient that there is nothing to be afraid of.
Eye Movement Desensitization and Reprocessing (EMDR)
EMDR is a novel type of therapy that takes on many different approaches. It has been proven to be very affective for trauma, panic attacks, phobias and many others. Scientists believe that EMDR influences the brain, specifically information processing. After a successful EDMR therapy, the patient will not be relieving anxiety provoking thoughts, will not process the upsetting images and feelings. The memory is still there, however, the anxiety and the pain are significantly decreased. It’s a technique that allows people to understand and see the traumatic experience but not affect them as much.
The medications used for agoraphobia are similar to other anxiety disorders, specifically the panic disorder.
The first line of medication nowadays involves selective serotonin reuptake inhibitors (SSRI’s) and benzodiazepines. Common SSRI’s include Prozac, Luvox, Zoloft and others, while benzodiazepines include Xanax, Klonopin or Valium. Before you take any medication, please consult with your doctor first!
Agoraphobia real life examples
Despite what people think, agoraphobia can affect anybody. However, it’s difficult to understand how famous people are able to have agoraphobia but it does happen. Here are a few notable mentions of famous people who have suffered with the condition.
- Howard Hughes: aerospace Engineer, director, entrepreneur. He experienced agoraphobia and OCD after a plane crash.
- Brian Wilson: songwriter, musician. Lived two years in isolation at his house, showed addictive behaviors. He also had depression and certain schizophrenia symptoms.
- Emily Dickinson: poet. She lived in seclusion for a very long amount of time. She did not like conversing with people
- Macaulay Culkin: actor. He spoke about his agoraphobia in an interview along with extreme paparazzi anxiety.
- Kim Basinger: actress. Has talked about her continuing fight with agoraphobia including panic attacks, and being secluded in her house for half a year.
Agoraphobia in media
The less severe the disorder is, the easier it is to treat it. Luckily, the majority of the people do get better with the help of cognitive-behavioral therapy, EMDR and exposure therapy, and the medications. It is important to provide help as soon as possible, because without it the disorder might become more difficult to treat.
Without proper help those who have agoraphobia might isolate themselves completely and become unable to function properly in any social situations. In addition, they might feel hopeless and helpless, lonely, develop depression and suicidal thoughts. They might also develop various addictive behaviors in an attempt to self-medicate themselves.
In conclusion, it is important to start treatment as soon as you start seeing any symptoms of agoraphobia, in order t to prevent complications.
Stein MB, Jang KL, Livesley WJ. Heritability of anxiety sensitivity: A twin study. Am J Psychiatry. 1999;156(2):246–51.
Mosing MA, Gordon SD, Medland SE, Statham DJ, Nelson EC, Heath AC, et al. Genetic and environmental influences on the co-morbidity between depression, panic disorder, agoraphobia, and social phobia: A twin study. In: Depression and Anxiety. 2009. p. 1004–11.
Kendler KS, Karkowski LM, Prescott CA. Fears and phobias: reliability and heritability. Psychol Med [Internet]. 1999;29(3):539–53. Available from: http://www.ncbi.nlm.nih.gov/pubmed/10405076
Engel K, Bandelow B, Gruber O, Wedekind D, Holzschneider K, Mulert C. Neuroimaging in anxiety disorders. Dialogues Clin Neurosci [Internet]. 2011;13(6):453–61. Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2694920&tool=pmcentrez&rendertype=abstract
Kim JE, Dager SR, Lyoo IK. The role of the amygdala in the pathophysiology of panic disorder: evidence from neuroimaging studies. Biol Mood Anxiety Disord [Internet]. 2012;2(1):20. Available from: http://www.biolmoodanxietydisord.com/content/2/1/20
Eser D, Leicht G, Lutz J, Wenninger S, Kirsch V, Schüle C, et al. Functional neuroanatomy of CCK-4-induced panic attacks in healthy volunteers. Hum Brain Mapp. 2009;30(2):511–22.
Nuss P. Anxiety disorders and GABA neurotransmission: A disturbance of modulation. Neuropsychiatr Dis Treat. 2015;11:165–75.