Anxiety & Mood
Agoraphobia: what it is, symptoms and treatment
What agoraphobia is, which situations it involves, how it links to panic attacks, and how gradual exposure therapy works, including starting online.
Agoraphobia is an intense fear of situations from which it would be hard to get away, or to find help, if you started to panic: public transport, open or enclosed spaces, queues and crowds, leaving home on your own. The fear leads to avoidance, and avoidance makes the fear grow. It is treatable, mainly with cognitive behavioural therapy using gradual exposure and, where needed, with medication.
What the word means
In ancient Greek, the “agora” was the central square, the public space of the city. Agoraphobia is not a fear of shopping. It is a fear of situations in which you feel trapped or helpless.
Which situations cause fear
The diagnostic criteria (DSM-5) describe five groups of situations [1]:
public transport, such as buses, trains, ferries and planes
open spaces, such as squares, bridges and car parks
enclosed spaces, such as shops, supermarkets and cinemas
queues or crowds
leaving home alone
For a diagnosis there needs to be intense fear in at least two of these, lasting at least six months [1].
“I’m afraid to leave the house” is something I hear in the practice, and it describes the trap exactly: avoidance brings relief today and more fear tomorrow. That is why the goal is not to wait for the anxiety to go away first and then go out. It is gradual exposure: small, planned steps that grow as the fear recedes.
How common it is
In World Health Organization surveys of 136,357 adults in 27 countries, 1.5% had had agoraphobia at some point in their life and 1.0% in the past year [2].
It is about twice as common in women. In one study, lifetime prevalence was 2.0% in women and 0.9% in men [1].
In the same WHO survey, among people who met the criteria of both of the last two editions of the diagnostic manual, 44% reported serious difficulty functioning, and almost all (92.9%) also had another mental disorder [2].
Agoraphobia and panic attacks
Agoraphobia is linked with panic attacks, but it is not the same thing. With DSM-5 it became a separate diagnosis, which can occur with or without panic disorder [1]. In a US survey of 9,282 adults, agoraphobia was also found in people who had panic attacks but not panic disorder. People who had both panic disorder and agoraphobia had the most severe picture: 86.3% had moderate or severe symptoms. Yet only 54.9% had received guideline-based treatment in the past year [3].
The vicious circle of avoidance
The circle goes like this: fear, avoidance, relief, and next time even more fear. “Safety behaviours” may be added: you only go out with a companion, you sit near the exit, you carry water or a pill “just in case”. They help in the moment, but they stop you from learning that you can manage without them.
How it is treated
Cognitive behavioural therapy. The guidelines of the World Federation of Societies of Biological Psychiatry (WFSBP) consider it the first-choice psychotherapy for anxiety disorders, including panic disorder with agoraphobia [4]. You learn how the cycle of fear and avoidance works, and you are gradually exposed to the situations you avoid and to the bodily sensations you fear. In an analysis of 72 studies with 4,064 patients with panic disorder, exposure to bodily sensations was linked with a better outcome, while adding muscle relaxation was linked with a worse one [5].
Medication. According to the same guidelines, the first-choice medication is antidepressants from the SSRI and SNRI classes [4]. The decision is made after the assessment, together with you.
At every step we ask concrete questions, such as: “If you planned three outings this week and managed two, is that a failure?” “All or nothing” thinking can keep you at home. We measure progress, not perfection.
Can treatment take place online?
Yes, and in agoraphobia this is especially valuable, because leaving home is the problem itself.
In a small study of 21 patients with panic disorder and agoraphobia, cognitive behavioural therapy by video call was as effective as face-to-face therapy. Six months later, 91% of those treated by video had no panic attacks [6].
In a review of 20 studies, guided internet-based therapy had overall the same effect as face-to-face therapy. The authors note that there are still few studies for each disorder separately [7].
When the problem is leaving home, there is no point in waiting to “get better” before starting treatment. The first session can take place online. After that, the exposure steps happen outside, in real life, and treatment continues online or at the practice.
When to ask for help
You have been avoiding places or travel for weeks or months.
You only go out with a companion or only on “safe” routes.
Your work, studies or relationships are becoming limited.
You have panic attacks or are constantly afraid of the next one.
You need alcohol or tranquillisers to go out.
Safety: If, together with the fear, you have thoughts that life is not worth living or thoughts of harming yourself, ask for help immediately: 166 (ambulance, EKAV), 112, or the Suicide Prevention Line 1018. Chest pain you have never felt before needs an urgent medical check.
How I can help
Book an assessment, at the practice in Trikala or online. If leaving home is difficult, start online: see how working with an online psychiatrist works. Sessions take place via Google Meet, WhatsApp or Viber. See also the page on anxiety and panic attacks and the article on the online psychiatrist in Greece and e-prescriptions for how a video appointment works, or book an appointment.
This article is educational and does not replace individual clinical assessment. Do not change or stop any treatment you are already taking without talking to your doctor.
Sources
Balaram K, Marwaha R. Agoraphobia. StatPearls, NCBI Bookshelf. Last updated 11 November 2024. https://www.ncbi.nlm.nih.gov/books/NBK554387/
Roest AM, et al. A comparison of DSM-5 and DSM-IV agoraphobia in the World Mental Health Surveys. Depress Anxiety. 2019. https://doi.org/10.1002/da.22885
Kessler RC, et al. The epidemiology of panic attacks, panic disorder, and agoraphobia in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2006. https://doi.org/10.1001/archpsyc.63.4.415
Bandelow B, et al. World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for treatment of anxiety, obsessive-compulsive and posttraumatic stress disorders – Version 3. Part I: Anxiety disorders. World J Biol Psychiatry. 2023. https://doi.org/10.1080/15622975.2022.2086295
Pompoli A, et al. Dismantling cognitive-behaviour therapy for panic disorder: a systematic review and component network meta-analysis. Psychol Med. 2018. https://doi.org/10.1017/S0033291717003919
Bouchard S, et al. Delivering cognitive-behavior therapy for panic disorder with agoraphobia in videoconference. Telemed J E Health. 2004. https://doi.org/10.1089/153056204773644535
Carlbring P, et al. Internet-based vs. face-to-face cognitive behavior therapy for psychiatric and somatic disorders: an updated systematic review and meta-analysis. Cogn Behav Ther. 2018. https://doi.org/10.1080/16506073.2017.1401115
