Agoraphobia: Information & Agoraphobia Specialists

Agoraphobia is an anxiety disorder. The term (from the Greek ἀγορά agorá = marketplace, φόβος phóbos = fear) refers to the fear of open spaces associated with this condition.

In addition, there may also be a fear of crowds and of traveling alone far from home.

Research suggests that biological factors and learning processes play an important role in the development of agoraphobia.

With regard to learning processes, the theory of avoidance learning proposed by the American psychologist Mowrer is of particular significance. In this process, those affected learn to associate fear responses with specific stimuli.

For example, a woman argues with her husband in a crowded supermarket. She becomes anxious in this situation because he threatens to break up with her. From then on, all stimuli associated with the concept of a “crowded supermarket” trigger anxiety.

In the next step, the woman avoids entering supermarkets to escape her fear. The reduction in fear feels internally like a reward for avoiding the supermarket. As a result, this behavior becomes more frequent.

This example illustrates the importance of learning processes not only in developing but also in overcoming agoraphobia.

Those affected often cite as the reason for their fears that they are afraid of being unable to escape from a particular situation. This could involve large crowds, for example. They may also fear fainting and not receiving help.

Those affected are therefore worried that they will no longer be able to control a certain situation. They fear feeling helpless and at the mercy of others.

Agoraphobia with Panic Disorder

In the vast majority of cases, agoraphobia is associated with panic disorder. In the situations mentioned above, this leads to a feeling of intense fear.

In these situations, agoraphobia patients fear they are about to die, for example, from a heart attack. They therefore assume they are suffering from a life-threatening physical condition. As a result, the patient or a family member often calls an emergency doctor. These patients are frequently examined in cardiology departments to rule out, for example, an acute heart attack.

If panic attacks recur, this can lead to a long history of acute hospitalizations with the corresponding medical examinations.

Those affected experience these extreme states of anxiety as very threatening. As a result, they develop a fear of these anxiety attacks occurring—that is, a fear of fear (phobophobia). They do everything they can to avoid putting themselves at risk of having another anxiety attack. For this reason, they avoid situations that trigger anxiety.

This can lead to patients no longer leaving the house.

The key elements of treatment for agoraphobia, with or without panic disorder, are

• psychotherapy and
• medication.

The specific approach to combining these two treatment elements must be determined on a case-by-case basis.

In many cases, clinicians opt for a combination of both treatment approaches.

Cognitive Behavioral Therapy for the Treatment of Agoraphobia

Psychotherapy is typically conducted using cognitive behavioral therapy. An important technique involves presenting a logically coherent model of how the disorder develops and is maintained. The patient comes to realize that they often interpret their physical symptoms in a catastrophic way. In reality, however, there are almost certainly entirely different explanations.

When climbing stairs, a rapid heartbeat and shortness of breath typically occur. A patient with agoraphobia may interpret this as a warning sign of a heart attack. This is true even if repeated examinations have previously shown that they are in good cardiac health. For this reason, the patient feels threatened by these symptoms. A vicious cycle of anxiety takes hold.

A logical and reasonable explanation in this situation would be the following: The physical symptoms are related to the fact that the body has an increased need for oxygen during strenuous physical activity. This oxygen must be transported via the bloodstream. Heart palpitations and shortness of breath are therefore completely normal.

However, the anxious patient is initially unable to provide this explanation to themselves. Cognitive behavioral therapy helps the patient understand these rational explanations.

Exposure Therapy for Agoraphobia

First, a patient with agoraphobia learns to recognize these irrational thoughts. Then, the patient counters these thoughts with other thoughts.

This involves repeated confrontation with anxiety-provoking situations and stimuli. The goal is to become accustomed to these situations. As a result, over time, the intense physical anxiety reaction subsides and eventually disappears. Ultimately, the patient must learn that anxiety never disappears by avoiding an anxiety-inducing situation. It can only be overcome through repeated successful coping within the context of exposure.

This change can be illustrated with an example. Most people would feel anxious if, after a car accident, they drove the same route the next day. They fear that another accident might happen. If they drive this route repeatedly over the next few weeks without anything happening, the tension will soon subside.

After some time, there will be no increased tension compared to other routes because a habituation effect has set in.

The anxiety would persist if the patient had not gotten back into a car following the accident.

Medication for Agoraphobia

The first-line medications (psychotropic drugs) for agoraphobia are antidepressants from the group of so-called selective serotonin reuptake inhibitors (abbreviated SSRI). They are relatively well tolerated and do not cause dependence.

These include, for example, the active ingredients

• citalopram,
• sertraline, and
• paroxetine.

However, antidepressants from other classes of active ingredients may also be considered for agoraphobia. These often have more side effects, though they are similarly effective.

Caution is advised when using direct anxiolytics from the benzodiazepine class (e.g., lorazepam, diazepam). In the short term, they are highly effective because they cause a significant reduction in anxiety shortly after ingestion. In the long term, however, they lead to dependence that is difficult to treat.

The prognosis for agoraphobia is influenced by various factors. Without treatment, agoraphobia can quickly become chronic, which can lead to significant limitations in daily life. The prognosis is favorable if the condition has not been present for very long. The patient must be willing to confront their fears.

The prognosis is less favorable if agoraphobia is accompanied by other conditions. Depression or substance use disorder, for example, are particularly serious. Multiple previous unsuccessful treatments are also associated with a less favorable prognosis. A chronic course of agoraphobia is also associated with an increased risk of suicide.

The prognosis is also generally poor if the patient’s social situation leaves them with few opportunities to address their fears. An example would be a relationship conflict that the patient does not openly address because they feel financially dependent on their partner.

A patient’s application for disability benefits also contributes to a poor prognosis. In this case, the affected individual will make no effort to confront their fears, as doing so would reduce their chances of receiving disability benefits.

A 29-year-old woman reports that, following a heated argument with her long-term boyfriend, she experienced her first panic attack with

• severe shortness of breath,
• rapid heartbeat, and
• dizziness

. The emergency doctor, called by her boyfriend, sent the young patient to the hospital. There, she underwent a comprehensive medical evaluation, including an ECG and cardiac catheterization. There were no indications of heart disease or any other physical illness.

After being discharged from the hospital, the patient experienced repeated panic attacks in department stores and while visiting a friend. After four weeks of repeated panic attacks, the patient finds herself unable to leave the house alone. She now runs errands only when accompanied by her boyfriend. She is unable to continue working as a claims adjuster at an insurance company and is placed on sick leave.

After a detailed discussion with her primary care physician, the patient makes an appointment with a psychological psychotherapist. She begins outpatient behavioral therapy with her. In therapy, she learns to confront her fears. She recognizes the connection between her agoraphobia and her fears of separation and loss.

After 25 hours of outpatient behavioral therapy, she is able to face the situations she had previously avoided. As therapy progresses, the issues in her relationship are addressed in depth.

Ultimately, the patient breaks up with her boyfriend. She realizes that she and her boyfriend do not share common goals or future prospects. In particular, her desire for a family and children remains unfulfilled.

One year after the initial onset of symptoms, the patient is symptom-free. She faces all anxiety-provoking situations. She reports that she is less afraid of conflicts than she was before therapy.