Agoraphobia: Causes, Symptoms, and Treatment

What is agoraphobia?

Meaning “fear of the marketplace,” agoraphobia is commonly thought of as a fear of public spaces. But, more specifically, it’s a fear of experiencing anxiety, panic, and distress while in situations that are hard to escape. Agoraphobic people tend to stick to areas they deem safe, such as their homes or neighborhoods. They avoid situations they perceive as unsafe—even if the fear is irrational—such as driving, walking through town alone, shopping in grocery stores, or attending public events.

If you’re agoraphobic, you likely realize how this pattern of avoidance can affect your quality of life. In severe cases, you could be fearful of stepping out of your door. Even in milder cases, you may stick to a daily routine, commuting to work or school the same way, for example, never veering off course. Or you may rely on safety behaviors to get by, such as sitting near the emergency exit on public transport. You might also skip important events such as weddings, funerals, reunions, and graduations. And pass up important opportunities like job offers or romantic dates.

When you have agoraphobia, the outside world can feel unsafe and uncertain. You may frequently think to yourself, “I can’t trust myself to stay calm out there. I’ll be overwhelmed by panic.” This “anticipatory anxiety”—the fear of potential future distress—holds you back. Unfortunately, the more you practice avoidance, the more you'll doubt your own ability to cope.

No matter how severe your agoraphobia is, though, change is possible. Your world can expand, and you can enjoy all of life’s possibilities again. The path forward may involve discomfort, but that discomfort will often be a sign of progress. It all starts with understanding your fear, developing coping skills, and reconsidering your perception of anxiety.

Agoraphobia’s relationship to panic disorder

Panic disorder is marked by recurring panic attacks—sudden episodes of intense anxiety. These attacks come with symptoms such as shortness of breath, chest pain, dizziness, and a feeling of detachment from the world around you.

Some experts believe that agoraphobia is a subtype or complication of panic disorder. This is because, in many cases, people with agoraphobia stick to their safe spaces due to the anticipatory anxiety of panic attacks.

However, research shows that in rare cases agoraphobia can show up without panic disorder. For example, a person might fear being in public and experiencing violence, infection, or humiliation rather than a panic attack. This has led the Diagnostic and Statistical Manual of Mental Disorders (DSM) to recognize panic disorder and agoraphobia as separate but commonly co-occurring conditions

Symptoms of agoraphobia

About 1.7 percent of the population have agoraphobia. Symptoms tend to show up before the age of 35, with people in late adolescence and early adulthood being most at risk. Older people can also develop agoraphobia, but it's less likely to be associated with panic attacks.

For a formal diagnosis of agoraphobia, you must show a fear and avoidance of at least two of the following situations:

1. Using public transit, such as riding a bus or in a car.
2. Being in open spaces, such as a parking lot.
3. Being in enclosed spaces, such as stores or movie theaters.
4. Standing in line with other people or in being in a crowd.
5. Leaving your home alone.

The fear surrounding these activities can be so intense that you either avoid them entirely, feel extremely distressed when doing them, or need another person present to endure them. The fear is out of proportion to the actual danger, lasts for at least six months, and interferes with your day-to-day functioning.

A mental health professional will also want to rule out other potential causes for your symptoms. They will consider whether you’re struggling with a different phobia, for example, or if substance abuse is affecting your mental health.

Similar and co-occurring conditions

Many people with agoraphobia can also meet the criteria for another diagnosis—most likely another anxiety disorder, such as panic disorder or social anxiety disorder. The following are a few conditions that might occur with or be mistaken for agoraphobia:

Panic disorder. Agoraphobia is most likely to go hand-in-hand with panic disorder. The fear of sudden, recurrent panic attacks can lead a person to become agoraphobic. However, it’s also possible to have panic attacks without agoraphobia.

[Read: Panic Attacks and Panic Disorder]

Specific phobia. If your irrational fears center on one particular type of situation, you might be diagnosed with a specific phobia instead of agoraphobia. Claustrophobia, a fear of enclosed spaces, is one example of a specific fear that could be mistaken for agoraphobia.

Social anxiety. If you have social anxiety, you may have a fear of being judged by others. Your anxiety might lead you to avoid social situations, such as parties and other crowded events, which can easily be mistaken for agoraphobic avoidance.

Separation anxiety disorder. This condition involves a fear of being separated from trusted figures, like close friends or family, or from your home. Some research shows that people who experience separation anxiety disorder are more likely to struggle with panic disorder with agoraphobia.

Post-traumatic stress disorder (PTSD). If you have PTSD, you might avoid places, people, and situations that specifically relate to your past trauma. If PTSD leads you to avoid places like grocery stores or theaters, for example, it could be mistaken for agoraphobia. The key difference is that agoraphobics avoid situations even if they are unrelated to trauma.

Major depressive disorder. When you're depressed, you may prefer to self-isolate or stay in your home for long periods of time. However, this self-isolation is more due to a lack of energy or apathy rather than fear of anxiety and panic.

Causes of agoraphobia

If you have agoraphobia with panic disorder, you may be able to trace your condition back to a specific incident: your first panic attack. The physical shaking, the pounding of your heart, feeling like the room is spinning, the unexplainable sense of derealization, and feelings of doom. It’s a vivid experience that you likely never want to repeat.

From there, you may have begun to avoid situations that could return you to that terrifying state—such as parties, concerts, or small gatherings. Your world shrank until you found yourself living in a small bubble. But why is this happening to you?

Anxiety disorders, including agoraphobia, are the result of an overactive stress or “fight-or-flight” response. When you perceive danger, your body floods your system with hormones like adrenaline and cortisol, prepping you to act—to fight or flee.

But sometimes that stress response activates even when there's little to no actual danger, leading to phobias, panic attacks, and other conditions.

Tip 1 for overcoming agoraphobia: Build your motivation to address the issue

In many cases, it's possible to manage agoraphobia through a series of lifestyle changes. However, the path to recovery will require you to step outside of your safety zones. So, start by mentally preparing yourself for the journey.

Consider what you may regain once you overcome your fears. Write a list of actions you’d take or goals you’d set for yourself if agoraphobia wasn’t standing in your way. Such as:

• Drive to visit family members in a different city.
• Explore a nearby amusement park.
• Ask friends out for lunch.
• Travel abroad with a loved one.

You can take this exercise a step further and dedicate a journal entry to elaborating on your dreams. Where do you want to take your friends for lunch? What will you order? What attractions do you want to see when you travel abroad or visit the amusement park?

Once you’re able to see the ways in which agoraphobia has restricted you, you may feel more motivated to face your fears despite the discomfort.

Find inspiration in agoraphobia support groups

Hearing about how other people cope with agoraphobia or panic disorder might inspire you, boost your optimism, and further your understanding of the conditions. Along with providing motivation, support groups can also make you feel understood and less alone in your struggles.

Online support groups might be easier to find simply due to the nature of agoraphobia. However, you may also find groups that work their way up to in-person sessions, or groups that permit you to bring a support person.

[Read: Support Groups: Types, Benefits, and What to Expect]

For even more inspiration, search for books, websites, and podcasts about people who have overcome agoraphobia.

Tip 2: Challenge inner negativity

As someone with agoraphobia, you likely spend a lot of time ruminating on worst-case scenarios. For example, the day before a trip, you might envision yourself having a panic attack. That anticipatory anxiety then undermines your plans. Or disparaging statements such as “I can’t handle this” constantly loop in your mind.

A negative mindset can become so habitual that you’re not even aware of your thinking patterns. So, practice identifying cognitive distortions—irrational, unhelpful, and negative ways of looking at the world. Look for:

• All-or-nothing thinking: “If I step outside of the house, I won't just have anxiety; I'll have a full-blown panic attack.”
• Jumping to conclusions: “I will inevitably panic in the grocery store and make a fool of myself.”
• Catastrophizing: “I'll have a panic attack that will lead to a heart attack.”
• Labeling: “I am agoraphobic. I'll always be this way.”
• Diminishing the positive: “I was able to leave the house yesterday, but that progress won't last.”

Weigh the evidence. When you experience these types of thoughts, ask yourself, “Is there evidence to support this?” You can probably recall times that you stepped outside without experiencing a panic attack. And the fact that you’re still alive is proof that panic attacks aren’t fatal.

Try opposite thinking. Aim to replace negative thoughts with opposite thoughts or more realistic expectations. Instead of, “I will always be agoraphobic,” try, “I can overcome this by learning to cope with my anxieties.” When doing this, create a vivid mental image to go with your thoughts. Imagine yourself calmly riding a bus or going for a casual stroll around your neighborhood.

Create coping statements. Coping statements can be little mantras that ground you in reality and build your confidence in difficult situations.

• “Anxiety is a normal thing that everyone experiences.”
• “A panic attack is not going to kill me. It’s just anxiety.”
• “A panic attack doesn’t last forever. It will pass.”
• “I have endured high anxiety and panic attacks before.”

You can use the above examples or brainstorm a list that feels more personal to your needs.

Tip 3: Find calm through breath control

Hyperventilation, or rapid breathing, often occurs during a panic attack as your body tries to take in more oxygen. This results in a temporary imbalance in oxygen and carbon dioxide in your blood and leads to common panic symptoms, such as dizziness.

Breathing practices can help you minimize or avoid hyperventilation. With most breathing exercises, the goal is to lengthen your exhalation. This calms your nervous system, reducing symptoms such as a racing heart rate.

Because it can be difficult to think clearly as anxiety is rising, try to memorize one of the following techniques:

Basic paced breathing

• Inhale slowly through your nose for two to four seconds.
• Allow the air to fill and expand your chest and your belly as you inhale.
• Exhale slowly through pursed lips for four to six seconds—ensure it’s longer than the inhale.
• Repeat as necessary.

4-4-8 breathing

• Slowly breathe in through your nose while counting to four.
• Hold your breath and count to four.
• Exhale through pursed lips as you count to eight.
• Repeat the steps several times.

Cyclic sighing

• Inhale slowly through your nose.
• Take a shorter, deep inhale to further fill your lungs.
• Exhale slowly through your mouth.
• Repeat for about five minutes.

[Listen: Mindful Breathing Meditation]

Tip 4: Experiment with the DARE method

In his book “DARE: The New Way to End Anxiety,” author Barry McDonagh describes a four-step method for dealing with feelings of anxiety and panic.

This method is based on the idea that anxiety is not something to fear. It's really just your body's misguided attempt to protect you from harm. So, rather than resist the waves of anxiety, aim to ride them.

DARE isn't necessarily about calming you down. It's about reframing your relationship to anxiety. The goal is to get to the point where the symptoms don't scare or upset you.

Step 1: Defuse. Panic and anxiety feed off “what if” statements. For example, when you leave the house, you might think, “What if this anxiety rises into a panic attack?” or “What if a panic attack lasts a long time?”

Respond to these thoughts with, “So what?” Remind yourself that you’ve experienced panic attacks before, and you’ve always survived them.

Step 2: Accept and allow the feelings. Try to observe the physical symptoms and thoughts without categorizing them as “good” or “bad.” Maybe your heart is beating hard, or you feel yourself shaking a bit. You don’t need to stop or control any of it. They’re just temporary bodily sensations.

It might help to visualize anxiety as a harmless creature that shows up on occasion. Greet it and allow it to exist. It should begin to dissipate on its own.

Step 3: Run toward it. If the first two steps aren’t enough, and you notice panic symptoms rising, say, “This feeling isn't a threat. This feeling excites me.” Invite the symptoms to increase in strength. That might seem counterintuitive. However, it allows you to fully experience the physical symptoms you’ve been fearing, and then reach the realization that they’re harmless.

During this step, remember that fear and excitement are similar in that they’re both states of high energy—both involve a surge of adrenaline. The main difference is your perception of all that energy. Reframe it as a brief, harmless wave that you can choose to ride until it recedes.

Step 4: Engage. When you're idle, you might be pulled back into ruminating. Instead, move on to an activity that occupies your full attention. Talk to a friend, read a book, or go for a bike ride. Engaging isn't about distracting yourself. It's about accepting that anxiety is present but not blocking you from going about your life. When anxiety intrudes, go through the steps of DARE again.

Tip 5: Work your way up a fear ladder

A fear ladder is a method of gradually exposing yourself to things that make you anxious or panicky. Over time, you realize you can tolerate each situation, as well as the intense emotional discomfort you experience in those moments. This is a common approach to treating specific phobias and irrational fears, and it may prove effective for agoraphobia as well.

Start by brainstorming a list of situations that trigger your panic. The list could include “leaving home alone” or “sitting in a movie theater.” Try to rank those fears from least to most intense. Next, expose yourself to each situation, starting with the one that feels the least anxiety-inducing.

A sample fear ladder:

Step 1: Sit on the front porch for 20 minutes.

Step 2: Go for a walk around the neighborhood with a close friend.

Step 3: Follow the same walking route alone.

Step 4: Walk to a bus stop and take a short bus ride with a friend.

Step 5: Repeat the bus ride alone.

Step 6: Take a longer bus ride alone.

Some things to keep in mind as you do this:

• Practice minimizing safety behaviors, such as distracting yourself, sitting near an emergency exit, or gripping a loved one’s hand. The goal is to actually experience the discomfort.
• Rely on healthier coping strategies, such as DARE.
• Stick to confronting the same “rung” or fear until you feel ready to move up the ladder.
• You can modify each situation to make it slightly easier. For example, you might practice riding an empty bus before riding at a busier time.
• Expect your anxiety to rise as you enter the situation, but reduce in time.
• The amount of time it takes for your anxiety to subside will vary. Be patient with yourself.

Tip 6: Practice self-care

Basic self-care won’t be a miracle cure for agoraphobia, but it can go a long way in reducing your overall anxiety levels. Here are a few habits to stick to each day:

Make time for physical activity. Exercise is a great way to de-stress, release tension, and improve your mood. Certain forms of exercise, such as running, can potentially serve as exposure therapy for someone with agoraphobia. Prolonged exercise sessions allow you to get used to physical sensations that you typically try to avoid, including rapid breathing and increased heart rate. In addition, activities like running and biking let you practice stepping outside of “safe areas,” such as your home or neighborhood.

Get plenty of quality sleep. Sleep deprivation or low sleep quality can spike your anxiety levels. Make it a goal to get between seven and nine hours of rest each night. If sleep doesn’t seem to come easy, take steps to adjust your sleep environment, experiment with relaxation techniques, or control your exposure to light.

[Read: How to Fall Asleep Fast and Sleep Better]

Connect with loved ones. Knowing that you have social support can improve your mood and mental health and ease the pain of loneliness. Regularly invite friends and family members to spend time with you in a comfortable environment, such as your home. You could also try to stay connected through video calls or texts. Later, when you have a better grip on your fear, practice visiting them for face-to-face time.

Break away from self-medicating behaviors. People with agoraphobia often turn to substances like drugs and alcohol to help them cope. You might find that you're less apprehensive about going into public spaces if you have a few drinks beforehand. This can put you at risk of developing a separate substance-abuse disorder that will also affect your health. In addition, substances such as alcohol actually increase your anxiety in the long run.

Professional treatment

If self-help strategies aren’t enough, talk to your physician or mental health professional about therapy or medication.

Cognitive behavioral therapy (CBT) has been shown to be effective for dealing with anxiety disorders. The premise of CBT is that your thinking patterns affect your feelings and drive unhealthy behaviors. For example, your perception that you can’t cope with a panic attack leads you to avoid leaving your home or neighborhood. A CBT therapist can help you examine how you perceive the world, shift your thinking, and develop healthier patterns of behavior.

[Read: Therapy for Anxiety Disorders]

Medication

If you’re struggling with severe agoraphobia, a doctor might prescribe you medication to reduce your symptoms. Some forms of medication could include:

• Selective serotonin receptor inhibitors (SSRIs)
• Serotonin-norepinephrine reuptake inhibitors (SNRIs)
• Tricyclic antidepressants (TCAs)
• Benzodiazepines

Each anxiety medication can come with different side effects, so you might have to try several before you find a good match. Medication may also be more effective when used in combination with therapy and self-help techniques.

How to help someone with agoraphobia

If you have a friend or family member who’s struggling with agoraphobia, you may feel a combination of concern and exhaustion. You might be concerned about how avoidance and isolation is affecting their mental health, or frustrated about their tendency to cancel plans or leave early. Sometimes, you may want to just drag them out into the sunlight and force them to face the world. Unfortunately, it’s not that easy.

Here are a few steps you can take to actually help your loved one:

Learn as much as you can. Read books, listen to podcasts, talk to mental health experts. The more you know, the better positioned you'll be to provide help. If possible, expand your knowledge beyond agoraphobia and learn about anxiety disorders in general. Knowing how to help your loved one through a panic attack can be especially helpful.

Don't set a timeline to their recovery. Each person's journey can differ based on factors like the severity of their condition and the types of setbacks they experience. Your loved one might seem to be doing better one week, only to be housebound again the next.

Be patient and supportive of their efforts to leave their safety zones. You might have a hard time understanding their fears, but don't trivialize their struggles or make comments like, “Riding the bus is easy!” Don’t try to pressure them into doing things they’re not ready to do.

Ask them what their specific needs are. On a bad day, they might need a ride to work because they’re terrified of taking public transportation. But be realistic about what you can offer. If you don't have the time to help, maybe you can ask someone else who can.

Help them help themselves. You can't force another person to seek help, but you can nudge them in the right direction and offer encouragement. This could involve anything from helping them find a therapist to brainstorming a fear ladder to climb. Your role is to support them in their recovery, not take responsibility for their recovery. Believe that they can overcome this challenge with you at their side.

Whether it’s you or a loved one who’s experiencing agoraphobia, be patient and know that the goal isn’t to erase anxiety completely. Anxiety is natural, so when experiencing the symptoms, don’t think of it as a step backwards. The goal is to recognize that you can endure and work with uncomfortable feelings. Once you have that sense of confidence, agoraphobia can’t hold you back from living a full life.