Identifying the Causes of Agoraphobia - A Comprehensive Guide

What Causes Agoraphobia (Fear of Leaving Home)?

Researchers have not been able to identify the exact cause of why some people develop agoraphobia or a fear of leaving home. However, this mental health condition often occurs in association with a panic disorder. 

People with panic disorder experience panic attacks, which are short, intense episodes in which they feel extreme fear in the absence of any actual danger. 

About a third of the people with an existing panic disorder go on to develop agoraphobia. However, in some people, agoraphobia occurs without an underlying panic disorder.

Biological Factors

Your body’s “fight or flight response” is designed to protect you from stressful and dangerous situations. Panic disorders are closely related to this natural response. When you experience anxiety and fear, your body releases adrenaline and other hormones. These hormones increase your heart rate and breathing to prepare you for a threat or danger. Research suggests people with a panic disorder have a more intense fight or flight response, which results in panic attacks. As mentioned, panic disorder can progress to agoraphobia in some people.

Psychological Factors

Some people are more prone to develop anxiety disorders. People with a history of mental illnesses such as depression, anxiety, eating disorders (anorexia nervosa or bulimia), and drug or alcohol abuse are at a higher risk of developing agoraphobia.

Environmental Influences

Agoraphobia can be triggered by traumatic childhood events, such as the death of a parent or sexual abuse. In adults, experiencing stressful life events such as a divorce, job loss, bereavement, or relationship stress can lead to agoraphobia. 

Research shows that agoraphobia often begins after a stressful event, such as a divorce or job loss. The distress causes you to limit contact with the outside world (this is known as avoidance behavior). Over time, you start experiencing uncomfortable symptoms in more and more public areas, ultimately becoming confined to your home. 

In some cases, a stressful life event triggers a panic disorder. To avoid experiencing panic attacks, you start avoiding activities that might trigger them. Eventually, many places and situations become feared, and the illness progresses to agoraphobia. 

Agoraphobia Without Panic Disorder and Panic Attacks

Agoraphobia often develops in people with a panic disorder, but this is not always true. It is possible to develop agoraphobia without experiencing a panic disorder or panic attacks. For instance, in some people, agoraphobia is triggered by another specific phobia, such as a fear of falling, not getting to the bathroom on time, getting lost, catching an infection, or becoming the victim of a violent crime.

What is Agoraphobia?

Agoraphobia is a type of anxiety disorder in which you develop a fear of and avoid certain places and situations that might cause you to be trapped, helpless, or experience a panic attack. 

Symptoms of agoraphobia can occur in places and situations that you perceive to be unsafe or difficult to escape from, such as:

• Open spaces like parking lots or open markets.

• Enclosed spaces such as elevators or small stores.

• Public transportation.

• Crowded places such as malls or movie theaters.

• Standing in line.

• Anywhere outside your home.

If you have agoraphobia, these situations and places can provoke panic attacks. They can make you extremely anxious because of the fear you will be unable to find help or escape if you have a panic attack. You may also fear that you will have other embarrassing symptoms like fainting, falling, or diarrhea. Ultimately, these fears and anxieties can cause you to avoid leaving home without a companion and then avoid leaving home altogether.

How Does a Person Develop Agoraphobia?

A person can develop agoraphobia if the fear of a place, situation, or activity leads to overwhelming anxiety, causing them to avoid it. 

As mentioned, many people with agoraphobia develop the condition after experiencing one or more panic attacks. They worry about having another panic attack, which causes them to avoid whatever caused the previous panic attack. 

Over time, it can become hard for people with agoraphobia to feel safe in more and more places and situations. They may want a companion to accompany them. Eventually, the fear can become so overwhelming that they cannot leave their home. 

Common Misconceptions

Myth: Agoraphobia and panic disorder are the same.

Fact: Agoraphobia and panic disorder are not the same. You can have panic disorder without agoraphobia. You can also have agoraphobia without a panic disorder. However, sometimes, agoraphobia develops in people with a panic disorder. 

Myth: People with agoraphobia never leave their homes.

Fact: Some people with agoraphobia find it extremely challenging to leave their homes, but this is not true for everyone with the condition. 

Myth: People with agoraphobia are just lazy.

Fact: Agoraphobia is not a personality trait or character flaw. It is a mental health condition in which there is intense anxiety and fear in situations and places where there is perceived danger.

Myth: People with agoraphobia are antisocial.

Fact: Agoraphobia and social phobia are two separate mental health conditions with different symptoms. People with agoraphobia have a fear of being in public spaces, but they don’t dislike or avoid other people. Social anxiety causes an intense fear of being judged by others. People with social phobias experience anxiety in social situations.

Who Is Most Likely to Develop Agoraphobia?

Agoraphobia can develop in children but is more common during late adolescence and early adulthood. It typically develops in young adults before age 35 and is more common in women than in men. Agoraphobia risk factors include:

Genetics 

• Having a first-degree (blood) relative with agoraphobia or panic disorder

Personality Traits

• Having a nervous or anxious personality.

• Responding to panic attacks with excessive fear, apprehension, or avoidance.

Mental Health Risk Factors

• Panic disorder and panic attacks

• Phobias or irrational fears

• Other anxiety disorders, such as generalized anxiety disorder

• Major depressive disorder

• Substance use disorders

Life Experiences

• Stressful life events, such as sexual abuse, the death of a loved one, divorce, job loss, or being the victim of a violent crime or assault

Symptoms of Agoraphobia

Physical Symptoms

The physical symptoms in people with agoraphobia can be similar to a panic attack:

• Rapid or pounding heartbeat.

• Fast breathing (hyperventilation) or trouble breathing.

• Dizziness or feeling faint.

• Sweating.

• Trembling.

• Feeling sick.

• Chest pain.

• Stomach pain, nausea, diarrhea.

Cognitive and Psychological Symptoms 

The cognitive and emotional symptoms of agoraphobia include a general feeling of anxiety and dread as well as more specific fears such as: 

• Having a heart attack or not being able to breathe.

• Not being able to escape from a place or situation.

• Looking stupid or being embarrassed.

• Losing control, blushing, trembling, fainting, or having diarrhea in public.

Behavioral Symptoms

• Avoiding situations and places that could trigger panic attacks.

• Avoiding going too far from home.

• Needing a companion to go anywhere.

• Remaining at home for prolonged periods, even missing important events.

Diagnosing Agoraphobia

According to the American Psychiatric Association, a diagnosis of agoraphobia is made based on symptoms, a physical examination and laboratory testing to rule out other conditions, and an in-depth interview with a mental health professional.

Mental health providers use the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) to make a diagnosis of agoraphobia. To be diagnosed with this condition, you should feel extreme fear and anxiety in at least two of the following situations, and your symptoms should be present for 6 months or longer. 

• Being in open spaces.

• Being in enclosed places.

• Being in crowded places or standing in line.

• Using public transportation.

• Being alone outside your home.

In addition, the following behavioral changes must be present for an agoraphobia diagnosis to be made: 

• You avoid certain places or situations.

• The same situations typically trigger your symptoms.

• You must have a friend or family member (companion) to go outside the home.

• Your anxiety, extreme fear, and avoidance behaviors are not in proportion to any actual danger. 

• Your agoraphobia symptoms cause significant distress or prevent you from doing your job properly or having a social life.

What Conditions Are Similar to Agoraphobia?

Related disorders and medical conditions that can cause similar symptoms to agoraphobia include panic disorder, other phobias, social anxiety disorder, separation anxiety disorder, major depressive disorder, and posttraumatic stress disorder.

What is the best treatment for agoraphobia?

It can be challenging to manage agoraphobia because it requires you to confront extreme fear and anxiety. However, treatment with talk therapy and medications can help you live a more fulfilling daily life. 

Cognitive Behavioral Therapy (CBT) for Agoraphobia

Cognitive behavior therapy (CBT) is a type of talk therapy in which you work with a therapist in individual and group settings. You learn coping strategies and practical skills to reduce anxiety, fear, and panic symptoms. CBT is proven to be effective for anxiety disorders, including agoraphobia. It teaches you:

• To identify what triggers and worsens panic-like symptoms and anxiety levels.

• To cope with symptoms of anxiety and panic.

• To challenge and confront your fears and gradually return to the places and situations you have avoided because of your condition. 

In addition to cognitive behavior therapy, exposure therapy plays an important role in managing agoraphobia. This type of therapy teaches you to approach avoided activities in a gradual, controlled, and repetitive manner. 

Note: Given that people with agoraphobia have trouble leaving their homes, it may be necessary for such individuals to work with mental health experts and find alternatives to traditional therapy appointments in the office, at least in the initial part of agoraphobia treatment. This may include home visits by the therapist, taking a trusted friend to the appointments, video or phone appointments, or meeting in a safe place. In severe cases, it may not be possible to access care in traditional ways. If this is the case, a person with agoraphobia might benefit from an inpatient (residential) hospital program for initial treatment. 

Medications for Agoraphobia

Some of the medications that can help in treating agoraphobia include:

• Antidepressants such as selective serotonin receptor inhibitors (SSRIs), for example, fluoxetine (Prozac) and sertraline (Zoloft); serotonin norepinephrine reuptake inhibitors (SNRIs), for example, duloxetine (Cymbalta) and venlafaxine (Effexor); and tricyclic antidepressants (TCAs), for example amitriptyline and nortriptyline. These drugs can take several weeks to have an effect and manage agoraphobia symptoms.

• Anti-anxiety medications called benzodiazepines, for example, alprazolam (Xanax). These drugs provide faster relief from anxiety symptoms, for example, during a panic attack. However, they can be used for the short term only because they are habit-forming.

Self-Help Techniques and Support Groups

Herbal Remedies: Check with your healthcare provider before taking any dietary supplements or herbal remedies for anxiety, panic, or agoraphobia. For example, while the herbal supplement kava kava may reduce anxiety, it can cause severe liver damage in some people. The U.S. Food and Drug Administration (FDA) has issued warnings against kava, but it is not banned in the U.S. 

Lifestyle Changes: 

• Keep all your therapy appointments. 

• Take your prescribed medicines.

• Discuss different approaches to confront your fears with your psychiatrist or therapist, and try to confront your fears by practicing going to places and situations that cause distress, if appropriate. 

• Learn skills to calm and soothe yourself in stressful situations. Yoga, meditation, breathing exercises, visualization, and massage are relaxation techniques that can help if you practice them daily and apply them when you’re under stress.

• Avoid drinking alcohol or using recreational drugs, and limit the use of caffeine. These substances can make anxiety symptoms worse.

• Eat a healthy diet, get daily exercise, and ensure enough sleep.

• Join a support group for people with agoraphobia or anxiety disorders and learn from others who are facing similar challenges.