What is Agoraphobia?
Have you heard of agoraphobia? Perhaps you heard an adult refer to a reclusive elderly person as an “agoraphobe” while growing up. Maybe the word came to your attention during 2020 and 2021 when government lockdowns and fear of getting a novel disease turned many people away from leaving home for any reason. Maybe you watched the movie Kimi, where Zoë Kravitz plays a brilliant agoraphobic software engineer who uncovers a dangerous conspiracy within her company and takes down the baddies (mostly) from home. Or maybe you’ve come across the term on social media, where so much of our exposure to mental health-related content comes from now - whether or not it is accurate.
Agoraphobia is commonly and stereotypically understood to be a fear of leaving one’s house. But while leaving home can undoubtedly be a big fear for folks who suffer from agoraphobia, a general fear of going outside doesn’t primarily define the condition. Instead, it has much more to do with the types of “What If” (ever-present in anxiety disorders) an agoraphobic person asks themselves. And agoraphobia can be well understood in the context of conditions like panic disorder, OCD, and health anxiety, too. With the holiday season fast approaching, many of us might be experiencing fears or anxieties related to travel, spending time away from home, being in new places, losing our routines, or other such worries. Which types of holiday-related dread could be considered agoraphobic anxiety? Which types are just typical for the season? Read on to find out.
In The Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM–5; American Psychiatric Association, 2013), agoraphobia is diagnosed when there is a marked fear or anxiety about two (or more) of the following five situations:
Using public transportation
Being in open spaces
Being in enclosed spaces (e.g., shops, theaters, cinemas)
Standing in line or being in a crowd
Being outside the home alone
The Diagnosis
Diagnosis requires that the feared situations are avoided altogether or if experienced, are endured with marked distress or with anxiety about having a panic attack or experiencing panic-like symptoms. Individuals suffering from agoraphobia often feel they need a companion to engage in feared experiences. Importantly, agoraphobic situations almost always provoke fear or anxiety for the sufferer, and the fear or anxiety is out of proportion to the actual danger posed by the situations, even when accounting for sociocultural context.*
As we can see, agoraphobia can be diagnosed even if someone leaves their home quite often or without much difficulty. What diagnosis is based on, then, has much more to do with the specific situations that are avoided and the emotional, cognitive, and physical experiences that are feared - just like other anxiety disorders! Here are additional similarities between agoraphobia and other anxiety disorders:
Anxiety is experienced in anticipation of feared situations, not just during the situations themselves. This is called anticipatory anxiety and accounts for the avoidance behaviors.
Anxiety arises, at least in part, from mental catastrophizing - or thinking of the worst possible outcome that could be experienced.
Sufferers often develop safety behaviors meant to curtail the anxiety - in this case, aside from the avoidance, a noted safety behavior is the reliance on having a companion.
The experience of anxiety and the fearful reaction to it can often lead to a downward spiral into the feared situation itself - in this case, a panic attack.
The reliance on avoidance and safety behaviors can lead to a vicious cycle in which feared situations become increasingly daunting, safety behaviors stop working and need to be increased, and life, generally, gets smaller and smaller for the sufferer.
So, people suffering from agoraphobia are worried about having panic attacks? How does this differ from panic disorder? The two conditions are intimately linked, but the key difference is that people with agoraphobia might not have panic attacks. Just the experience of panic-like symptoms and the fear of having a panic attack are required for this diagnosis. Agoraphobia is also linked to more specific and stable situations than panic disorder. In contrast, individuals with panic disorder are often preoccupied with the fear of having a panic attack in any situation at all.
The What Ifs
In light of the holiday season, let’s take a look at the different “What Ifs” that someone experiencing agoraphobic anxiety might experience better to understand the feared experiences at the heart of agoraphobia:
“What if I’m on the plane to LA for Thanksgiving and start to feel panicky and need to get off - but I can’t get off?!”
“There’s no way I’m getting to that Hanukkah dinner by bus, and Ubers will be way too expensive - I have to take the T. But what if it’s so crowded that I can’t breathe?”
“Now that my sister has moved, I must drive myself to Connecticut for Christmas this year. But I’ve never driven that far alone. I hate how the highways are so big and open - what if I black out while driving there and crash?”
“I know my Mom will need me to help her with all her gift shopping - and she still goes to the mall instead of using Amazon! What if it’s so crowded there that I get overwhelmed and freak out?”
Do any of these sound familiar? Most people dislike highly crowded places, long plane rides, or being stuck somewhere without the freedom to leave. But when these fears begin to feel life-or-death, and meaningful life experiences are avoided, missed, or not enjoyed due to the fear itself, then that could be a sign of agoraphobia or another related anxiety disorder.
Contact Soultality!
Luckily, it is well-known that therapy techniques such as Cognitive Behavioral Therapy, Exposure and Response Prevention, and Acceptance and Commitment Therapy can help sufferers of agoraphobia and related disorders get their life back. By learning to relate to thoughts and feelings in new ways, taking committed action and value-aligned behaviors, and practicing moving through - rather than away from - anxiety, it is possible to live life how you decide for yourself instead of how anxiety decides for you. Our clinicians at Soultality Center for Psychotherapy in Cambridge, MA, are experts in these and other modalities - email admin@soultality.com or call (617)631-8284 to learn how we can help you reclaim your life from agoraphobia and anxiety.
Written by Jeff Adams, LMHC
*Please note that the full DSM-V criteria for diagnosis with agoraphobia were not listed in this article and that this article is not a sufficient resource for diagnosis with Agoraphobia or any other mental health condition.