UNC Health Talk

The Fear of No Escape: Facing Agoraphobia

Right now, during a pandemic, it’s natural to feel fearful in public spaces like the grocery store or the movie theater.

For people with agoraphobia, these feelings aren’t pandemic-specific. This mental illness is marked by persistent fear and avoidance of certain places and situations. People with agoraphobia are fearful that if they are in a crowd or with a group of people, they might feel intense anxiety and not be able to escape.

UNC Health psychiatrist Rachel Frische, MD, explains more about the disorder and why some people with no history of agoraphobia might develop symptoms now.

Agoraphobia Basics

Agoraphobia is an anxiety disorder in which a person has trouble feeling safe in places outside of his or her home, particularly in crowds. This can be triggered by going to a concert or sporting event, or by traveling in a car, bus or airplane. When the person with agoraphobia feels anxious or trapped, he or she could have a panic attack.

People with agoraphobia have a difficult time differentiating between a perception of fear versus actual danger, and they fear that a loss of control (as in, the ability to leave a space quickly) will make them unsafe.

Signs and Symptoms of Agoraphobia

People with agoraphobia commonly experience:

  • Intense fear of crowds, enclosed spaces or wide-open spaces
  • Worry
  • Rapid heartbeat
  • Rapid breathing (hyperventilation)
  • Headaches
  • Double or blurry vision
  • Elevated blood pressure
  • Sweaty or clammy skin

“Our physical body can react to stress in many different ways. Some people may only experience worrisome thoughts or emotions, while sometimes the body may physically respond. Most people have a combination of the two,” Dr. Frische says.

Agoraphobia Risk Factors and Causes

Diagnosable agoraphobia is relatively uncommon; Dr. Frische says only about 1 percent of the population has it.

“Women are two times as likely as men to have this type of anxiety. It’s more common in young adults, and it is rare for children. We normally see it emerge during a person’s 20s and 30s,” Dr. Frische says.

Other risk factors may include:

  • History of depression or social phobia
  • Family history of anxiety or phobias
  • Lack of access to a support system

The cause of agoraphobia is different for every person, Dr. Frische says. Anxiety disorders are known to have both genetic and environmental components; that is to say, the genes you inherit and the environment you inhabit both play a role in your mental health.

Sometimes a person has a panic attack in a given situation and then becomes afraid of that situation in the future. Negative childhood experiences, unhappy relationships and stressful or traumatic events can also trigger agoraphobia.

Psychiatrists say chemical messengers in the brain can affect mood and behavior as well.

“The goal of the brain is to process fears and worries and accurately decide if this is a reality-based fear or not. The problem with agoraphobia is if those receptors in those areas of the brain don’t have the ability to function at the maximal amount, then they tend to misrepresent if that fear is factual or not,” Dr. Frische says.

Agoraphobia and COVID-19

Right now, because of the coronavirus disease 2019 (COVID-19) pandemic, people with agoraphobia may be under additional stress, and people with no history of agoraphobia could develop some of its features, Dr. Frische says.

“The world is struggling together with the anxiety of uncertainty, with the fear of the unknown and what that means for their safety and their health,” she says.

We’re all receiving messages that public places are dangerous—because in terms of COVID-19, they can be. And one of the most discussed symptoms of COVID-19 is shortness of breath, which can also happen during a panic attack. It can be hard to differentiate whether you’re experiencing true physical symptoms or if your mind is causing you to have a physical response, Dr. Frische says.

“We are self-imposing physical distancing that can accentuate any underlying degree of agoraphobia. And the words ‘quarantine’ or ‘physical distancing’ can trigger those fears of being cut off from people or not wanting to leave your house,” Dr. Frische says.

Symptoms of agoraphobia might emerge for people who are going back to work for the first time, taking their children back to school or day care, or attending an event. Many people, with and without agoraphobia, will struggle to feel safe at this time, Dr. Frische says.

Long-Term Effects of Agoraphobia

In severe cases of agoraphobia, a person can become housebound for years, and if left untreated, this mental disorder can damage the body. Being under stress causes overproduction of the hormone cortisol, which has been linked to diabetes and heart disease.

“If we’re pumping tons of cortisol because we’re so stressed all the time, that can cause our bodies to be put under a lot of physical stress, which can lead to a chronic physical illness,” Dr. Frische says.

Treatment for Agoraphobia

If a person is experiencing any type of anxiety that is keeping him or her from living the life he or she wants to live, then it’s time to seek treatment, Dr. Frische says.

Options include:

  • Cognitive behavioral therapy: This type of treatment involves a person meeting with a therapist to discuss fears of leaving home and not being safe. The person with agoraphobia and the therapist will work together to discuss the fears and plan careful, gradual exposures. About 50 percent of patients typically improve with this type of therapy, Dr. Frische says.
  • Medication: Antidepressants, particularly selective serotonin reuptake inhibitors, or SSRIs, help reduce the symptoms of anxiety and mood changes.

“Admitting that you’re struggling is the first step in helping yourself. When you see and identify these issues arising in yourself, seek help,” Dr. Frische says.

If you are struggling with symptoms of stress or mental illness, talk to your doctor. If you don’t have one, you can find one here.