Need to know
Quarantining after the COVID-19 pandemic began was a shocking disruption to life, but it wasn’t new to me. I’d been quarantined before, unable to leave my apartment, or bedroom, or bed, for days or weeks and, once, for months. I was prisoner to couches, living rooms and bathrooms many times before, hiding from a dangerous world.
I was first diagnosed with agoraphobia as a complication of panic disorder in 2015. After more than a decade of panic attacks outside of the home – in the classroom, at the grocery store, in the car, on the subway, at the gym – I started to associate leaving the house with panic. So, to avoid the panic attacks, I wouldn’t leave the house at all. One by one, I gave up things I loved: yoga classes, teaching, a coveted job at a magazine that I’d spent months applying for, dinners with friends. When you avoid something you fear, you feel immediate relief because you’ve escaped what you believe was causing your panic. But, like a drug, you need more and more avoidance to maintain feelings of safety, and your world gets smaller and smaller.
So the first weeks of quarantining in 2020 came as something of a relief. ‘It’s the life I’ve always wanted,’ I joked to my husband. Childcare was cancelled, so I spent most of my time with our then one-year-old and my husband. My teaching moved online. We existed in our backyard and living room, had our groceries delivered, drove nowhere, saw no one. I’d never been able to relax into a quarantine before, because previously, they were self-imposed, coming from disorder, and something I had to work through to resume a functioning life.
Agoraphobia is defined by the US National Institute of Mental Health as a type of anxiety disorder that causes ‘intense fear and anxiety of any place or situation where escape might be difficult’. The fear is so intense that we agoraphobics avoid those situations even though it shrinks and then decimates our lives. People with agoraphobia avoid places they might feel trapped, helpless or embarrassed if they needed to leave, like in line at the supermarket, in the dentist’s chair, in traffic, or in tight spaces, like elevators, movie theatres and crowded stores – all places where I’ve panicked several times. Buses, trains and planes also pose a problem for many agoraphobics as, once they get on, they are not in control of when they get off.
Perhaps you have come to this Guide because you’re experiencing some of the symptoms I did. Maybe you’ve had panic attacks in certain places and that has made you want to avoid going there in the future. Gauri Khurana, a psychiatrist and clinical instructor at Yale University School of Medicine, explains that, while agoraphobia is often associated with a fear of crowded spaces, ‘to those who suffer from it, it is more a fear of having anxiety or a panic attack, and avoiding anywhere that has occurred or might occur. People who suffer from agoraphobia feel trapped in their homes because leaving, or even the thought of leaving, triggers symptoms of panic, like trembling, dizziness, nausea, diarrhoea and dissociation. Home feels like a safe space when nothing else in the world does.’
Agoraphobia is estimated to affect about 1.5 per cent of adults at some time in their lives. It commonly co-occurs with panic disorder, another type of anxiety disorder, though it can also occur on its own. The disorder typically starts in the late-teen and early adult years, usually before age 35, with a median onset of 20 years old. I was 30 when mine started, but 35 when I was finally diagnosed. Like other anxiety disorders, agoraphobia is more common in women than in men.
‘Classical conditioning happens with anxiety disorders [such as agoraphobia],’ says Karen Cassiday, a clinical psychologist and managing director of the Anxiety Treatment Center of Greater Chicago. ‘For example, if you panicked on the highway, you then associate the highway with panic and think, If I get back on the expressway, I might feel the way I did before – and so you avoid it.’ She notes, ‘it’s very common for someone to start avoiding the places and situations where they’ve panicked because they think the situation causes their panic, as opposed to their panic hijacking the situation.’
There was a time when giving up my life outside the walls of my Manhattan apartment seemed like a fair trade for evading the abject terror that swallowed me when I left – the dry-mouthed, shaking-muscled, world-spinning derealisation of panic attacks. My best friends brought food and books, lay with me in bed when I couldn’t be alone. It took years of therapy and medication to free me from that paralysed, self-quarantined state. It is hard, constant work, and I used to wish the world would shut down along with me so I wouldn’t have to wean myself back onto it.
But after the world finally did shut down, and a few months passed, I surprised myself by saying to my husband, while we cuddled on the couch in a Fanta-orange sunset: ‘I miss the world.’ I missed taking our baby to the library’s story hour. I missed running to the store, even though it made my stomach cramp and my head spin. I missed the static shocks we’d get sliding our baby down the plastic slide on cold mornings at the playground. I longed for the traffic, the children, the hordes of people eating ice cream on the sidewalk – everything that used to give me anxiety and panic, I wanted to see again.
Tackling re-entry into the outside world can be daunting for someone with agoraphobia. As Cassiday says: ‘We’re hardwired to avoid things that make us uncomfortable, so it makes perfect sense that we avoid places we’ve panicked.’ But what’s important to remember is that ‘in trying to avoid the scene of the crime, we accidentally reinforce the fear and make it worse.’
If this sounds like your experience, know that, while agoraphobia is an overwhelming and debilitating condition to have, it is eminently treatable. Cassiday estimates that, with proper treatment, it is possible to resolve agoraphobia symptoms within a matter of months. In facing your anxiety, she says, ‘the key is to stop avoiding and to reclaim the territory anxiety has stolen from you.’ In the rest of this Guide, we’ll look at the steps you can take to recover lost ground.
What to do
Recognise the symptoms
Reflecting on whether you experience the symptoms of agoraphobia in your own life – and, ultimately, consulting a healthcare professional – can help you determine whether you should begin treatment for the condition. For a more formal breakdown of the symptoms, the current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; 2013) describes a person with agoraphobia as regularly experiencing fear or anxiety about at least two of the following:
- Using public transportation
- Being in open spaces
- Being in enclosed places
- Being in line or in a crowd
- Being outside of the home alone
Someone with agoraphobia, according to the DSM-5, fears or avoids these situations because they think that, if they experience ‘incapacitating or embarrassing’ symptoms, such as those of a panic attack, it will be hard to escape or get help. The person either avoids the situations altogether, needs someone else to be there with them, or enters the situations and feels intense fear or anxiety. Importantly, the aversive feelings are out of proportion to any real danger involved in being in these situations. The fear, anxiety or avoidance is ongoing (usually for six months or longer) and causes significant distress or impairment in important areas of one’s life, such as at work or in social relationships.
The two most important steps in overcoming agoraphobia, Khurana advises, are to recognise that you are suffering and to seek treatment – specifically, finding a therapist and/or a psychiatrist for a formal diagnosis and treatment plan.
Enlist help and begin the process of recovery
Finding a mental health professional can feel like an overwhelming task, especially when you are in the throes of anxiety, panic or agoraphobia. For those in the United States, Cassiday suggests that an excellent way to find a therapist who specialises in agoraphobia or anxiety disorders is through the Find a Therapist section of the Anxiety and Depression Association of America website. The Association for Behavioral and Cognitive Therapies has a similar feature. ‘Everyone in these listings will have evidence-based training for treating anxiety and agoraphobia,’ Cassiday says. She also suggests that, if you search through your insurance company or on a therapy directory such as the one offered by Psychology Today (which lists professionals in various countries), you make sure to look for someone who mentions cognitive behavioural therapy (CBT), exposure therapy or other evidence-based treatments for agoraphobia in their descriptions and offerings. It can also be helpful to directly ask a therapist about the specific services they provide, and about their training and experience with treating anxiety disorders.
CBT, which can be paired with medicine, is considered the gold-standard treatment for agoraphobia and most anxiety disorders. It involves patient education, goal setting, practice confronting what scares you, and building skills to both reduce anxiety symptoms and tolerate them when they arise. The bulk of CBT treatment for agoraphobia involves exposure therapy, in which you systematically expose yourself to places and situations that you fear with guidance from your therapist. In doing so, you learn to tolerate the panic and anxiety until it lessens with repetition. A goal of therapy is ‘to get people to stop avoiding’, says Cassiday. ‘We want them to learn that they can handle the anxiety they might get in those situations and not be undone by it.’
Know what to expect in exposure therapy
Exposure therapy helps people to confront their fears, and lose their fear response with practice. For example, if a patient with agoraphobia wanted to start going shopping but had been avoiding it because of panic attacks, the steps to going back could start small and gradually progress from there. ‘First, you might get in a calm and relaxed state and just visualise yourself going there,’ Cassiday explains. ‘You imagine each step of the way – putting on your jacket, leaving the house, walking to your car, driving there, walking to the venue. Then you might just walk or drive there and look at the market. Then you might go in with a friend for just five minutes, or 10 minutes. Then go while on the phone with a friend, then go alone, and so on.’ Typically, through a series of manageable steps – sometimes accompanied by a therapist, but often practised alone or with a trusted friend or family member – a person exposes themselves to what they fear, lets the fear response calm, and then pushes a little further the next time.
I kept a log on my phone of exposures my therapist assigned me and notes on how they went. Some excursions ended with me in a sweaty, shaking panic, calling a friend to come get me at the doctor’s office, or at least talk to me while I drove home. Some I succeeded in with blessed triumph, texting my therapist pictures of my smiling face in the cereal aisle or the empty university classroom where I had managed to lecture through a massive panic attack.
For exposure therapy to be effective, you need to feel some amount of anxiety, and remain in that situation until the anxiety abates. On a scale of 1 to 10, the anxiety in an effective exposure might start at around a 6 or 7, significant enough to cause discomfort, but not a full 10 (which could overwhelm the system and cause someone to flee or end the exposure early). You then remain in the anxiety-provoking situation until the anxiety drops to a 4 or 5. That way, you learn: I’m in that same situation, but things aren’t getting worse, they’re getting better. ‘The average panic is self-limiting in 90 seconds to 3 minutes,’ Cassiday explains. ‘If a person can wait out a panic attack in a feared situation, they will realise: I’m not completely falling apart. I can tolerate it.’
In addition to accompanying clients with agoraphobia during some exposures, therapists help them to better understand the nature of anxiety and prepare them to take on exposure exercises out in the world. To desensitise her therapy clients to the physical sensations of anxiety symptoms, Cassiday employs an approach called interoceptive exposure. ‘We practise hyperventilating to mimic the shallow breathing of a panic attack, spinning in a chair to get dizzy like many feel when anxious, and drinking carbonated beverages and then doing 50 jumping jacks to feel nauseous. In these ways, we learn not to be so afraid of these physical sensations – and that it just feels weird as opposed to terrifying, dangerous or catastrophic.’
Exposure therapy is not easy, but it can be invaluable for overcoming agoraphobia. A programme of graduated exposure, according to Cassiday, should involve choosing things you need to do or wish you could do and coming up with ways to approach them, most often by breaking them down into small, doable parts. If someone initially can’t bring themselves to do an exposure on their own, a therapist or a support person like a family member or friend can come with them – though, she notes, ‘ultimately they’ll need to do them on their own’. She has had clients who read books about CBT, exposure therapy and agoraphobia and self-help books about panic that ‘dramatically transformed their lives’. Some have been able to set up their own schedule of exposures and follow it through. ‘If you can do it on your own, great. If you need support from a therapist or friend, also great,’ she says. ‘You need to do whatever works to get better.’
Reaffirm your motivations for change, and keep going
Exposure therapy can take weeks, or months, or longer. But agoraphobia and panic disorder are highly treatable, and the most important thing, again, is to reclaim territory that they have stolen from you. ‘Decide for yourself that it’s really worth the effort to get your freedom back,’ Cassiday says. ‘You have to have a meaningful reason for yourself because you still have the option to avoid. You have to be convinced that [avoidance] is no longer good for you, your mental health, joy, sense of purpose and meaning. Try to shift your sense of yourself from feeling fragile to living like an adventurer. Part of that adventure is taking risks, making mistakes, and realising: This is how I become the hero or heroine of my own story.’
Anxiety experts agree that a mistake many people make is waiting to feel good before they do an exposure. They want to wait until they feel less anxious, or more confident in their coping skills, or less tired, depressed or whatever the unpleasant feeling they’re experiencing is. But the trick with exposure is that you must do it afraid. That’s how you teach yourself that the feared outcome will not happen, and that, if you do panic, you can tolerate it and wait until the panic passes.
One’s resolve is the single most important aspect of a successful exposure, Cassiday believes. She coaches her patients: ‘Are you willing to accept that it’s going to be uncomfortable and talk yourself through it in a compassionate way? You deserve to have more freedom to move, to choose to go places. You can’t afford to not practise.’
Consider talking with a doctor about medication
If you’re not seeing the progress you want to see with exposure and CBT alone, it’s important to be willing to consider adding a medication to your treatment plan, Cassiday says. Khurana takes it one step further: ‘I think medications and therapy should be started concurrently. If we can get cortisol, serotonin and other bodily hormones and molecules under control, the better that what is discussed in therapy and accomplished through exposures can be processed and integrated in real time to elicit change. If meds aren’t used, a person’s nervous system and mind can be too activated to take in anything around them, and then the anxiety continues to worsen,’ she says.
A primary care physician, psychiatrist, psychiatric nurse practitioner or physician’s assistant can all prescribe medications to help boost your progress in therapy. We’ll get more in-depth about medication types and choices in the Learn More section below.
Practise self-care and self-compassion
A number of self-care strategies can be helpful in healing from agoraphobia. These can include psychoeducation (learning more about your condition), calming meditations, breathing exercises, and visualisations of desired outcomes. ‘Creative visualisation and imagery have been employed for years in sports to help athletes envision perfect races and anticipate problems so they can better problem-solve during the race,’ Khurana says. ‘People with agoraphobia can use this technique to help them imagine successful trips to the market, right down to the details of getting their shoes on, their clothing and the items they’re going to buy.’ Additionally, yoga can help to lower general anxiety and keep you connected to your body and breathing, a connection that anxiety can disrupt.
Perhaps most importantly, treat yourself with patience and gentleness as you venture out on exposures, and experience the inevitable failures and setbacks that are part of winning your freedom back. And remember to celebrate your wins! Healing from anxiety, panic and agoraphobia is challenging work. When you have a success, really appreciate yourself for your strength, resilience and bravery in facing a kind of fear that many people don’t have to grapple with.
Key points – How to overcome agoraphobia
- Agoraphobia can isolate you from important parts of your life. What starts with an avoidance of being in certain places – in a crowded store, at a class, driving in traffic – can expand and even lead to an avoidance of leaving home.
- Panic disorder and agoraphobia often coincide. Experiencing panic attacks in particular situations can encourage someone to avoid those situations, which reinforces the fear of them.
- Recognise the symptoms. Agoraphobia commonly involves persistent fear or anxiety about public transportation, open spaces, enclosed places, being in lines or crowds, or leaving home alone, driven by a concern about experiencing panic or other difficult or embarrassing states.
- Enlist help and begin the process of recovery. Agoraphobia, like other anxiety disorders, is very treatable. Seek a mental health professional with experience in an evidence-based therapy, such as cognitive behavioural therapy (CBT).
- Know what to expect in exposure therapy. Therapy for agoraphobia, including CBT, typically includes exposures, in which one approaches feared situations in a step-by-step manner – gradually overriding the fear response.
- Reaffirm your motivations for change, and keep going. Exposure to feared places and situations can be challenging, so it’s important to remind yourself why reclaiming your freedom is worth the effort.
- Consider talking with a doctor about medication. By helping to control the fear response on a physiological level, medication might support the process of change that unfolds in therapy.
- Practise self-care and self-compassion. Activities such as breathing exercises and yoga can help reduce anxiety and encourage you in your recovery. Accept that there will be setbacks, and celebrate successful exposures and other wins along the way.
Medications in the treatment of agoraphobia
There are multiple types of medication a doctor can potentially prescribe you in the course of your treatment. Both Cassiday and Khurana agree that antidepressants – specifically, selective serotonin reuptake inhibitors (SSRIs) – are the first-line medications for treating agoraphobia and other anxiety disorders. ‘“Antidepressants” is a bit of a misnomer in that they treat both depression and anxiety by increasing serotonin in the body,’ Khurana says. Common antidepressants used in the treatment of anxiety disorders are fluoxetine (Prozac), sertraline (Zoloft) and escitalopram (Lexapro). ‘A second-line antidepressant/anti-anxiety medication that I often prescribe is duloxetine (Cymbalta), from a different class of medications called SNRIs (selective norepinephrine reuptake inhibitors), which serve to increase both serotonin and norepinephrine,’ Khurana adds.
SSRIs can take weeks to work, so while patients are tapering up on a longer-term medication, fast-acting anti-anxiety medications might also be used. ‘To help patients manage in the interim and to treat acute panic attacks, I often prescribe anxiolytics that work rapidly to help decrease anxiety,’ Khurana says. Some of these anxiolytics are buspirone and benzodiazepines.
Benzodiazepines, such as Klonopin, Xanax and Ativan, are short-term emergency tools that work fast. ‘Let’s say there’s an emergency and you need something that acts quick – you need to fly to a funeral tomorrow, or you’re having a huge panic attack right before a presentation at work,’ Cassiday says. For such instances, one of these drugs could be helpful. ‘But as a long-term treatment, there are better choices that don’t build a tolerance or cause dependence,’ a risk with benzodiazepines.
Some doctors might recommend taking benzodiazepines to help blunt the fear response when first starting with exposures. Cassiday says that experts are divided on this, as some believe that anything that helps you confront the feared situation is OK at first, while others argue that if you take a medication before an exposure, you might attribute your success to the medicine and not to your being able to handle the situation.
‘The more you avoid, the worse the agoraphobia becomes, so no matter what, you want to find a way – either with or without medication – to try to reclaim the territory of your life,’ Cassiday says.
Teletherapy and online resources
Sometimes, because of where one lives, transportation challenges, or the nature of agoraphobia itself, getting to a therapist’s office can present a barrier to treatment. In these cases, technology can help bridge the gap by offering a virtual connection to a therapist – typically through a video-calling app on your computer or smartphone.
Many therapists who practise in person – and whom you might find via the online directories mentioned above – also offer online sessions. (US News & World Report offers a helpful FAQ on choosing an online therapist.) You might also want to consider therapy apps such as BetterHelp or Talkspace. Many insurance plans cover telehealth, so it’s a good idea to call your insurance provider to see if they offer this coverage or partial reimbursement. Additionally, there are mood-tracking and mental health apps that are low-cost or free, and accessible to anyone with a smartphone.
Re-engaging with life
Take small steps every single day to take back what agoraphobia has made off-limits, Cassiday advises. ‘If you only feel comfortable walking in a certain zone in your neighbourhood, make it your goal to go five minutes in a different direction. It’s OK to start small, but it’s important to start. It’s much easier to move something when it’s in motion than when it’s inert. Tell yourself: I’m worth the effort and the discomfort. As often as you can, take these little risks or adventures and get out there. Every day, do something that will make you feel like: This is my world, my life, and no anxiety is going to rob it from me.’
My experience in therapy and my practice with exposures have helped me to learn how to tolerate anxiety and panic symptoms, and equipped me with the knowledge and skills I need to fight against agoraphobia confining me again. But, like almost anyone recovering from any tenacious condition, I maintain an ongoing vigilance against the recurrence of symptoms, and need to stay practised and engaged with strategies to counter them when they arise.
After COVID-19 had kept my family at home in 2020, our state of Massachusetts saw a consistent decline in cases, and I went shopping for the first time in months. The usually packed parking lot of the grocery store was still mostly empty. Plastic gloves and abandoned paper masks blew on the concrete. Hardly anyone was in the store. I took in the people behind the deli counter, the fish counter, the bakery, leaning on their elbows on their glass cases, no customers to serve. It made re-entry easier – I didn’t have to deal with lines or crowds – but it also made me sad, what we’ve been through, and what might wait for us in the future.
As crowds re-emerge and formerly feared places such as packed restaurants and bustling bars regain their customers, I hope I’ll be able to delight in society healing, in people being able to connect again the way they did before. I hope I’ll feel so grateful to be able to pop into a store for the right kind of tomato sauce that I won’t cower under the bright lights or feel my pulse race when I see a line for the cashier. I hope that I’ll be better able to push away the fears of panic attacks and getting trapped and focus instead on my delight in humanity, in resilience.
Most likely, I’ll have at least some of the panicked feelings, at least some of the time, and I’ll have to work through them and push against them, as I always have. Perhaps, as someone recovering from agoraphobia, you will have to continue to work through these feelings, too. For me, they will probably come and go like they did before this all began. And yet, just like I used to thrill at venturing out after a period of panic, I hope to thrill at re-entering a populated world, people filling the previously quiet spaces, out for runs along the Charles River in Boston, holding hands on the sidewalk. A whole world of people living lives in public.
Links & books
Dare: The New Way to End Anxiety and Stop Panic Attacks (2015) is the most helpful book I’ve found for understanding anxiety and its related problems – such as agoraphobia, panic attacks, derealisation – and the best ways to manage them. Barry McDonagh’s approach is to normalise anxiety and to stop taking it so seriously. You can also download the very helpful and free Dare app with its relaxation exercises, affirmations and SOS scripts to de-escalate panic attacks.
Drew Linsalata hosts an incredibly useful podcast, The Anxious Truth, about anxiety, agoraphobia, panic disorder, and the best practices for treatment and recovery. His book The Anxious Truth (2020) is a step-by-step guide on how to implement the strategies he discusses in his podcast. Linsalata himself was long debilitated by severe anxiety, panic, agoraphobia and depression, but has been symptom-free since 2008.
My Age of Anxiety: Fear, Hope, Dread, and the Search for Peace of Mind (2014) is humorous, honest and meticulously researched. What I loved most about the journalist Scott Stossel’s memoir was the weaving of his own harrowing journey with profound philosophical and cultural questions about what anxiety is and what significance it holds.
In his book The Anxiety and Phobia Workbook (2020), Edmund J Bourne offers practical how-tos for overcoming phobias (including agoraphobia), anxieties, obsessive thinking, negative self-talk, panic attacks and other anxiety-related challenges. He also offers a wide array of tools in terms of relaxation, imagery, desensitisation, guidance for medication, skills for coping with panic attacks and more.
The Mastery of Your Anxiety and Panic workbook (5th ed, May 2022) by the pioneering clinical researchers David Barlow and Michelle Craske dives into how the ‘negative cycles’ of panic attacks and agoraphobia work, and how they can be undone, covering proven techniques for coping with and reducing symptoms.
Rewire Your Anxious Brain: How to Use the Neuroscience of Fear to End Anxiety, Panic, and Worry (2015) by Catherine M Pittman and Elizabeth M Karle is a fantastic book for understanding how anxiety affects your brain. Many people with anxiety and panic disorder find great comfort in understanding what is happening in their bodies, as the experience is often marked by feeling incredibly out-of-control and in the dark.
The Anxiety and Depression Association of America offers resources for understanding anxiety, depression and co-occurring disorders. These include links for peer-support groups, both virtual and in-person, and for finding therapists.