What is Agoraphobia?
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Adults with agoraphobia avoid situations where they think they will not be able to escape or find help. They avoid these situations due to fear of having a panic attack or other anxiety-related feelings.
What are the avoided situations?
The types of situations that people avoid include:
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Using public transportation (e.g. bus, train, car)
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Being in open spaces (e.g. fields, parks)
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Being in enclosed spaces (e.g. elevators, tunnels)
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Standing in line or being in a crowd
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Being outside of the home alone
NOTE: Sometimes you fear a situation because you think it will be embarrassing to leave the situation (e.g. lunch with a friend, line at the grocery store) and not that you will be unable to leave (e.g. elevator).
What am I trying to avoid?
Anxiety-related feelings including:
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Panic attacks (see Panic Disorder for more information)
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Incapacitating or embarrassing panic-like sensations (e.g. loss of bowel control, feeling dizzy or falling over)
NOTE: Although it is common to have both, there are some people with agoraphobia who do not have panic disorder. Individuals who have agoraphobia without panic disorder tend to fear having incapacitating or embarrassing panic-like sensations; however, they don't have a history of experiencing unexpected and repeated panic attacks.
How do I know if I have agoraphobia?
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Individuals with agoraphobia avoid at least 2 of the types of situations mentioned above (e.g. riding on buses and standing in line).
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The fear experienced is out of proportion to the situation. Avoiding a situation that is dangerous (e.g. a dangerous neighborhood) is NOT considered agoraphobia.
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Some individuals with agoraphobia are able to enter these situations but do so with extreme dread and discomfort.
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Once someone with agoraphobia begins avoiding certain situations they often find themselves avoiding more and more situations until they are avoiding almost everything.
Self-help strategies for agoraphobia
Step 1: Learning about anxiety
This is a very important first step as it helps you to understand what is happening in your body when you are feeling anxious. All the worries and physical feelings you are experiencing have a name: ANXIETY. Learn the facts about anxiety.
Fact 1: Anxiety is normal and adaptive as it helps us prepare for danger. Therefore, the goal is to learn to manage anxiety, not eliminate it.
Fact 2: Anxiety can become a problem when our body tells us that there is danger when there is no real danger.
To learn more details about anxiety, see What is Anxiety?
Step 2: Understanding agoraphobia
Individuals with agoraphobia often avoid places or situations where they may feel trapped or have a panic attack (for more information on treating panic attacks, see My Anxiety Plan for Panic Disorder.
Sometimes individuals with agoraphobia find they are able to manage these situations when someone else is with them. If you are only able to go out to certain places when someone is with you, you may still have agoraphobia
Without treatment agoraphobia tends to get worse with time. The more you avoid, the more you are likely to avoid in the future.
Step 3: Building your toolbox
The best way to begin managing agoraphobia is to start building a toolbox of strategies that you can use to help manage your anxiety. However, it is important to remember that anxiety is not dangerous. Therefore, the goal is not to eliminate anxiety, but to learn to live your life despite the anxiety. For agoraphobia, tools in the toolbox include:
Tool #1: Learning to relax
Two relaxation strategies can be particularly helpful:
1. Calm Breathing: This is a strategy that you can use to help reduce some of the physical symptoms experienced during a panic attack. We tend to breathe faster when we are anxious, which can make us feel dizzy and lightheaded, which in turn can make us even more anxious. Calm breathing involves taking slow, regular breaths through your nose. However, it is important to realize that the goal of calm breathing is not to stop a panic attack because it’s dangerous, but to make it a little easier to “ride out” the feelings.
For more information, see How to do Calm Breathing.
Key point: If you are using relaxation to help you STOP a panic attack, this is NOT helpful. If you are using relaxation to help you turn down the volume on the feelings (but not avoid them) this IS helpful!
2. Muscle Relaxation: Another helpful strategy involves learning to relax your body. This technique involves tensing various muscles and then relaxing them, to help lower overall tension and stress levels, which can contribute to panic attacks.
For more information, see How to Do Progressive Muscle Relaxation.
Key point: Although it can be helpful to learn to relax, it is important to realize that it is not necessary to control anxiety, because anxiety is not dangerous.
Tool #2: Realistic thinking
The next tool involves learning to identify scary thoughts that can trigger and fuel physical feelings of panic. First, ask yourself what you are afraid will happen if you go out. Examples include: “I will faint,” “I will have a panic attack,” or “I’ll embarrass myself,” To become more aware of your specific fears, try to identify your thoughts (and write them down) whenever you feel anxious or feel an urge to avoid or escape a situation. Repeat this exercise for a week or so.
Thoughts related to agoraphobia can be grouped into two categories:
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Overestimating: This happens when we believe that something that is highly unlikely is about to happen; for example, when we believe that we will faint or die as a result of a panic attack when facing a feared situation. This type of thinking is usually related to physical fears (such as fainting and hurting oneself, having a heart attack, going crazy, or dying).
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Catastrophizing: This is when we imagine the worst possible thing is about to happen and that we will not be able to cope. For example: “I’ll embarrass myself and everyone will laugh” or “I’ll freak out and no one will help.” This type of thinking is often related to social concerns (such as embarrassing oneself).
To help you figure out whether you are overestimating or catastrophizing, ask yourself the following questions:
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What would be so bad about that?
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What would that lead to?
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What would happen then?
Example of overestimating:
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What am I afraid will happen when I go to the grocery? I’ll have a panic attack and won’t be able to breathe.
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What would happen then? I would die.
Example of catastrophizing:
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What am I afraid will happen when I ride the bus? I’ll get very scared.
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What would be so bad about feeling scared? I would get so scared I would pass out.
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What would be so bad about that? Other people would notice.
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What would happen then? They might laugh or think something is seriously wrong with me.
Challenging overestimating:
First, it is important to realize that your thoughts are guesses about what will happen, not actual facts. Next, evaluate the evidence for or against your thoughts. Individuals with agoraphobia often confuse a possibility with a probability (for example, just because it can happen, doesn’t mean that it likely will). Here are some questions to ask yourself:
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How many times have I had this when thinking about going out or being out?
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How many times has it actually happened?
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Next time I have this thought, how likely is it that it will really happen?
It is helpful to realize that some of the things you fear are VERY unlikely to occur. Even though you have had this thought many times, it has not come true.
Example:
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What am I afraid will happen? When I’m at the grocery store, I am afraid that I will have a panic attack and won’t be able to breathe or that I’ll die.
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How many times have I had this thought when I am at the grocery store? A lot!
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How many times has it actually happened? Never. Even when it feels like I am going to die, nothing bad has happened. However, what if THIS is the time it happens?
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How many times have I had that thought? Many times.
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How many times has it actually happened? Never.
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How likely is it that it will really happen? The chances of something bad happen are extremely small. It's important to remind myself of that when I am at the grocery store.
Challenging catastrophizing:
To challenge catastrophic thinking, ask yourself to imagine the worst and then figure out how you would cope. Here are some questions to ask yourself:
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What’s the worst that can happen?
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How bad is it REALLY?
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Is it a hassle or a horror?
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Will it make a difference in my life in a week or year from now?
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What could I do to cope if it did happen?
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Have I been embarrassed in the past? How did it turn out? Did it make a difference?
It is important to understand that some of the things you fear are more of a hassle than a horror, and that there are things you can do to cope with the situation.
Example:
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What am I afraid will happen? I will get sick while on the bus.
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What would be so bad about that? I might throw up and others will notice.
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What’s the worst that could happen? Everyone will look at me. I would be so embarrassed I would just freeze.
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How bad is it really? Well, it would be very embarrassing to “lose it” on the bus.
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Is it a hassle or a horror? It wouldn’t feel very good, but I guess it’s more of a hassle than a major horror.
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Will it make a difference in my life in a week or year from now? In a week people may still remember that I had one, but I may never see them again and in a year from now it’s unlikely that anyone will remember.
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How could I cope if it did happen? I could get off at the next stop and find a place to clean myself up.
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Have I been embarrassed in the past? Yes, I tripped and fell on the bus once.
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How has that turned out? Did it make a difference? I felt uncomfortable for the rest of the bus ride. It didn’t really make a difference in my life. I don’t think anyone remembers.
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So, how bad is it to embarrass myself? It doesn’t feel good, but it’s not that bad.
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You can challenge your worrisome thinking whenever you feel anxious or feel an urge to avoid or escape a situation. Writing it down helps!
For more information on identifying and challenge scary thoughts see Realistic Thinking.
Tool #3: Making coping cards
It can be tough to remember how to challenge scary thoughts when we are anxious. It can help to make up a “coping card” that includes realistic thoughts about panic attacks (e.g., “It’s a hassle, not a horror,” “It won’t last for forever”) that you can carry with you during the day to help manage anxiety. To make a “coping card,” use an index card or a piece of paper, write down your realistic thoughts, and keep it with you (i.e., in your purse, wallet, or pocket). It can be helpful to read this card daily, just as a reminder!
Tool #4: Facing fears
The most important step in managing anxiety is to face what you fear, which includes:
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Avoided situations, places, or activities
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Unpleasant body sensations associated with panic attacks (see My Anxiety Plan for Panic Disorder)
Facing feared places or situations: It will be important for you to start entering situations that you have been avoiding due to anxiety or fear. First, identify feared situations or places (e.g., going places alone, entering crowded stores, riding the bus). Then, arrange the list from the least scary to the most scary. Starting with the situation that causes the least anxiety, repeatedly enter the situation and remain there until your anxiety decreases. Once you can enter that situation without experiencing much anxiety (on numerous occasions), move on to the next thing on the list. Remember, you will experience anxiety when facing fears -this is normal. For more information, see Facing Your Fears – Exposure.
It will also be important to start eliminating various “safety behaviours” and subtle ways you avoid. These behaviours include carrying safety objects (e.g., medication, water, cell phone), sitting near exits, using distraction (as a means to avoid feeling anxious), avoiding certain foods (spicy dishes) or beverages (caffeine or alcohol), constantly seeking reassurance from others, or being accompanied by a trusted companion. First, make a list of your safety behaviours. Second, try to gradually reduce these behaviours, starting with the ones that are easiest to drop.
Step 4: Building on bravery
Learning to manage anxiety takes a lot of hard work. If you are noticing improvements, take some time to give yourself some credit: reward yourself! For example, purchase a special gift for yourself (DVD, CD, book, treat) or engage in a fun activity (rent a movie, go to the movies, go out for lunch or dinner, plan a relaxing evening, watch your favorite television program). Don’t forget the power of positive self-talk (e.g., “I did it!”)
How do you maintain all the progress you’ve made?
Practice! Practice! Practice!
In a way, learning to manage anxiety is a lot like exercise – you need to "keep in shape" and practice your skills regularly. Make them a habit! This is necessary even after you are feeling better and have reached your goals.
Don't be discouraged if you start using old behaviours. This can happen during stressful times or during transitions (for example, starting a new job or moving). This is normal. It just means that you need to start practising using the tools. Remember, coping with anxiety is a lifelong process.
For more information on how to maintain your progress and how to cope with relapses in symptoms, see Learning about Relapse Prevention.
About the author
Anxiety Canada promotes awareness of anxiety disorders and increases access to proven resources. Visit www.anxietycanada.com.
