4 Signs Your Panic Attacks Aren't Just Standard Anxiety — They're Symptoms Of Agoraphobia
The differences are subtle and often misunderstood.
Ursula Ferrara / Shutterstock I experienced the first of what became recurring anxiety attacks in 2013, but I wasn’t given the diagnosis of panic disorder with agoraphobia until 2017.
In those four years, my life became increasingly narrowed by fear, until it reached the point at which I was no longer able to drive on freeways or in the left lane, fly, take elevators, or go to the grocery store.
What is agoraphobia?
The Diagnostic and Statistical Manual of Mental Health Disorders (DSM 5), classifies this condition as an anxiety disorder, more specifically, "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 [and/or] being outside the home alone."
To be diagnosed as agoraphobic, the following criteria must also be met:
- The situations are avoided (e.g., travel is restricted) or else are endured with marked distress or with anxiety about having a panic attack or panic-like symptoms, or require the presence of a companion.
- The agoraphobic situations almost always provoke fear or anxiety.
- The fear or anxiety is out of proportion to the actual danger posed by the agoraphobic situations and to the sociocultural context.
- The fear, anxiety, or avoidance is persistent, typically lasting 6 months or more.
- The fear, anxiety, or avoidance causes clinically significant distress or impairment in important areas of functioning.
- The anxiety or phobic avoidance is not better accounted for by another mental disorder.
As explained in Very Well Mind, "Agoraphobia is often misunderstood to be simply a fear of leaving home, however, this is not quite accurate. Agoraphobia is a phobia of being in a situation where escape would be difficult or impossible, or help would be unavailable if a panic attack should occur."
Even after I was diagnosed with agoraphobia, I had a hard time believing it. I didn't know anyone else who had this disorder, and I could barely find any information on it.
Research on the prevalence of anxiety disorders has found that somewhere between 0.8 to 2.6 percent of people in the U.S. will experience agoraphobia at some point in their lives, with 20 being the median age of onset for agoraphobia without panic attacks, and women are about twice as likely to be diagnosed with the condition than men.
I was around that age when I first began struggling with the condition. Due to the fact that I was diagnosed with a generalized anxiety disorder at the age of 11, however, I attributed my newly developed panic attacks to a lifetime of anxiety.
But agoraphobia is rarely an isolated condition.
In fact, while agoraphobia can be diagnosed with or without panic disorder, more than 95 percent of people who seek help are also diagnosed with panic disorder, and studies show rates of comorbidity — the existence of two or more illnesses or disorders in one person — with social anxiety disorder and major depression as well.
What causes agoraphobia?
Some of it has to do with biology.
According to the Mayo Clinic, certain individuals are more likely to develop the condition, such as those who:
- Have been diagnosed with panic disorder or other phobias
- Respond to panic attacks with excessive fear and avoidance
- Have experienced stressful life events, such as abuse, the death of a parent, or being attacked
- Have an anxious or nervous temperament
- Have a blood relative with agoraphobia
Additionally, there appears to be a high correlation between agoraphobia and substance dependence, with a history of substance abuse predating the onset of agoraphobia in the majority of cases.
As for myself, I developed agoraphobia after both of my parents were diagnosed with stage 3 cancer.
Unfortunately, agoraphobia can go undiagnosed for a long time due to the nature of the condition, as people with agoraphobia may avoid everything from cars to doctors’ offices, making it even harder to get to the root of the issues.
That certainly happened to me. I put off my doing what was necessary to receive a diagnosis for years until my symptoms became unmanageable.
In some ways, it feels like I lost years of my life.
I don’t want that to happen to others, so I decided to talk with experts and others who deal with agoraphobia in an attempt to develop a layman's list of common, easy-to-overlook signs and symptoms — something I wish I had read back in 2013.
Important note: The symptoms of a panic disorder or agoraphobia may mimic those of other anxiety disorders and/or medical issues. Only your physician or a qualified mental health professional can diagnose you or anyone else with this or any other condition.
If you're struggling with any of the following four symptoms, know that you are not alone and you can get help.
1. Panic attacks are controlling your life.
As mentioned above, people who are diagnosed with agoraphobia are typically also diagnosed with panic disorder, a condition involving recurrent and unexpected panic attacks, defined as "a sudden episode of intense fear that triggers severe physical reactions when there is no real danger or apparent cause."
When a person has a panic disorder with agoraphobia, they avoid specific situations because they’re afraid they’ll have a panic attack.
One young woman I spoke with, Emily*, age 27, can relate to this.
She was in her second half of college when she was accepted into an animation program. Due to the workload and a decline in her mental health, she withdrew from school and had a nervous breakdown. She’s now on the Ontario Disability Support Program, which provides financial aid to people with disabilities.
“I feel a mixture of gratitude and deep shame and embarrassment about this,” she says. “I’ve heard and seen cruel remarks online about people on disability or welfare, and I think from being in this position, I have a lot more empathy for people in the same boat.”
Todd Farchione, Ph.D., Associate Director, Unified Treatment Program and Director, Intensive Program of the Center for Anxiety and Related Disorders at Boston University explained to me that avoiding certain triggers, such as driving on the freeway or standing in line, may provide temporary relief for an individual, it can eventually form a pattern that dominates a person’s life.
“It’s really about avoidance and patterns of avoidance that is an emotional regulation strategy for people with anxiety disorders,” he says.
Farchione works with people to unlearn avoidance behaviors in cognitive behavioral therapy (CBT), where patients are slowly exposed to their triggers.
I personally went through this CBT in 2017, and it worked wonders. While the fear of certain situations may never completely dissolve, CBT teaches patients it’s okay to feel fear.
“They can feel physical symptoms, they can feel the panic response and know that nothing bad will happen,” Farchione said.
2. You find yourself steering clear of specific situations.
The term agoraphobia comes from the Ancient Greek words agora (ἀγορά, agorá), which roughly translates to "place of assembly, marketplace", and phobia (φόβος, phóbos), which means "fear" — so agoraphobia literally means a fear of the marketplace.
For certain people with agoraphobia, this rings particularly true.
When my agoraphobia was at its worst, I would have massive panic attacks while standing in line, especially at the grocery store. One day, I was waiting in line at my local Walgreens when I had a panic attack that was so severe, that I crawled into the fetal position on the floor. This was one of the most embarrassing moments of my life, even though I clearly needed help.
People with agoraphobia may avoid expansive spaces such as parking lots, or enclosed spaces such as theaters or shops. For some, this can impact their ability to work.
Emily tried working in customer service, but she experienced such significant anxiety, that she couldn’t work efficiently.
“I can't work anywhere I’m likely to run into people, which triggers panic attacks,” she says. “I’ve done work as a janitor cleaning the town hall washrooms, which I actually loved doing because it gave me a sense of purpose, and I was always completely alone.”
3. Transportation is super stressful.
Raven, 26, started experiencing symptoms of agoraphobia about five months ago. When she was recently diagnosed, her therapist attributed her development of the disorder, along with co-occurring depression and anxiety, to significant life changes and weight gain.
While Raven is doing significantly better since her diagnosis, she still struggles with driving. In fact, one of the most common symptoms of agoraphobia is fear and avoidance of transportation, such as cars, buses, trains, ships, and planes.
“It’s been really stressful. I haven’t been able to drive myself anywhere,” she explains. “Luckily, I’ve been able to go to work and come home every day.”
At its most severe, agoraphobia renders people unable to leave their homes.
As someone who has worked with countless patients dealing with agoraphobia, Alison Alden, Ph.D., a clinical psychologist at the Anxiety Treatment Center of Greater Chicago, notes that while this extreme example of becoming house-bound due to agoraphobia is excruciating for patients, it’s not the norm.
“The media paints it that if you have agoraphobia, you’re a shut-in and unable to leave the house,” she says. However, she continues, “it’s such a small percentage of people with agoraphobia who are housebound. I treat hundreds of cases of panic disorder and agoraphobia every year, and almost none of them require me to go meet a patient at their house.”
In fact, this misconception can lead to someone going undiagnosed.
When I was trying to figure out what was wrong with me, I thought agoraphobia meant you were unable to leave the house, but I could. Because of that, I avoided seeing a therapist for years, thinking my case was not severe enough.
4. You’re getting treatment for a different condition, but nothing’s working.
Kate, 23, struggled with panic attacks in 2014 and 2015, but they completely stopped in the summer of 2015. Then, after quitting school and dealing with significant family stress in 2018, the symptoms started creeping back into her life.
“I was looking for a job and getting invited to interviews, but I started having panic attacks more regularly, making it impossible to work 9 a.m. to 5 p.m.,” she says.
She was initially diagnosed with Hashimoto’s thyroiditis (sometimes also called Hashimoto's Disease), a condition in which your body's immune system attacks your thyroid, causing a range of symptoms that may include anxiety and depression. She was prescribed medication and told her panic attacks would stop eventually.
“I believed [the doctors] and thought my panic attacks were thyroid symptoms. I never saw a therapist because why would I?” she explains. “Fast forward nearly a year later, my thyroid levels are fine again but the anxiety stuck.”
When she realized her anxiety wasn’t getting better, she started working with a therapist who eventually diagnosed her with agoraphobia. She is still receiving treatment for her Hashimoto’s under the care of a physician, but now she knows that she needs more than just a regulated thyroid to recover from her panic attacks. She hopes that she can start working again next January.
“I’m slowly fighting my way back,” she shares. “The anxiety is still there, but I changed a lot of my habits, and I can see at least some progress.”
These days, I’m in the same boat as Kate.
I can drive on the freeway, stand in line and take elevators without a panic attack derailing me. Sometimes I struggle with freeway driving, but I’ve learned coping mechanisms such as deep breathing to push through it.
I also don’t want agoraphobia to get the better of me. I’ve dealt with it for six and a half years, and I refuse to let it dominate the rest of my life.
Whenever I feel like I’m too scared to do something, I repeat a mantra from research professor and author Brené Brown: “Courage over comfort.”
I’ll keep repeating that to myself for as long as it takes.
*Some names have been changed for privacy.
Bonnie Horgos is a freelance writer who writes about feminism, LGBTQ issues, gender-based violence, health, and wellness. For more, visit her website.