Agoraphobia: A Care Staff Guide to Fear of Leaving Safe Places

Agoraphobia is often described as a fear of open spaces, but that is only part of the picture. For many people it is a fear of being somewhere they cannot easily escape from, or where help would not be available if something went wrong. It can shrink a person's world until leaving the house, travelling or even sitting in a busy room feels impossible. Care staff who understand it can help people take small steps back towards the life they want.

What is agoraphobia?

The NHS defines agoraphobia as a fear of being in situations where escape might be difficult or help might not be available if things go wrong. It is more complex than a simple fear of open spaces. People may avoid public transport, shopping centres or leaving home. Some will only go out with a friend or partner, and some arrange for others to shop for them or order groceries online.

The link with panic

The NHS explains that agoraphobia can develop as a complication of panic disorder. A person may link panic attacks to the places where they happened and then avoid those places. Some people with agoraphobia have never had a panic attack, and their fear may instead relate to crime, terrorism, illness or accidents. In stressful situations a person may experience a racing heartbeat, fast breathing, feeling hot and sweaty, and nausea. Our guide to generalised anxiety and panic disorder explains panic in more detail, and our guide to social anxiety disorder covers a related condition where avoidance is driven by fear of judgement.

How it shows up in care settings

• Declining to leave a room, a floor or the building, or only going out with a trusted person.
• Cancelling appointments, outings or family visits at short notice.
• Becoming distressed on transport, in lifts, in queues or in crowded areas.
• Needing a clear exit or a seat near the door.
• Relying on others for shopping, banking or collecting medicines.

These behaviours can be mistaken for reluctance, stubbornness or low motivation. Asking gently what the person fears, and what they are worried might happen, gives a much clearer picture.

What the NHS recommends

The NHS describes a stepped approach to treating agoraphobia and any underlying panic disorder. The first step is learning about the condition, making lifestyle changes and trying self-help techniques. The second is a guided self-help programme, in which a person works through a CBT-based workbook or computer course with a therapist's support. The third is more intensive treatment, such as cognitive behavioural therapy (CBT) or medicine.

CBT targets unrealistic thinking, such as believing that a panic attack will be fatal, and replaces it with more accurate thoughts. It is usually combined with exposure therapy, which starts with modest goals such as visiting a local shop and builds up to harder ones such as eating in a busy restaurant. The NHS says a course typically runs for 12 to 15 weekly sessions of about an hour. Applied relaxation, which teaches people to recognise tension and relax their muscles, is another option. Medicines may also be used, usually an SSRI, and the NHS notes that stopping should be gradual, under the GP's guidance.

Self-help during a panic attack

The NHS suggests staying where you are, focusing on something non-threatening, breathing slowly and deeply, challenging fears, using calming mental images and not fighting the attack. Lifestyle measures include regular exercise, a healthy diet, avoiding drugs and alcohol, and cutting out caffeine. Staff can help by staying calm, speaking slowly, and reminding the person that panic passes.

Supporting someone day to day

• Do not force or rush. Pushing a person into a feared situation can increase fear. Therapy builds exposure in planned steps.
• Support the plan. If the person is doing exposure work with a therapist, ask how you can help between sessions.
• Offer choices. Let them choose a seat, route or time of day that feels safer.
• Celebrate small steps. Reaching the garden, the shop or the corner of the street is progress.
• Avoid doing everything for them. Taking over shopping or errands can reinforce avoidance, so agree with the person what support is helpful.

Getting help

The NHS advises seeing a GP if you think agoraphobia is affecting you, and notes that a telephone appointment may be possible. People can also refer themselves directly to NHS talking therapies, such as CBT, without seeing a GP. Children and young people under 18 have separate mental health support routes.

Supporting staff learning

Anxiety conditions are common and often hidden. Learnsignal's CPD library offers learning options for care and healthcare teams who want to build confidence in mental health support.

Frequently asked questions

Is agoraphobia just a fear of open spaces? No. According to the NHS it is a fear of situations where escape might be difficult or help unavailable.

Can it happen without panic attacks? Yes. The NHS says some people have never had a panic attack and instead fear crime, terrorism, illness or accidents.

What treatment helps? A stepped approach of self-help, guided self-help and CBT with exposure, sometimes with medicine.