AKRON, Ohio – Most of us have experienced a healthy dose of anxiety over the past year about leaving home and risking exposure to the deadly coronavirus. But for some of us, the anxiety is developing into a potentially long-lasting and debilitating disorder.
The disorder is known as agoraphobia and, in cases brought on by the pandemic, involves an inability to distinguish between the rational fear of the virus and an irrational fear of venturing out. And psychologists expect to see more cases in the coming months, with women and young adults most susceptible.
“It would be highly understandable if the symptomatology went up as we open our doors and get more comfortable, moving outside and getting more into the square, into the agora,” said Charles Waehler, professor of counseling psychology at the University of Akron.
Cleveland.com and The Plain Dealer reached out to Waehler, and Dr. Scott Bea, clinical psychologist at the Cleveland Clinic, to answer questions posed by our readers. As more people are vaccinated and the pandemic subsides, will agoraphobia be more common? How can you distinguish rational fear of the virus and irrational anxieties? What should you do if you’re experiencing symptoms of agoraphobia?
Here is what we learned:
First, a brief primer on agoraphobia.
The disorder typically involves the anticipation of being away from home or in a particular situation, a crowded place or stuck in traffic, that results in a disabling fear of becoming trapped or embarrassed.
To be diagnosed with agoraphobia – a term coined for a fear of the agora, or the Greek marketplace – a patient has to have consistent symptoms for at least six months, Waehler said. Those symptoms can include panic attacks, intense fear or anxiety around situations including using public transportation, being in open spaces, being in enclosed spaces, standing in lines or crowds and being outside your home alone, according to the Diagnostic and Statistical Manual of Mental Disorders.
There’s a strong genetic component to agoraphobia, so people are more likely to be diagnosed if they have a relative with the disorder, Waehler said. It’s also more common among women. The most severe and debilitating cases of agoraphobia – when people can’t leave their homes – are about 80 to 90% women.
Most agoraphobia develops when people are in their 20s and 30s, which Waehler attributed to older people having a deeper pool of lived experience to draw from, which allows them to know that a certain anxiety-producing situation was safe or acceptable before, so it might be again.
Distinguishing between the rational fear of the virus and irrational anxiety can prove difficult, and could cause feelings of agoraphobia.
Some amount of anxiety is good because it “keep us safe and it keeps us smart,” Waehler said.
“We look both ways when we cross the street because we’re afraid we’re going to get hit by a car. That’s a good thing,” he said. “I tell my students, what do we call somebody who has no anxiety? We call him dead. We need a little bit of anxiety.”
And with the pandemic, it’s good for people to have some fear of the virus if it means they wear a mask, wash their hands and practice social distancing.
“But there is a certain number of the population who are going to spin out of control, that their anxiety is going to get the best of them and they’re going to go to very negative places,” Waehler said.
Bea described the beginning of the pandemic, when we didn’t know much about the virus and grocery shopping was suddenly a major event. Most of us put on a mask and gloves, maybe a face shield too, and were constantly sanitizing before the main event of wiping down our groceries with disinfectant.
“I remember feeling tense in that, as though it were a military operation,” Bea said. “As we’ve gotten further into the pandemic, people did habituate… That’s what human brains do pretty routinely: we start to get used to uncomfortable situations that we’re exposed to. And I think some people, unfortunately, let their guards down in response to that. But that was happening all along.”
Most of us are now at ease when it comes to putting away groceries because we know more about how the virus spreads from person to person. This knowledge allows us to be safe and a little bit of anxiety can keep us on our toes. But it can sometimes go too far and make us irrationally afraid of certain situations and the unpredictability in going somewhere.
“A lot of anxiety is an anticipation of a future that we can’t see and that produces a reflex or different sensation in our body,” Bea said. “A lot of anxiety is a result of a thinking experience. It’s not the thing itself – it’s the thoughts about the thing. Even with the virus: it’s not the virus itself, it’s the thoughts about the virus that are producing a lot of our tension.”
Waehler predicts that symptoms of agoraphobia will lessen for many people over time as they have new experiences and become more comfortable with encountering the world outside their home.
“I would anticipate for people who didn’t have agoraphobia before, or different phobias, is that they’ll get back to their natural state much more quickly than people who might be on the upswing and developing it at a younger age,” Waehler said.
People might experience symptoms of agoraphobia, but actually be suffering from “COVID anxiety.”
Fear of the coronavirus could more accurately be described as “COVID anxiety” rather than agoraphobia. Although people with agoraphobia may fear a crowded grocery store or leaving their home, they don’t feel that way because of anxiety over a virus.
COVID anxiety, while not an official diagnosis, is a term psychologists are using to describe anxiety surrounding the virus and pandemic. Many people have experienced COVID anxiety to a degree, and some have seriously struggled.
A recent report from the American Psychological Association includes a statistical analysis of how anxiety and other mental-health problems worsened as a result of the pandemic.
“Even people that weren’t anxious before, experienced COVID anxiety,” Bea said. “And, obviously, I think we still do that. I think people have some encouragement with the vaccine, but anxiety still remains pretty high, and we’ve probably developed some habit toward anxiety in our culture.”
After a year of evolving health guidelines and advisories, including orders encouraging people to “stay at home,” some people may have developed anxieties around certain situations because of the pandemic. Bea said it’s likely that this COVID anxiety will be difficult for some as reopenings and a return to normalcy continue.
Bea said some of his patients, including those with obsessive compulsive disorder (OCD) and illness anxiety disorder, were really challenged by the pandemic and “developed elements” of agoraphobia.
“They didn’t want to go out,” Bea said. “It wasn’t that they were feeling being trapped. It wasn’t that element, and you couldn’t really diagnose this as traditional agoraphobia, but they just didn’t want to go encounter the world.”
What to do if you’re experiencing COVID anxiety or symptoms of agoraphobia:
Anyone struggling with their mental health should consider seeking professional help. Phobias are very treatable, Waehler said, so clinicians and other professionals are able to work with individuals experiencing symptoms of agoraphobia. Some psychiatrists may prescribe anti-anxiety medications.
The standard treatment for agoraphobia, and many phobias, is exposure therapy that allows patients to familiarize themselves with experiences and eventually become more comfortable. That allows them to associate positive feelings with the fear, rather than negative, Waehler said. So, try to get away from your safe zone and slowly put yourself into uncomfortable situations.
Bea encourages his patients to be courageous and challenge themselves to “break free of barriers in a graded way.”
If someone is afraid of being a certain distance from their house, or in a certain condition such as a crowded place, they select destinations that could push the patient’s comfort level. The patient travels there and rates their discomfort on a scale of 0 to 100, ranging from completely relaxed to unbearable tension. Then, the patient stays at that distance or in that circumstance until at least half their tension diminished by staying in that condition.
“The brain starts to learn an emotional lesson and responds with less distress in those conditions,” Bea said.
Bea and Waehler each said it’s important for people to become familiar with their anxiety and how it feels, rather than gravitating toward avoiding those feelings.
“When people avoid,” Bea said, “their tension is reduced immediately, and our brains love that. What people really want to do is to be able to go out or venture outside their safety zone or into these places feeling comfortable or at low-tension. That’s probably not going to happen.”
There’s been a lot of “avoiding” since the pandemic began, Bea said – avoiding going into a physical workplace, avoiding going out to get food. And we are just going to have to put in some work and challenge out brains to be comfortable with some anxiety, rather than avoiding it.
“We have gotten in some really interesting new habits,” Bea said. “They say it takes about 66 days to create new habits. We have all created new habits. Going back to the stuff we used to do, that might actually produce some challenge. Being more freely about in the world is something people want to do, but it might be a little harder than they anticipate because it hasn’t been our habit for a while.”
People unable or unwilling to work with a therapist should consider confiding in a friend and asking for their help in getting out of their comfort zone. Waehler said it’s good if “you have somebody who can be a thoughtful guide and ally with you and have some empathy for what you’re going through… to figuratively hold your hand as you go through that experience.”