The COVID-19 pandemic may have prompted some people who had their agoraphobia under control to backslide.
Certain tools that helped us work around the pandemic, such as telehealth visits and remote work, may actually be contributing to the problem now that vaccines, boosters, and widely available masks have made a return to normal behaviors safer.
Clinicians can watch for agoraphobia warning signs and refer patients to mental health providers when appropriate.
With the onset of the COVID-19 pandemic, social distancing became a norm. But for some, this period of isolation marked the beginning of a new or revived struggle with agoraphobia—one that persists despite widespread mask availability and the advent of vaccines and boosters.
Anxiety and panic disorder experts suggest that agoraphobia is another aspect of the burgeoning mental healthcare crisis stemming from the COVID-19 pandemic.
MDLinx spoke to two clinicians with extensive experience in treating agoraphobia and panic disorders. Karen Cassiday, PhD, is a clinical psychologist and managing director of the Anxiety Treatment Center of Greater Chicago. Brenda Wiederhold, PhD, is a clinical psychologist and co-founder of the Virtual Reality Medical Center.
Both clinicians felt that the pandemic had a rekindling effect for patients who previously had their agoraphobia under control. Social distancing, while justified, enabled these patients to fall back on old behaviors they were reluctant to relinquish after vaccines and boosters made normal activities safer.
"I had patients I hadn’t seen for years calling me and saying, ‘I can’t drive anymore,’ or ‘I can’t use public transportation,’ or ‘I’m having a really hard time getting my kids to school.'"
— Karen Cassiday, PhD
“I’ve been hearing this from colleagues across the country and around the world. We’re seeing greater severity because people have been allowed to hide for so long," Dr. Cassiday added.
‘I don’t need to leave my home’
Things like remote work, telemedicine, and food delivery services may have gotten us through the challenging early days of the pandemic, but according to Dr. Wiederhold, these tools are double-edged swords.
"If you have that anxiety and have that avoidance already, it just enables you to say, ‘I don’t need to leave my home. I don’t need to go into the office, or leave for meetings. I can do everything online.’"
— Brenda Wiederhold, PhD
Dr. Wiederhold added that secondary effects of the pandemic are increasing agoraphobia difficulties. “Other people had maybe subclinical anxiety,” she said. “Then with all the other compounding anxieties of COVID, of the economy, of the war, they said, ‘I can’t do this. I need some help.’”
How can we best help these patients? It starts with a more nuanced understanding of agoraphobia.
“Agoraphobia is what happens when someone is avoiding something for fear of getting a panic attack,” Dr. Cassiday said. “They’re making a spurious correlation between a situation internal or external.”
For example, a person may be afraid of exercising because their accelerated heart rate and sweating could trigger a panic attack, so they avoid the gym. Being in an inescapable location, such as an airborne plane or crowded elevator, could trigger the same feelings of anxiety, prompting a person to avoid both.
But locations don’t need to be crowded to trigger a panic attack for someone with agoraphobia. They could experience fear and anxiety about being on a wide-open mountain range where help can’t reach them, for example.
DSM 5 puts agoraphobia in the Anxiety Disorders diagnostic class. Diagnostic criteria require feelings of fear or anxiety about two or more of these situations:
Being out of one’s home alone
Riding on public transportation
Being in a crowd or standing in line
Being in open spaces
Being in enclosed spaces, such as theaters or stores
These situations will nearly always cause fear or anxiety for people with agoraphobia, and those emotions will be disproportionate to the actual danger inherent to the situations. People experiencing these symptoms will avoid the aforementioned situations, or endure them with great stress and anxiety about having a panic attack.
An agoraphobia diagnosis requires that these negative emotions or avoidance of these scenarios last for 6 months or more, and that the emotions cause distress that’s clinically significant or impairs vital areas of functioning.
Teaching patients coping skills
Drs. Cassiday and Weiderhold said that assisting patients with COVID-related agoraphobia begins with identifying it. Pandemic-related indicators include:
Avoidance of in-person visits regardless of vaccination status
Multiple questions that seek reassurance about the safety of certain behaviors, such as going to the store
Unjustifiable requests for medical letters excusing patients from in-person work or education
All may be signs that a mental-health referral is appropriate.
Exposure therapy is the gold standard for teaching patients with agoraphobia the coping skills they need.
Mental healthcare providers will often pair this with cognitive behavior therapy, which teaches patients to more rationally evaluate thoughts and emotions that arise from agoraphobia-prompting scenarios.
Dr. Weiderhold also incorporates biofeedback training, which teaches patients to control their breathing and heart rate, building familiarity with what relaxation and stress feel like and helping patients physiologically control these emotions. She pairs this with in-office virtual reality simulations of agoraphobia-provoking scenarios, such as jet takeoffs or crowded subways.
Dr. Cassiday has also seen success with interoceptive exposure, during which patients use guided hyperventilation to simulate the physiology and sensations of a panic attack. Through this controlled exposure, patients realize they can handle the situation.
Ultimately, the interventions are about teaching patients that agoraphobia does not need to control them.
“The thing it takes to have a panic attack is to misperceive the situation as alarming, to believe those alarm signals,” Dr. Cassiday said.
"The whole purpose of that exposure practice is to teach someone, ‘I don't have to misperceive it.’"
— Karen Cassiday, PhD
What this means for you
While remote work, telehealth visits, and food and grocery delivery were indispensable tools in April 2020, in 2022 they may be serving as crutches or limiting behaviors for some people with agoraphobia. Mental health referrals may be appropriate for patients who continue to limit or modify their lifestyles despite the absence of justifiable medical conditions.