Some people with agoraphobia struggle as pandemic wanes
As people start to venture out, Ashley Perkins might be struggling more than most. For years she had been living life relatively large despite her agoraphobia, until pandemic constraints shrank her world to the drive between work and home. "This is by far worse than even before I was diagnosed in 2008," the 38-year-old pharmacist said.
The anxiety disorder, which affects about 1% of U.S. adults and is more common in women, is frequently associated with a fear of leaving the home. But the core issue often is an underlying panic disorder that can first flare in a place seemingly routine, such as the grocery store, said Sally Winston, a clinical psychologist and executive director of the Anxiety and Stress Disorders Institute of Maryland in Towson.
"Agoraphobia is the fear of having a panic attack in a place or situation in which you feel trapped or unable to get to safety," Winston said. That first panic attack with its surge of adrenaline, rapid heartbeat and other symptoms can feel physically overwhelming, "like a traumatic catastrophe," she said, and makes people retreat to a perceived safe space, often their home.
Agoraphobia can't be diagnosed until someone has experienced at least six months of symptoms, severe enough to affect daily life. So, it's too soon to know whether the ongoing pandemic has amplified rates of the anxiety disorder, mental health clinicians say. But some worry that months of limited exposure to the rigors of daily commutes, crowded malls and other activities might have seeded new cases, as well as worsened symptoms in those individuals already diagnosed.
Nine months into the pandemic, clinical psychologist Karen Cassiday started seeing patients who had been coping well with the disorder for a decade or longer. "They were saying, `I'm scared to drive. I'm scared to go into a big box store, or even go in a store where I can't get out quickly. I'm afraid to go to the dentist or get my hair done,' " said Cassiday, who treats patients with anxiety disorders in the Chicago area.
"Or I had people calling and saying, 'I just need to talk with you because I'm white knuckling my way through things that I could do before the pandemic.' " Also, she said: "People who never had agoraphobia were coming in, and they've got it."
But Winston, who hasn't noticed a similar uptick in new cases among her adult patients, is dubious.
"Somebody who does not have that genetic predisposition, it would be highly unlikely," she said. Agoraphobia runs in families, she said. Also, someone can inherit a trait called anxiety sensitivity, which is the fear of arousal, that can be part of agoraphobia, Winston said.
That doesn't mean that people might not have settled into new patterns and routines that might prove challenging to break, Winston said.
"To get out of them, yes, there's some discomfort, some distress and certainly anticipatory anxiety," she said. "But that's within a normal realm - it's not the disorder agoraphobia."
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The risk of developing agoraphobia should in theory increase with any stressor, "particularly a stressor that threatens one's personal health and safety," said Steven Taylor, a clinical psychologist and professor in the psychiatry department at the University of British Columbia in Vancouver who wrote, "The Psychology of Pandemics." But it will take years to know if rates have changed in the wake of the pandemic, he said.
"The challenge," he said, "is it is very difficult to assess agoraphobia in a situation where whole communities are told to stay inside, they are told that there is some risk for doing outside activities, and they are told to make their home environments as comfortable as possible for the duration of lockdown."
The pandemic has accelerated people's tendency to cocoon, complicating efforts to sort out the agoraphobics from the homebodies, Taylor said. "You're creating a pleasure palace," he said. "You've got your Netflix, you've got everything delivered to you, the food is delivered. You don't need to go outside."
While anxiety disorders tend to run in families, there's also an element of learned behaviors related to agoraphobia that can date back to childhood, Cassiday said. As part of developmental growth, one must learn to face one's fears and anxieties, whether that's battling nerves through a play audition or the discomfort of asking someone out, she said.
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Over the past two years, people have been more likely to avoid some locations or activities to reduce their viral risk, Cassiday said. "So we know that for anyone with an anxiety disorder, that if you are not living what I call an exposure-based lifestyle or a face-your-fear lifestyle, that you increase the risk that something is going to become a fear, an anxiety problem for you," she said.
As one example, Cassiday said she has noticed a deep-rooted aversion among some patients to returning to in-person work.
"They are justifying it by saying, `Why should I waste that time commuting?' " she said. "But really, it's that, 'I'm afraid to be away from home, to be on the expressway, to be where I feel trapped and can't get to my safe comfort zone.' "
Agoraphobia, which may include panic attacks, involves elevated and persistent fear about at least two of the following situations, according to the latest diagnostic criteria. They include public transportation; open spaces such as a marketplace; enclosed spaces such as a store; standing in line or being in a crowd; being alone outside the home.
If someone is worried that their heightened anxieties might meet diagnostic criteria, one question to consider is whether their fears are irrational, said Priscilla Dass-Brailsford, a professor of psychology at Georgetown University in Washington. But answering that question, she added, is not easy given the ongoing risk of contracting the coronavirus, particularly for those at greater health risk.
Other questions to weigh, Dass-Brailsford said, are: How do my behaviors interfere with my daily functioning? Have other people commented on my behavior?
Perkins sought help in 2008 after someone pointed out that people "don't normally avoid crowds like the plague like you do." Her anxiety improved with medication and therapy, including forays out to challenge herself. "I hated every minute of it," she said with a laugh. Shortly after her diagnosis, Perkins said, her therapist "made me go to the mall on a Saturday."
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Even those individuals who have not been diagnosed with the anxiety disorder should start pushing against their personal comfort boundaries, if they notice that they have developed new avoidance tendencies during the pandemic, Cassiday said.
If driving on the freeway provokes more anxiety than it used to, she suggested driving a few exits farther. If crowded restaurants have become a new stressor, try sitting a table or so away from the door, and then even farther into the room the next time, she said.
"What you're trying to teach yourself is that my body doesn't have to be afraid, and my mind doesn't have to be afraid - it's just an unpleasant sensation," Cassiday said. If someone can successfully push back against those avoidance patterns over time, they probably will not need to seek treatment, she said.
Perkins, who had been able to board crowded planes and eat in restaurants before March 2020, found it frustrating to watch her hard-fought gains slip. In late 2020, she became further isolated when she moved with her husband and young son from Huntington, W.Va., to a suburb of Jacksonville, Fla.
When she decided to fly to Boston last fall to pick up an award, she struggled, successfully, to avert a full-blown panic attack as people piled up in the security line. "I had my arms wrapped around me," she said. "I'm literally just rocking."
But this spring, Perkins resolved to expand her daily scope: "I want to go back out. I'm getting there."
In March, she met a small group of women at a restaurant, and soon, Perkins has plans to board a plane again, to attend a graduation back in West Virginia.
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