Agoraphobia is intense anxiety and/or avoidance of situations (eg, being in crowds or shopping malls, driving) that may be difficult to leave or in which help is not readily available if incapacitating panic-like symptoms were to develop. Diagnosis is based on clinical criteria. Treatment focuses on cognitive-behavioral therapy, specifically, exposure therapy.
(See also Overview of Anxiety Disorders.)
Agoraphobia is a common consequence of panic disorder, but the 2 disorders can also develop independently.
Agoraphobia affects about 2% of the population in a given year and is more common in women (1). Agoraphobia often develops in adolescence and young adulthood, but it can also develop in older adults, especially in the context of fears about safety and their own physical limitations.
General reference
1. Roest AM, de Vries YA, Lim CCW, et al: A comparison of DSM-5 and DSM-IV agoraphobia in the World Mental Health Surveys. Depress Anxiety36(6):499-510, 2019. doi: 10.1002/da.22885
Symptoms and Signs of Agoraphobia
Common examples of situations or places that create fear and anxiety in patients with agoraphobia include leaving home, standing in line, sitting in the middle of a long row in a theater or classroom, and using public transportation, such as a bus or an airplane. Some people develop agoraphobia in response to panic attacks that lead to avoidance of the potential triggers of the panic. Agoraphobia can be relatively mild but can also become so debilitating that the person becomes essentially housebound.
As is true for other anxiety disorders, symptoms of agoraphobia may wax and wane in severity.
Diagnosis of Agoraphobia
Diagnostic and Statistical Manual of Mental Disorders, 5th edition, Text Revision (DSM-5-TR) criteria
To meet the DSM-5-TR criteria for agoraphobia, patients must have marked, persistent (≥ 6 months) fear of or anxiety about 2 or more of the following situations (1):
Using public transportation
Being in open spaces (eg, parking lot, marketplace)
Being in an enclosed place (eg, shop, theater)
Standing in line or being in a crowd
Being alone outside the home
Fear must involve thoughts that escape from the situation might be difficult or that patients would receive no help if they became incapacitated by fear or a panic attack. In addition, all of the following should be present:
The same situations nearly always trigger fear or anxiety.
Patients actively avoid the situation and/or require the presence of a companion.
The fear or anxiety is out of proportion to the actual threat (taking into account sociocultural norms).
The fear, anxiety, and/or avoidance cause significant distress or significantly impair social or occupational functioning.
If another medical condition (eg, inflammatory bowel disease, Parkinson disease) is present, the fear, anxiety, and/or avoidance are clearly excessive.
In addition, the fear and anxiety cannot be better characterized as a different mental disorder (eg, social anxiety disorder, body dysmorphic disorder).
Diagnosis reference
1. Diagnostic and Statistical Manual of Mental Disorders, 5th edition, Text Revision DSM-5-TR. American Psychiatric Association Publishing, Washington, DC, pp 246-250.
Treatment of Agoraphobia
Cognitive-behavioral therapy (CBT)
Exposure therapy
Selective serotonin reuptake inhibitors (SSRI)
The most effective treatment approach, based on the most robust evidence, is exposure therapy that uses CBT principles (1). Agoraphobia may resolve without formal treatment, possibly because some affected people conduct their own form of exposure therapy and also because anxiety symptoms (and precipitating stressors) fluctuate with time.
Many patients with agoraphobia also benefit from pharmacotherapy with an SSRI (2).
Treatment references
1. Carpenter JK, Andrews LA, Witcraft SM, et al: Cognitive behavioral therapy for anxiety and related disorders: A meta-analysis of randomized placebo-controlled trials. Depress Anxiety 35(6):502-514, 2018. doi: 10.1002/da.22728
2. Chawla N, Anothaisintawee T, Charoenrungrueangchai K, et al: Drug treatment for panic disorder with or without agoraphobia: Systematic review and network meta-analysis of randomised controlled trials. BMJ 376:e066084, 2022. doi: 10.1136/bmj-2021-066084
