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.

• 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).

• 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).