Fear or avoidance of ≥2 of 5 situations (transit, open spaces, enclosed spaces, crowds, outside home alone) due to fear of escape difficulty or incapacitation.
Also known as: agoraphobia
Overview
DSM-5-TR: marked fear or anxiety about being in ≥2 of 5 specific situations — (1) using public transportation, (2) being in open spaces (parking lots, bridges), (3) being in enclosed places (stores, theaters), (4) standing in line or being in a crowd, (5) being outside the home alone. The person fears that escape may be difficult or help unavailable in the event of incapacitating or embarrassing symptoms (e.g., panic, falling, incontinence). Situations almost always provoke fear, are avoided or endured with distress or require a companion, persist ≥6 months with impairment. Now a standalone diagnosis (separate from panic disorder).
Epidemiology
12-month US prevalence ~1.7% in adolescents and adults; lifetime ~1-2%. Female predominance ~2:1. Bimodal onset: late adolescence/early adulthood and after age 40.
Try two board-style Agoraphobia questions
Real questions from the FirstPassPA bank, with the full explanation. Pick an answer — no signup, no email.
Question 1PsychiatryMedium
A 34-year-old woman reports that over the past 9 months she has progressively avoided riding the city bus, shopping in crowded grocery stores, and waiting in checkout lines. She fears that if she becomes dizzy or panicky in these places she will be trapped and unable to get help, so she now only leaves home when her sister can come with her and sit near an exit. She denies any concern about being judged or embarrassing herself socially. A prior workup including ECG, TSH, and orthostatic vitals was unremarkable. Which of the following is the most likely diagnosis?
AIllness anxiety disorder
BSpecific phobia, situational type
CSeparation anxiety disorder
DAgoraphobia
Reveal answer & full explanation
Correct answer: D — Agoraphobia
AIllness anxiety disorder
BSpecific phobia, situational type
CSeparation anxiety disorder
DAgoraphobia✓
Why Agoraphobia is correct
DSM-5-TR requires fear or anxiety about at least 2 of 5 situations: public transportation, open spaces, enclosed spaces, lines/crowds, or being outside the home alone. This patient endorses buses, crowded stores, and checkout lines (3 of 5).
The core fear is that escape may be difficult or help unavailable if incapacitating symptoms (dizziness, panic) occur, with avoidance, reliance on a companion, duration over 6 months, and impairment.
A negative cardiac, endocrine, and vestibular workup appropriately excludes a medical cause for the feared incapacitation before assigning the diagnosis.
Why the others are wrong
Illness anxiety disorder — requires preoccupation with having or acquiring a serious disease; her fear is of being trapped without help in specific situations rather than of a hidden illness, and she avoids those places rather than pursuing repeated medical evaluation.
Specific phobia, situational type — limited to a single situation such as flying or elevators, whereas she fears multiple agoraphobic situations.
Separation anxiety disorder — fear about being apart from an attachment figure; here the companion is a safety behavior to make feared situations tolerable, not the object of the fear itself.
Question 2PsychiatryMedium
A 29-year-old woman presents with 8 months of escalating fear of leaving her home alone. She avoids the bus, grocery stores, and standing in checkout lines because she worries she will be unable to escape or get help if she becomes dizzy and panicky in public. She now only goes out when her sister accompanies her and has missed several shifts at work. Vital signs, cardiac exam, and ECG are normal, and TSH and a basic metabolic panel are unremarkable. She declines structured psychotherapy and asks for a medication to start today. Which of the following is the most appropriate initial management?
ASertraline
BBuspirone
CClonazepam
DPropranolol
Reveal answer & full explanation
Correct answer: A — Sertraline
ASertraline✓
BBuspirone
CClonazepam
DPropranolol
Why Sertraline is correct
This vignette meets DSM-5-TR criteria for agoraphobia: fear of ≥2 of the 5 situations (public transportation, stores, standing in line, being outside the home alone), fear that escape will be difficult or help unavailable during incapacitating symptoms, avoidance requiring a companion, duration ≥6 months, and functional impairment.
Guideline first-line pharmacotherapy for agoraphobia (and related anxiety disorders) is an SSRI such as sertraline, escitalopram, or paroxetine, or the SNRI venlafaxine ER. CBT with in-vivo exposure is the most effective and durable treatment, but this patient declined psychotherapy and wants to start medication today, making an SSRI the appropriate initial choice.
Start at half the usual starting dose to avoid the initial activation/jitteriness that drives early discontinuation in anxious patients.
Why the others are wrong
Clonazepam is a benzodiazepine that provides only a short-term bridge and is not a first-line maintenance agent. It functions as a safety behavior that interferes with the safety-learning needed for exposure-based recovery, and it carries dependence risk.
Propranolol is a beta-blocker that blunts peripheral autonomic symptoms (tremor, palpitations) and is used for performance-type situational anxiety, but it does not treat the core fear and avoidance of agoraphobia.
Buspirone is a 5-HT1A partial agonist approved for generalized anxiety disorder; it has not demonstrated efficacy for agoraphobia or panic-spectrum disorders and is not a recommended first-line agent here.
🔒 Free preview limit reached
Keep reading — start your free trial
You've read your 2 free diagnosis previews. Create your free account to unlock the full Agoraphobia outline — plus all 514 diagnoses, 6,500+ board-style questions, flashcards, and an AI tutor. Your 7-day free trial includes everything, and there's no credit card required.
Conditioned avoidance after panic or panic-like symptoms in situational contexts. Amygdala hyperactivity and impaired safety-learning in prefrontal-amygdala circuits.
Clinical presentation
Symptoms
Avoidance of multiple specific public situations
May require companion to leave home, sit near exits, plan routes
Anticipatory anxiety with marked physiologic symptoms on exposure
Housebound in severe cases
Often comorbid panic attacks (with or without panic disorder)
Signs / physical exam
Tachycardia, diaphoresis, tremor, hyperventilation during exposure
Otherwise normal exam
Differential diagnosis
Panic disorder — Unexpected panic attacks ± concern about future attacks; agoraphobia may coexist but is now a separate diagnosis
Social anxiety disorder — Fear of social evaluation, not of escape difficulty or incapacitation
Specific phobia, situational type — Fear of one situation (e.g., flying) rather than ≥2 of the 5 agoraphobic situations
Separation anxiety disorder — Fear about separation from attachment figures rather than about the situation itself
PTSD — Avoidance linked to trauma reminders
Major depressive disorder with avoidance — Avoidance driven by anhedonia/amotivation rather than fear
Medical: vestibular dysfunction, orthostatic intolerance, cardiac arrhythmia — Realistic concern about incapacitation — workup before diagnosing agoraphobia
Diagnostic workup
Diagnostic criteria
DSM-5-TR: fear/anxiety about ≥2 of the 5 agoraphobic situations; fear of escape difficulty or unavailability of help; situations almost always provoke anxiety; avoidance/endurance/companion; ≥6 months; impairment; not better explained by another disorder.
Labs
TSH, CMP, CBC
Cardiac evaluation (ECG ± Holter) if syncope or palpitations dominate
Vestibular evaluation if dizziness prominent
Imaging
Not routinely indicated
Diagnostic algorithm
Feature
Agoraphobia
Panic disorder
Social anxiety disorder
Core fear
Escape difficulty / incapacitation in public situations
Recurrent unexpected panic attacks
Negative social evaluation
Triggers
≥2 of 5 agoraphobic situations
Unexpected; may be uncued
Social/performance situations
Avoidance
Multiple public situations, may be housebound
Variable; may overlap with agoraphobia
Social/performance contexts
First-line tx
CBT + SSRI/SNRI
CBT + SSRI/SNRI
CBT + SSRI/SNRI
Beta-blocker role
Not effective
Not first-line
Performance subtype only
Distinguishing agoraphobia from panic disorder and social anxiety disorder — overlapping symptoms but distinct core fears.
Treatment
First-line
Cognitive behavioral therapy with in-vivo exposure (most effective, durable)
SSRIs (sertraline, escitalopram, paroxetine) or SNRI (venlafaxine ER) — start low to avoid initial activation
Combined CBT + SSRI for moderate to severe presentations
Second-line / adjunct
Switch SSRI/SNRI class if inadequate response after 8-12 weeks
Tricyclics (imipramine, clomipramine) effective but worse tolerability
Benzodiazepines (clonazepam, lorazepam) — short-term bridge only; can interfere with exposure learning
Beta-blockers do not treat agoraphobia
Complications
Severe disability — up to one-third become housebound
Major depression (very high comorbidity)
Substance use disorders, especially alcohol
Loss of employment and social network
Suicidal ideation
PANCE pearls
Agoraphobia is now diagnosable independent of panic disorder; comorbidity is common but separable.
The fear is of escape difficulty or incapacitation, NOT of social judgment — that distinction separates agoraphobia from SAD on exam questions.
Start SSRIs at half the usual starting dose in anxiety disorders to avoid initial activation that drives discontinuation.
Exposure works best when the patient does NOT use safety behaviors (companion, water bottle, benzodiazepine) — these maintain the avoidance pattern.
Always rule out cardiac, vestibular, and endocrine contributors when avoidance centers on physical symptoms.
References
DSM-5-TR — American Psychiatric Association. DSM-5-TR. 2022.
NICE CG113 — National Institute for Health and Care Excellence. Generalised Anxiety Disorder and Panic Disorder in Adults: Management. CG113, 2011.
APA 2009 — American Psychiatric Association. Practice Guideline for the Treatment of Patients with Panic Disorder, 2nd ed.
Practice Psychiatry/Behavioral questions on FirstPassPA
Turn this outline into retention. 6,500+ board-style questions with an AI tutor that explains every answer — free to start, no card required.
Educational use only. This outline is a study aid for PA students and is not medical advice or a substitute for clinical judgment. FirstPassPA is an independent study tool and is not affiliated with, endorsed by, or sponsored by NCCPA or PAEA. PANCE® and PANRE® are registered trademarks of the National Commission on Certification of Physician Assistants; End of Rotation™ is a program of the Physician Assistant Education Association.