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.
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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.
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