Agoraphobia, in DSM-5, is marked fear of two or more situations from which escape would be difficult or help unavailable if anxiety symptoms emerged: public transportation, open spaces, enclosed places (theaters, malls), lines or crowds, being outside the home alone. The pattern is consistent — anywhere escape feels constrained.
The disorder is now its own diagnosis (separated from panic disorder in DSM-5), though the two frequently co-occur. Many patients develop agoraphobia after panic disorder — having experienced panic in a particular setting, they avoid it, the avoidance expands, and gradually the world shrinks. Some patients have agoraphobia without ever having had full panic attacks.
The functional cost can be substantial. Severe agoraphobia leaves patients housebound, dependent on others for grocery shopping and medical appointments, unable to work outside the home. Even moderate agoraphobia substantially constrains life — the patient cannot fly, cannot use public transit, cannot drive on highways, cannot attend events.
Treatment cornerstone: in-vivo exposure therapy. The patient systematically faces avoided situations in graded difficulty, learning through experience that catastrophic predictions don't come true. The structured progression builds tolerance — start with easier situations, increase difficulty as confidence grows, with cognitive work supporting the behavioral exposure. CBT for agoraphobia has strong evidence with effect sizes often exceeding those of pharmacotherapy alone.
Pharmacotherapy: SSRIs/SNRIs help reduce baseline anxiety and panic susceptibility, but do not replace exposure work. Pharmacology without exposure tends to mask rather than resolve — the patient feels less anxious but the avoidance pattern persists. Combined treatment is the standard of care.
Treatment challenges: severe agoraphobia may prevent the patient from coming to clinic. Home visits, telehealth therapy, or initial in-home behavioral interventions may be necessary. Family support helps but family accommodation (doing tasks for the patient to avoid their distress) can perpetuate the disorder.
When you encounter a patient with substantial functional restriction tied to avoided situations, agoraphobia may be the diagnosis. Treatment is highly effective when the patient engages with exposure work. The world can be reclaimed; the avoidance pattern can be reversed.