Agoraphobia is a fear-and-avoidance disorder organized around situations from which escape might be difficult or help unavailable if panic-like, embarrassing, or incapacitating symptoms emerge. In DSM-5-TR it is a stand-alone diagnosis, decoupled from panic disorder, and defined by marked fear of at least two of five canonical situational clusters with persistent avoidance, endurance with intense distress, or the need for a companion.¹ The disorder is more prevalent in women, typically begins in late adolescence or early adulthood, and is highly comorbid with panic disorder, major depressive disorder, and other anxiety conditions.^2-3 First-line treatment combines cognitive behavioral therapy with graded in-vivo exposure and an SSRI or SNRI; benzodiazepines are reserved for short-term, narrowly indicated use because of dependence and avoidance-reinforcement risks.^4-5 Untreated agoraphobia tends to be chronic, functionally disabling, and a leading cause of housebound presentations in primary care and emergency settings. The clinical bottom line: diagnose on the situational fear-and-avoidance pattern, treat with exposure plus a serotonergic antidepressant, and resist the pull toward as-needed benzodiazepines that quietly cement the avoidance you are trying to extinguish.

Agoraphobia is uncommon in epidemiologic samples but disproportionately disabling among those affected. Lifetime estimates from the National Comorbidity Survey Replication and similar surveys place it in the low single digits.^2,6

Prevalence and demographics

• Lifetime prevalence approximately 1.3-1.7% in U.S. adults; 12-month prevalence around 0.8-0.9%.^2,6
• Female-to-male ratio roughly 2:1, consistent with most anxiety disorders.²
• Bimodal age of onset with a primary peak in late adolescence and early adulthood (median onset around age 17-21) and a smaller secondary peak after age 40.^1-2
• Onset before age 10 is uncommon; symptoms beginning in mid-life should prompt scrutiny for medical, neurologic, or substance-related contributors.¹

Comorbidity

• Approximately 90% of individuals with agoraphobia meet criteria for at least one other psychiatric disorder over the lifetime.^1-2
• Strongest associations are with panic disorder, other specific phobias, social anxiety disorder, generalized anxiety disorder, and major depressive disorder.^2,7
• Substance use disorders, particularly alcohol use disorder, occur in a meaningful minority and often reflect self-medication of anticipatory anxiety.²
• Comorbid depression substantially elevates suicide risk relative to agoraphobia alone.¹

Risk factors

• Female sex, behaviorally inhibited temperament, and a personal or family history of anxiety or depressive disorders.^1,3
• Childhood adversity, including parental loss, separation, and physical or sexual abuse.³
• Stressful or traumatic precipitants in the year before onset, including assaults, motor vehicle collisions, and acute medical events.^1,3
• A first-degree relative with panic disorder or agoraphobia, with twin-study heritability estimates around 60% for the agoraphobia phenotype.³

Agoraphobia is best understood as a learned fear of internal sensations and external situations, layered onto an inherited tendency toward autonomic hyperreactivity. The neurobiology overlaps substantially with panic disorder and other fear-circuit conditions.

Neurobiology

• Hyperactivity of the Amygdala and reduced prefrontal top-down regulation, the canonical fear-circuit signature, with engagement of the periaqueductal gray and brainstem autonomic nuclei during panic-like states.^8-9
• Dysregulated serotonergic and noradrenergic signaling, with secondary involvement of GABAergic tone, providing the rationale for SSRI, SNRI, and time-limited benzodiazepine effects.^4,9
• Heightened interoceptive sensitivity to bodily signals such as carbon dioxide elevation, lactate infusion, and orthostatic shifts, supporting Anxiety sensitivity as a key cognitive-biological trait.^8-9
• Functional imaging studies show altered insula and anterior cingulate activity during interoceptive and threat-anticipation tasks; structural findings are inconsistent.⁹

Genetics

• Twin studies estimate heritability of the panic-agoraphobia phenotype at roughly 30-60%, with shared genetic loading across panic disorder, agoraphobia, and other anxiety disorders.³
• No single gene of large effect; GWAS implicate small-effect variants in stress-response and monoaminergic pathways.³

Environmental factors

• Early adverse experiences, parental overprotection, and modeling of fearful-avoidant behavior contribute to the developmental trajectory.³
• A sentinel panic attack often anchors situational learning: the patient links a public place to the catastrophic interpretation of bodily sensations and begins avoidance.^1,8

Integrative model

• A diathesis-stress framework integrates these strands: a temperamentally anxious individual experiences an unexpected panic attack, develops catastrophic interpretations of bodily sensations (anxiety sensitivity), and through operant conditioning narrows the range of safe situations.^8-9
• Avoidance is the central maintaining factor and the principal target of evidence-based treatment.^4-5

DSM-5-TR codifies agoraphobia as an independent disorder requiring marked fear or anxiety across at least two of five situational clusters, with the fear specifically tied to the difficulty of escape or the unavailability of help if panic-like or incapacitating symptoms occur.¹ The reorganization away from panic disorder, formalized in DSM-5 and retained in DSM-5-TR, captures patients who avoid these situations without ever having a full panic attack.

DSM-5-TR criteria

• Marked fear or anxiety triggered by, or anticipated in, at least two of the following five clusters: using public transportation; being in open spaces; being in enclosed places; standing in line or being in a crowd; being outside the home alone.
• The patient fears or avoids these situations because of thoughts that escape might be difficult or help unavailable should panic-like, embarrassing, or incapacitating symptoms develop (such as falls in older adults or fear of incontinence).
• The agoraphobic situations almost always provoke fear or anxiety.
• The situations are actively avoided, require a companion, or are endured with intense distress.
• The fear or anxiety is out of proportion to the actual danger and to the sociocultural context.
• Symptoms are persistent, typically lasting six months or longer.
• Symptoms cause clinically significant distress or impairment in social, occupational, or other important domains.
• If a medical condition such as inflammatory bowel disease or Parkinson disease is present, the fear is clearly excessive.
• The disturbance is not better explained by another mental disorder, including specific phobia (situational type), social anxiety disorder, obsessive-compulsive disorder, body dysmorphic disorder, post-traumatic stress disorder, or separation anxiety disorder.

Comorbidity coding

• Agoraphobia is diagnosed independently of panic disorder. When both are present, both diagnoses are recorded.¹

ICD-11 differences

• ICD-11 retains agoraphobia within the anxiety and fear-related disorders grouping (chapter 06) and continues to recognize a panic-disorder link, but does not require two of five situational clusters; one situation suffices if the avoidance and impairment thresholds are met.¹⁰
• ICD-11 emphasizes the functional impact and the fear of panic-like or incapacitating symptoms rather than enumerating situational categories.¹⁰

The clinical picture is dominated by anticipatory anxiety, situational avoidance, and a progressive narrowing of the patient's geographic and social world. Many patients describe a sentinel panic attack in a public place, after which the situation itself becomes a conditioned trigger.

Symptom clusters

• Cognitive: catastrophic interpretation of bodily sensations ("I am going to faint, fall, lose control of my bowels, or die"), preoccupation with escape routes, and rehearsal of feared scenarios.
• Autonomic: tachycardia, dyspnea, dizziness, derealization, paresthesias, and gastrointestinal urgency, often described in the language of Panic attack symptoms.
• Behavioral: avoidance of triggering situations, reliance on safety signals (a trusted companion, a water bottle, a benzodiazepine in the pocket), and pre-trip planning that shrinks the patient's effective territory.
• Functional: late or missed appointments, refusal of public transit, work loss, and at the severe end, becoming housebound.

Course

• Onset is typically subacute over weeks to months following an index panic episode or a stressful precipitant.¹
• A waxing-and-waning chronic course is the rule. Spontaneous remission within a year is uncommon when avoidance is well-established.^1,7
• Functional impairment frequently exceeds the severity of overt symptoms because avoidance limits exposure-based correction of fearful predictions.

Prototypical presentation

• A young woman in her early twenties with a sentinel panic attack on a crowded subway. Over six months she stops taking transit, then stops driving on highways, and eventually agrees to leave the apartment only with her partner. She describes panic-like episodes whenever she contemplates a return to the subway and now misses work twice a week.

Atypical presentations

• Older adults presenting with fear of falling, syncope, or incontinence rather than panic. The phenotype meets criteria when avoidance and impairment thresholds are reached, even without classic panic.¹
• Adolescents whose primary complaint is school refusal driven by fear of being trapped or unable to access a parent. Differentiate from separation anxiety disorder, which centers on the attachment figure rather than the situation.
• Patients with comorbid medical illness (irritable bowel syndrome, vestibular dysfunction) whose realistic concern about symptoms in public has crossed into disproportionate avoidance.

Red flags

• Acute, abrupt onset of agoraphobia-like avoidance after age 40, particularly with neurologic findings, syncope, or new cardiopulmonary symptoms, demands medical workup before settling on a primary anxiety diagnosis.¹
• Avoidance restricted to a single circumscribed situation (specific phobia) or driven primarily by social-evaluative fears (social anxiety disorder) argues against agoraphobia.
• Progressive housebound behavior with prominent depressive features and active suicidal ideation reframes the case as a high-acuity affective presentation requiring urgent assessment.

The differential turns on the content of the fear and the topography of the avoidance, not on the autonomic symptoms themselves. Two patients can both refuse public transit; the diagnosis hinges on what they fear will happen there.

Psychiatric differentials

• Panic disorder without agoraphobia: recurrent unexpected panic attacks with worry about future attacks, but without the situational fear-and-avoidance pattern across two or more agoraphobic clusters.¹
• Specific phobia, situational type: fear circumscribed to one situation (such as flying or elevators), without the broader pattern of avoidance and without the escape/help-unavailability cognition central to agoraphobia.¹
• Social anxiety disorder: fear of negative evaluation in social or performance contexts. The patient avoids being observed, not being unable to escape.¹
• Generalized anxiety disorder: pervasive worry across multiple life domains rather than situational fear with escape-focused cognitions.¹
• Separation anxiety disorder: fear centers on separation from an attachment figure rather than the situation itself; the patient may travel comfortably with anyone considered a safe companion.¹
• Post-traumatic stress disorder: avoidance is trauma-cue specific, accompanied by intrusion symptoms, alterations in mood and cognition, and hyperarousal.¹
• Major depressive disorder: withdrawal can mimic agoraphobic avoidance but is driven by anhedonia, fatigue, and hopelessness rather than panic-focused fear.¹
• Psychotic disorders: avoidance driven by paranoid delusions or command hallucinations should not be diagnosed as agoraphobia.¹

Medical mimics

• Cardiovascular: arrhythmias (especially supraventricular tachycardia), unstable angina, and orthostatic hypotension can produce situational palpitations and dizziness.
• Endocrine: hyperthyroidism, pheochromocytoma, and hypoglycemia mimic autonomic panic symptoms.
• Neurologic: vestibular disorders (benign paroxysmal positional vertigo, vestibular migraine), temporal lobe seizures, and Parkinson disease (where fear of falling is realistic but can become disproportionate).
• Pulmonary: asthma, COPD exacerbations, and pulmonary embolism present with dyspnea and air hunger that can be misread as panic.

Substance-related

• Stimulant intoxication (cocaine, methamphetamine, high-dose caffeine), cannabis, and hallucinogens can precipitate panic attacks that anchor situational learning.
• Sedative-hypnotic, alcohol, or benzodiazepine withdrawal generates autonomic symptoms that may be misattributed to a primary anxiety disorder.
• A careful timeline locating symptoms relative to substance use is essential before assigning a primary agoraphobia diagnosis.¹

Assessment combines a structured clinical interview, validated rating scales, and a focused medical evaluation calibrated to the patient's age, symptoms, and comorbidities. The goal is to confirm the situational fear-and-avoidance pattern, screen for comorbidity and suicidality, and exclude medical mimics without ordering expensive tests reflexively.

Interview approach

• Map the geography of avoidance: which situations, how often, with whom, and how long has the pattern been present.
• Elicit the feared catastrophe: what does the patient anticipate will happen, and why is escape or help-availability central.
• Identify the index event: a sentinel panic attack, an acute medical illness, an assault, or a major loss often anchors the onset.
• Screen for panic disorder, depression, social anxiety, OCD, PTSD, and substance use; ask about suicide explicitly.
• Quantify functional impact: missed work, school absences, loss of driving, and reliance on a companion.

Mandatory history elements

• Past psychiatric history including prior anxiety episodes, treatment trials, and benzodiazepine exposure.
• Family history of anxiety, depression, and substance use disorders.
• Developmental history, with attention to childhood adversity and behavioral inhibition.
• Medication and substance review including caffeine, decongestants, beta-agonists, thyroid hormone, and stimulants.
• Suicide assessment using a validated framework such as the Columbia Suicide Severity Rating Scale.

Physical exam considerations

• Vital signs including orthostatic measurements.
• Cardiac examination for murmurs, irregular rhythm, and signs of heart failure.
• Neurologic examination including gait, with attention to vestibular and cerebellar findings in older patients.
• Thyroid examination.

Validated rating scales

• Panic and Agoraphobia Scale (PAS): clinician-rated, captures panic, anticipatory anxiety, and agoraphobic avoidance dimensions.¹¹
• Mobility Inventory for Agoraphobia (MI): self-report measure of avoidance across situations, rated alone and accompanied.¹²
• Agoraphobic Cognitions Questionnaire (ACQ): maps catastrophic interpretations of bodily sensations.¹³
• Anxiety Sensitivity Index (ASI): trait measure of fear of anxiety symptoms; predicts panic and agoraphobic course.¹³
• PHQ-9 and GAD-7: brief screens for comorbid depression and anxiety symptom burden.

Labs and imaging

• Targeted, not reflexive. Reasonable baseline workup includes TSH, CBC, basic metabolic panel, and an EKG when palpitations or chest symptoms are prominent.
• Urine drug screen when substance use is suspected or unclear.
• Echocardiography, Holter monitoring, vestibular testing, and neuroimaging are pursued only when history or examination raises specific concern.

What not to order

• Routine MRI, extensive autoimmune panels, and serial troponins in patients with a clear panic phenotype and unremarkable examination add cost and reinforce illness conviction without changing management.

Treatment combines exposure-based psychotherapy with a serotonergic antidepressant, calibrated to severity, comorbidity, and patient preference. Strong evidence supports cognitive behavioral therapy with in-vivo exposure as the foundational psychological treatment; SSRIs and SNRIs are the first-line pharmacologic agents.^4-5,14

Pharmacotherapy

• First-line agents: SSRIs (sertraline, escitalopram, paroxetine, fluoxetine) and the SNRI venlafaxine extended-release. Multiple guidelines and meta-analyses support efficacy across panic-agoraphobia phenotypes.^4-5,14
• Start low to avoid early activation: sertraline 25 mg daily, escitalopram 5 mg daily, paroxetine 10 mg daily, venlafaxine XR 37.5 mg daily, with titration over 1-2 weeks to standard antidepressant dosing.¹⁵
• Therapeutic effect typically emerges over 4-12 weeks. Counsel the patient that anxiety may transiently worsen in the first 1-2 weeks.^4-5
• Continuation for 12 months or longer after remission is commonly recommended to reduce relapse risk; consider longer maintenance after multiple recurrences.^4-5
• Second-line and adjunctive options include tricyclic antidepressants (clomipramine, imipramine) and monoamine oxidase inhibitors, which retain evidence in treatment-resistant cases but carry larger adverse-effect and interaction burdens.^4,15
• Benzodiazepines (clonazepam, alprazolam) provide rapid symptomatic relief but are limited by tolerance, dependence, cognitive effects, and reinforcement of avoidance through their use as safety signals. Reserve for short-term bridging or narrowly indicated cases, ideally with explicit taper planning.^4-5,15
• Beta-blockers, gabapentinoids, and atypical antipsychotics have a limited evidence base for primary agoraphobia and are not first-line.^4,15

Psychotherapy

• Cognitive behavioral therapy with graded in-vivo exposure is the foundational treatment, with strong evidence for symptom reduction and durable remission.^4-5,16
• Standard CBT protocols run 10-16 sessions and combine psychoeducation, cognitive restructuring of catastrophic interpretations, interoceptive exposure to feared bodily sensations, and a hierarchy-driven program of in-vivo exposure.¹⁶
• Self-directed and clinician-guided exposure produce comparable outcomes when adherence is adequate; family or partner involvement can improve generalization.¹⁶
• Internet-delivered CBT shows moderate evidence for accessibility and outcome comparable to face-to-face CBT in mild-to-moderate cases.¹⁷
• Acceptance and commitment therapy and mindfulness-based protocols have growing but lower-tier evidence; psychodynamic psychotherapy has limited evidence for the specific agoraphobia phenotype.¹⁶

Neuromodulation

• Repetitive transcranial magnetic stimulation has preliminary evidence in panic disorder; data specific to agoraphobia are limited and it is not currently a guideline-recommended option.[CITE NEEDED]
• Electroconvulsive therapy is not indicated for primary agoraphobia and is reserved for severe comorbid affective illness on its own indications.

Adjunctive

• Caffeine reduction, sleep regularization, and aerobic exercise reduce baseline arousal and support exposure work.¹⁶
• Treatment of comorbid depression, alcohol use disorder, and other anxiety disorders is essential; outcomes are markedly worse when comorbidities are unaddressed.⁷
• Family psychoeducation aimed at reducing accommodation behaviors (driving the patient everywhere, calling in sick on their behalf) protects the gains made in exposure.
• A written relapse-prevention plan with explicit early-warning signs, booster sessions, and a low threshold to re-engage exposure should anchor the end of acute treatment.⁵

Treatment is generally safe and effective, but each modality carries harms that must be weighed against the disability of untreated agoraphobia. The evidence base, while substantial, has well-recognized methodological limits.

Pharmacotherapy harms

• Common SSRI/SNRI adverse effects: gastrointestinal upset, headache, insomnia or sedation, sexual dysfunction, sweating, and transient early activation.¹⁵
• Discontinuation syndrome with abrupt cessation, particularly with paroxetine and venlafaxine; taper over weeks to months after long-term use.¹⁵
• Serotonin syndrome with combination serotonergic agents, including triptans, tramadol, linezolid, and MAOIs; counsel patients accordingly.¹⁵
• TCAs carry anticholinergic, weight, and cardiac conduction effects and are lethal in overdose; prescribe with attention to suicide risk and limited dispensing.¹⁵
• Benzodiazepines: tolerance, physiologic dependence, cognitive impairment, motor-vehicle accident risk, falls and fractures in older adults, and a withdrawal syndrome that can include seizures with abrupt cessation. Combined use with opioids substantially increases overdose mortality.^5,15

Psychotherapy harms

• Transient symptom worsening during early exposure trials, particularly with interoceptive work; this is expected and not a signal to abandon exposure.¹⁶
• Drop-out is more common in severe or housebound presentations, where in-home or graduated office-based starts may be necessary.¹⁶
• Poorly delivered exposure (insufficient duration, embedded safety behaviors) can paradoxically reinforce avoidance.¹⁶

Monitoring and discontinuation

• Counsel patients to expect a 4-12 week ramp to therapeutic effect and to anticipate gradual taper rather than abrupt stop after remission.^4-5
• Re-evaluate at 4, 8, and 12 weeks for response, adverse effects, and adherence; quantitative scales such as the PAS and MI track avoidance more sensitively than global impression.^11-12
• Plan benzodiazepine tapers explicitly and concurrent with active exposure work, not before or after.

Limitations of the evidence base

• Many trials enroll panic disorder cohorts with secondary agoraphobia; the pure-agoraphobia evidence base is comparatively thin.^4,14
• Follow-up durations in pharmacotherapy RCTs typically run 8-12 weeks, limiting inference about long-term benefit and durability after discontinuation.¹⁴
• Older adults, pregnant patients, and patients with significant medical comorbidity are underrepresented in efficacy trials.¹⁴
• Publication bias favoring positive industry-sponsored pharmacotherapy trials applies here as elsewhere.¹⁴

The diagnostic core holds across populations, but the calculus of pharmacotherapy and the texture of feared situations shifts with age, pregnancy, and medical comorbidity.

Pediatric

• Onset before age 10 is uncommon. Adolescents more often present with school refusal, social withdrawal, and somatic complaints than classical panic.¹
• CBT with developmentally adapted exposure is first-line; SSRIs are added when symptoms are severe, comorbid with depression, or refractory to therapy.¹⁸
• The FDA black-box warning regarding suicidality with antidepressants in patients under 25 applies; this is a counseling and monitoring issue, not a contraindication, when the indication is clear.¹⁸

Geriatric

• Older patients more often endorse fear of falling, syncope, or incontinence than panic per se. Avoidance can mimic dementia-related withdrawal.¹
• Start SSRIs at half the usual adult dose and titrate slowly. Avoid paroxetine because of anticholinergic burden and benzodiazepines because of falls and cognitive impairment.¹⁵
• Screen for vestibular disease, orthostatic hypotension, and cardiac arrhythmia before attributing all situational symptoms to anxiety.

Perinatal

• Untreated anxiety in pregnancy is itself associated with adverse obstetric and neonatal outcomes; treatment decisions weigh maternal illness against medication exposure.¹⁹
• Sertraline is commonly considered a reasonable first-line SSRI in pregnancy and lactation given its evidence base and low milk concentrations; paroxetine is generally avoided in the first trimester because of cardiac malformation signals.¹⁹
• CBT is preferred when available because it avoids fetal medication exposure altogether.¹⁹
• Postpartum onset or worsening is common; integrate care with obstetrics and pediatrics, and screen for postpartum depression.¹⁹

Comorbid medical illness

• Cardiovascular, vestibular, and gastrointestinal disorders complicate both the differential and the patient's interpretation of bodily sensations. Address realistic medical concerns and the disproportionate fear in parallel.
• In Parkinson disease and inflammatory bowel disease, fear of falling or incontinence may be partially realistic; the agoraphobia diagnosis applies when the fear and avoidance are clearly excessive given the actual risk.¹

Comorbid substance use

• Alcohol, benzodiazepine, and cannabis use complicate diagnosis, treatment selection, and exposure work. Treat the substance use disorder concurrently; benzodiazepine prescribing is generally contraindicated.
• Stimulant use can perpetuate panic and should be addressed before concluding pharmacotherapy is failing.

Cultural considerations

• Idioms of distress vary: ataque de nervios, dhat, and culturally specific somatic presentations may map onto agoraphobic phenomenology.¹
• Help-seeking, stigma, and access to female clinicians shape presentation and adherence; ask explicitly about cultural framing of symptoms.

Untreated agoraphobia is typically chronic and disabling. Treated agoraphobia has a substantially better course, with most patients achieving meaningful symptom reduction and many achieving remission, though residual avoidance and relapse risk remain real.

Natural history

• Without treatment, chronic course with waxing-and-waning severity is the rule. Spontaneous remission is uncommon once avoidance is entrenched.^1,7
• Comorbid depression and substance use worsen course and functional outcome.^2,7

Response and remission

• With first-line CBT or pharmacotherapy, approximately 50-70% of patients achieve clinically meaningful response, and a substantial subset achieve remission, though estimates vary by definition and follow-up.^4,16
• Combined CBT plus pharmacotherapy may offer additive benefit acutely, especially in severe or highly comorbid presentations.^4-5

Relapse

• Relapse rates rise after pharmacotherapy discontinuation, particularly when treatment is stopped before 12 months of sustained remission.⁴
• CBT gains are more durable; booster sessions further reduce relapse risk.¹⁶

Suicide and mortality

• Suicide risk is elevated relative to the general population, driven largely by comorbid depression and substance use rather than agoraphobia alone.^1,7
• Functional impairment, isolation, and unemployment are the dominant non-fatal outcomes; some patients become entirely housebound.¹

Most agoraphobia care is outpatient, but acute presentations to emergency departments are common, and a small subset require hospital-level intervention for safety or for concurrent affective illness.

Hospitalization criteria

• Active suicidal ideation with intent or plan, particularly with comorbid major depression or substance use.
• Severe functional decompensation, including inability to maintain nutrition or hydration in a housebound patient.
• Inability to engage in outpatient treatment because of severity, with available intensive outpatient or partial hospitalization programs being the more proportionate first step.

Suicide risk markers

• Comorbid major depression, alcohol use disorder, recent hopelessness, prior attempts, and acute psychosocial losses.
• Specific catastrophic interpretations of bodily sensations rarely drive suicidality directly but can fuel a desperate sense of entrapment.

Acute panic in the emergency department

• Triage cardiac, respiratory, and metabolic emergencies first; do not assume panic without an examination and minimum workup.
• Brief grounding techniques, validated reassurance, and avoidance of immediate benzodiazepine administration when feasible support exposure-consistent care; if a benzodiazepine is given, document the indication and avoid a refill on discharge.
• Connect to outpatient psychiatry and primary care; provide written information on panic-agoraphobia and a follow-up appointment.

Agitation and behavioral disturbance

• Frank agitation is uncommon in pure agoraphobia; consider co-occurring intoxication, withdrawal, or psychosis when present.

Safety-relevant comorbidity

• Screen for intimate partner violence in housebound patients whose partner is the principal companion.
• Identify caregiver burnout and accommodation patterns that may be unsustainable and undermining recovery.

Several questions remain unsettled and deserve foregrounding for residents preparing for boards or facing a real patient.

Diagnostic structure

• The DSM-5 and DSM-5-TR decision to uncouple agoraphobia from panic disorder remains contested. Critics argue that pure agoraphobia without any panic-like phenomenology is rare in practice; defenders point to older patients whose fear of falling and incontinence drives substantial avoidance without classical panic.^1,10
• ICD-11 took a more permissive route by allowing a single situation to qualify if avoidance and impairment thresholds are met, producing case-definition disagreements between systems.¹⁰

Treatment sequencing

• Whether CBT alone, pharmacotherapy alone, or combined treatment is optimal for moderate severity remains debated. Combined treatment offers acute additive benefit in some trials but introduces extra adverse-effect burden and may yield less durable post-discontinuation gains than CBT alone.^4-5
• The role of d-cycloserine and other cognitive enhancers as exposure adjuncts has shown mixed results across trials and is not in routine guideline recommendations.[CITE NEEDED]

Benzodiazepine prescribing

• Long-standing controversy persists between guidelines that strongly discourage chronic benzodiazepine use and clinical practices in which patients have been maintained on stable low doses for years. Tapering risks acute relapse; continuing risks the well-documented harms of long-term use.^5,15

Digital and self-directed therapy

• Internet-delivered CBT and app-based exposure programs have moderate evidence and clear access advantages, but quality varies widely, regulatory oversight is inconsistent, and severe presentations are typically underrepresented in trials.¹⁷

Neuromodulation

• rTMS and related neuromodulation techniques have preliminary evidence in panic disorder, with very limited data specific to agoraphobia. Routine use is not currently supported.[CITE NEEDED]

• DSM-5-TR requires marked fear in at least two of five situational clusters: public transportation, open spaces, enclosed places, lines or crowds, and being outside the home alone.¹
• DSM-5 (2013) and DSM-5-TR (2022) treat agoraphobia and panic disorder as separate diagnoses; both can be coded together.¹
• ICD-11 allows a single qualifying situation if avoidance and impairment thresholds are met, in contrast to DSM-5-TR's two-of-five rule.¹⁰
• Lifetime prevalence is approximately 1.3-1.7%, with a roughly 2:1 female predominance.^2,6
• Median age of onset is in late adolescence or early adulthood; new onset after age 40 should prompt medical workup.^1-2
• The fear in agoraphobia is specifically about difficulty escaping or unavailability of help if panic-like or incapacitating symptoms occur, not about the situation itself in isolation.¹
• CBT with graded in-vivo exposure is the foundational psychotherapy, with strong evidence for durable gains.^4,16
• SSRIs and venlafaxine XR are first-line pharmacotherapy; benzodiazepines are reserved for short-term bridging because they reinforce avoidance.^4-5
• Start serotonergic antidepressants at half the usual antidepressant dose in panic-prone patients to minimize early activation.¹⁵
• Sertraline is commonly considered a reasonable first-line SSRI in pregnancy and lactation; paroxetine is generally avoided in the first trimester.¹⁹
• The Mobility Inventory for Agoraphobia tracks avoidance both alone and accompanied, capturing the safety-companion dimension of the disorder.¹²
• Anxiety sensitivity, the trait fear of bodily anxiety symptoms, predicts onset and persistence of panic-agoraphobia symptoms.^8-9
• Twin-study heritability for the panic-agoraphobia phenotype is approximately 30-60%.³
• Approximately 90% of patients with agoraphobia meet criteria for at least one other psychiatric disorder over the lifetime.²
• Avoidance of a single circumscribed situation (such as flying) is better diagnosed as specific phobia, situational type, not agoraphobia.¹

No external funding. No conflicts of interest declared. Peer-review status: pending.