Agoraphobia
Agoraphobia is marked fear, anxiety, or avoidance of two or more situations, such as public transportation, open or closed spaces, lines or crowds, or being outside the home alone, driven by the concern that escape or help may be unavailable, present for 6 months or more and now diagnosed independently of panic disorder even though the two frequently coexist. First-line treatment is exposure-based cognitive behavioral therapy, with an SSRI as the pharmacologic adjunct.
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What this article covers
- Overview
Fear of situations, not of a single object: agoraphobia is irrational fear, anxiety, or avoidance while facing or anticipating 2 or more specific situations, such as public transportation, open or…
- Epidemiology
More common in women than men: agoraphobia shows a female predominance, consistent with panic disorder, social phobia, generalized anxiety disorder, and posttraumatic stress disorder, which are all more prevalent in women.
- Risk factors
A history of panic attacks or panic disorder: the anticipatory fear that defines agoraphobia is fear of developing paniclike symptoms where escape is hard, so a prior panic attack history is the most direct antecedent.
- Pathophysiology
An anticipatory fear response anchored to escape and help availability: agoraphobia is fear or anxiety triggered by the prospect of being unable to escape a situation, or unable to get help if…
- Clinical features
Fear or avoidance of 2 or more defined situation categories: using public transportation, being in open spaces, being in enclosed spaces, standing in line or being in a crowd, or being outside the…
- Differential diagnosis
Panic disorder: recurrent, unexpected panic attacks without a consistent situational trigger, followed by 1 month or more of persistent worry about further attacks; agoraphobia's fear is anchored to…
- Diagnosis
The diagnosis is clinical, made from the history: confirmed once the patient reports fear or avoidance of 2 or more of the defined situation categories, driven by concern about escape or help…
- Management
First action is exposure-based cognitive behavioral therapy (CBT): begin structured, gradual exposure to the avoided situations, pairing incremental in-person exposure with anxiety-management skills so the avoidance behavior extinguishes.
- Complications
Progressive confinement to the home: untreated agoraphobia can advance from avoiding select triggers to complete refusal to leave home, with loss of independence.
- Prognosis
Reversible avoidance pattern with treatment: because the disorder is sustained by avoidance behavior, systematic exposure that reverses the avoidance is the mechanism by which symptoms improve, and…
- Prevention
Early treatment of a first panic attack or emerging avoidance pattern: because agoraphobia commonly develops after panic attacks in public settings, prompt CBT engagement when routines first begin…
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Related articles
- Panic disorder
Panic disorder is an anxiety disorder defined by recurrent, unexpected panic attacks, discrete surges of fear that peak within 10 minutes with 4 or more characteristic symptoms, followed by at least 1 month of persistent worry about further attacks, worry about their consequences, or a maladaptive behavior change. Medical mimics such as acute coronary syndrome, pulmonary embolism, arrhythmia, hyperthyroidism, pheochromocytoma, and hypoglycemia must be excluded first. First-line treatment is a selective serotonin reuptake inhibitor such as sertraline, started low and titrated slowly, combined with cognitive behavioral therapy; benzodiazepines are reserved for short-term acute control.
- Specific phobias
Specific phobia is a marked, persistent fear or anxiety about a circumscribed object or situation, lasting 6 months or more, that is out of proportion to the actual danger, provokes immediate fear on exposure, and is actively avoided or endured with distress; the diagnosis is clinical. First-line treatment is graded exposure therapy (a form of cognitive behavioral therapy), with a short-acting benzodiazepine reserved for a single known, planned exposure.
- Social anxiety disorder
Social anxiety disorder is marked, persistent fear of scrutiny or embarrassment in social or performance situations lasting at least 6 months with significant functional impairment. Generalized social anxiety disorder is treated with cognitive behavioral therapy (CBT) plus an SSRI such as sertraline, while the performance-only subtype is treated with a PRN beta blocker such as propranolol taken before the anticipated situation.
- Generalized anxiety disorder
Generalized anxiety disorder is excessive, hard-to-control worry about multiple life domains occurring more days than not for at least 6 months, with at least 3 of 6 associated physical symptoms and functional impairment. Screen with the GAD-7 after excluding hyperthyroidism and substance use, then treat first-line with cognitive behavioral therapy and/or an SSRI or SNRI such as escitalopram or venlafaxine extended-release, reserving benzodiazepines for short-term severe symptom control only.
- Post-traumatic stress disorder
Posttraumatic stress disorder follows exposure to actual or threatened death, serious injury, or sexual violence, producing intrusive re-experiencing, avoidance, negative alterations in cognition and mood, and hyperarousal that persist beyond 1 month with significant distress or impairment. First-line treatment is trauma-focused cognitive behavioral therapy combined with an SSRI or SNRI, with prazosin added for persistent nightmares.
- Hyperthyroidism
Hyperthyroidism is the clinical syndrome of thyroid hormone excess, produced by a range of causes from Graves disease and autonomously functioning nodules to destructive thyroiditis and exogenous hormone ingestion. Diagnosis begins with a suppressed thyroid-stimulating hormone and elevated free thyroxine, followed by radioactive iodine uptake testing or antibody measurement to identify the cause, and first-line treatment is a beta blocker for symptom control while the underlying cause directs thionamide, radioactive iodine ablation, or thyroidectomy therapy.
- Pheochromocytoma and paraganglioma
Pheochromocytoma and paraganglioma are catecholamine-secreting tumors of adrenal medullary chromaffin cells and extra-adrenal sympathetic ganglia, causing sustained or paroxysmal hypertension with headache, sweating, and palpitations, diagnosed by plasma free or 24-hour urine fractionated metanephrines before any imaging is obtained. First-line treatment is surgical resection preceded by alpha blockade with phenoxybenzamine (or off-label doxazosin) for 10 to 14 days, with a beta blocker added only after alpha blockade is established.