Key diagnostic features

• Marked fear or anxiety about two (or more) situations: public transport, open spaces, enclosed spaces, standing in line/crowds, being outside the home alone.
• Fear stems from concern that escape might be difficult or help unavailable if panic‑like or incapacitating symptoms occur.
• Situations provoke anxiety and are avoided, require a companion, or endured with intense distress.
• Symptoms cause clinically significant distress or impairment and usually persist for 6 months or more.

Typical presentations & associated features

• Agoraphobia often follows panic attacks but can occur independently.
• Patients may become housebound, reliant on companions, or restrict activities like shopping, commuting or socialising.
• Commonly comorbid with depressive disorders, substance misuse (self‑medication), and other anxiety disorders.
• Safety behaviours (carrying medication, having a trusted companion) maintain avoidance and impede recovery.

Assessment checklist

1. Detailed history: onset, triggers, presence/history of panic, avoidance patterns, and dependence on others.
2. Functional impact: work, education, caregiving responsibilities, transport, and social participation.
3. Identify safety behaviours and map an avoidance hierarchy for exposure planning.
4. Screen for comorbidities: depression, PTSD, substance use, and medical conditions affecting mobility.
5. Risk assessment: suicidality, neglect, severe confinement and safety concerns.

Differential diagnosis

• Specific phobia or situational avoidance, severe social anxiety, psychosis‑related avoidance, and mobility limitations from medical illness.
• Depressive withdrawal vs anxiety‑driven avoidance—distinguish primary mood disorder from agoraphobic avoidance.
• Consider neurocognitive disorders in late‑onset cases with disorientation or memory issues.

Evidence‑based interventions

• Cognitive‑Behavioural Therapy (CBT): cornerstone treatment—includes psychoeducation, cognitive restructuring, graded in vivo exposure and behavioural experiments.
• Graded exposure: systematic, repeated exposure to avoided situations, with homework and variability across contexts to promote generalisation.
• Home‑based & guided self‑help: supported self‑help and internet CBT effective for mild–moderate cases when access to therapy is limited.
• Virtual reality exposure (VRET): useful when real‑world exposure is impractical or initially overwhelming.
• Pharmacotherapy: SSRIs and SNRIs are first‑line medications; benzodiazepines may provide short‑term relief but can hinder exposure learning and pose dependence risks.

Stepwise exposure plan

1. Create a collaborative hierarchy of avoided situations with SUDS ratings (0–100).
2. Begin with small, achievable tasks (e.g., step outside the front door for 1 minute) and practise frequently until distress reduces.
3. Use interoceptive exercises if panic symptoms are prominent; combine with situational exposures.
4. Gradually remove safety behaviours (e.g., companions, medication) to maximise learning and independence.
5. Set regular homework and increase variability (different locations, times) to aid generalisation.

Working with housebound or severe cases

• Start with home‑based exposures to expand the safety zone (doorway, balcony, short walks) and progress outdoors.
• Use telehealth, home visits or therapist‑assisted outings to coach exposures and provide in vivo support.
• Coordinate with social services for transport, mobility aids and caregiver support where needed.

Practical tips for clinicians

• Set small, measurable goals and emphasise frequent short exposures rather than rare large ones.
• Discuss and plan to reduce safety behaviours explicitly; involve family to support independence rather than enable avoidance.
• Coordinate pharmacotherapy to support engagement in CBT—SSRIs can reduce distress and improve response to exposure.

Key takeaways

• Agoraphobia is disabling but treatable—CBT with graded exposure is the most effective approach.
• Treat comorbid conditions, manage benzodiazepine use carefully, and adapt plans for housebound patients using telehealth and home‑based exposures.
• Frequent practice, removal of safety behaviours and coordination with services improve outcomes and restore functioning.