Agoraphobia

Background

• Agoraphobia is characterized by marked and unreasonable fear or anxiety about a situation, or the active avoidance of situations, in which escaping or obtaining help may be difficult or embarrassing if panic-like symptoms suddenly occurred.
• Frequent situations associated with agoraphobia include public transportation, open spaces, enclosed spaces, lines of people, crowds or people, and being alone outside of one's home.
• The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) describes agoraphobia as a diagnosable condition separate from panic disorder, although past versions of the DSM have linked agoraphobia as a subtype of panic disorder.
• Many patients with panic disorder also have agoraphobia. Agoraphobia may also be comorbid with other anxiety disorders and mood disorders.
• Like panic disorder, the pathogenesis of agoraphobia is unclear, but may result from a combination of genetic and environmental influences on fear processing and fear responses.
• The clinical course of agoraphobia is frequently persistent, and it may severely impact psychological, social, and physical functioning.

Evaluation

• Suspect agoraphobia in patients who persistently fear having panic attacks, being incapacitated, or being embarrassed in certain situations, or who avoid certain situations due to fear of panic attacks, incapacitation, or embarrassment.
• Diagnosis is clinical, based on at least 6 months of marked, unreasonable anxiety, or avoidance, of at least 2 typical situations (public places, open spaces, crowds, travelling away from home, or travelling alone).
• Testing is only indicated if it is needed to rule out other causes of anxiety or panic attacks, such as heart disease, hyperthyroidism and other endocrine disorders, seizure disorders, or substance abuse.

Management

• For the initial management of agoraphobia, advise psychotherapy or medication treatment based on patient preference (Strong recommendation). Consider combination therapy with counseling and medication if the patient prefers (Weak recommendation).
• For psychotherapy, cognitive behavioral therapy is recommended as the first-line option (Strong recommendation).
• First-line medications for treatment of agoraphobia include:
  • selective serotonin reuptake inhibitors (SSRIs), such as citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, or sertraline (Strong recommendation)
  • selective norepinephrine reuptake inhibitors (SNRIs), such as duloxetine or venlafaxine extended release (Strong recommendation)
• Consider a benzodiazepine, such as alprazolam, clonazepam, or lorazepam, as monotherapy or in combination with antidepressants for patients with very distressing or impairing symptoms in whom rapid symptom control is critical (Weak recommendation).
• Second-line medications to consider for treatment of panic disorder include:
  • a benzodiazepine, such as alprazolam, clonazepam, or lorazepam, with regular dosing (Weak recommendation)
  • tricyclic antidepressants, such as imipramine or clomipramine (Weak recommendation)
• For patients who are unresponsive to the initial treatment, options include augmentation with another first-line treatment or switching to another first-line treatment (Strong recommendation). Adding a benzodiazepine to an antidepressant to target residual symptoms may also be considered (Weak recommendation).
• For pregnant or breastfeeding patients and for children with agoraphobia, consider cognitive behavioral therapy (CBT).
• Monitor patients during the follow-up for changes in symptoms and potential adverse effects of medications (Strong recommendation).
• If discontinuing benzodiazepine treatment, consider tapering over 2-4 months with a decrease of no more than 10% of the dose per week (Weak recommendation) while continuing to offer cognitive-based therapy.