Section Learning Objectives

• Describe how agoraphobia presents itself.
• Describe the epidemiology of agoraphobia.
• Indicate which disorders are commonly comorbid with agoraphobia.
• Describe the treatment options for agoraphobia.

4.5.1 Clinical Description

Similar to GAD, agoraphobia is defined as an intense fear triggered by a wide range of situations; however, unlike GAD, the fears experienced in agoraphobia are related to situations in which the individual is in public situations where escape may be difficult. In order to receive a diagnosis of agoraphobia, fear must be present in at least two of the following five situations: using public transportation (e.g., planes, trains, ships, buses), being in large open spaces (e.g., parking lots, bridges), being in enclosed spaces (e.g., stores, movie theaters), being in a large crowd (e.g., concert), or being outside of the home in general (APA, 2022). When an individual is in one (or more) of these situations, they experience significant fear, often reporting panic-like symptoms (see Panic Disorder). It should be noted that fear and anxiety-related symptoms are present every time the individual is presented with these situations. Should symptoms only occur occasionally, a diagnosis of agoraphobia is not warranted.

Due to the intense fear and somatic symptoms, individuals will often engage in active avoidance where they will go to great lengths to avoid these situations, often preferring to remain within their home where they feel safe. This avoidance can cause significant impairment in daily functioning. The avoidance behaviors may be behavioral, including having food delivery to avoid going to grocery store or only taking a job that does not require the use of public transportation. Or avoidance may be cognitive and involve the use of distraction and other cognitive techniques to successfully get through the agoraphobic situation.

4.5.2 Epidemiology

The yearly prevalence rate for agoraphobia across the lifespan is roughly 1-1.7%. Females are twice as likely as males to be diagnosed with agoraphobia (notice the trend in the sex ratio of anxiety disorders). While it can occur in childhood, agoraphobia typically does not develop until late adolescence/early adulthood and typically tapers off in later adulthood. In most cases, initial onset occurs before age 35 with a mean age of onset in the 20s.

4.5.3 Comorbidity

Similar to other anxiety disorders, comorbid diagnoses are common. About 90% of people with agoraphobia are diagnosed with other psychological disorders, including other anxiety disorders, depressive disorders, and alcohol use disorder (APA, 2022).  Men are particularly likely to have a comorbid substance use disorder (APA, 2022). Approximately 30-50% of individuals with agoraphobia report experiencing panic attacks or have panic disorder that precedes the onset of agoraphobia (APA, 2022). While other anxiety disorders typically precede the onset of agoraphobia, depressive disorders and substance use disorders typically occur secondary to agoraphobia (APA, 2022).  Additionally, there is also high comorbidity between agoraphobia and PTSD. While agoraphobia can be a symptom of PTSD, an additional diagnosis of agoraphobia is made when all symptoms of agoraphobia are met in addition to the PTSD symptoms.

4.5.4 Treatment

Similar to the treatment approaches for specific phobia, exposure-based treatment techniques are among the most effective treatment options for individuals with agoraphobia; however, unlike the high success rate in specific phobia, exposure-based treatment for agoraphobia has been less effective in providing complete relief from the disorder. The success rate may be impacted by the high comorbidity rate of agoraphobia and panic disorder. Because of the additional presentation of panic symptoms, exposure-based treatments alone are not the most effective in eliminating symptoms as residual panic symptoms often remain (Craske & Barlow, 2014). Therefore, the best treatment approach for those with agoraphobia and panic disorder is a combination of exposure and CBT techniques (see panic disorder treatment).

For individuals with agoraphobia without panic symptoms, the use of group therapy in combination with individual exposure-based therapy has been identified as a successful treatment option. The group therapy format allows the individual to engage in exposure-based field trips to various community locations, while also maintaining a sense of support and security from a group of individuals whom they know. Research indicates that this exposure-based type of treatment provides improvement for nearly 60% to 80% of patients with agoraphobia; however, there is a relatively high rate of partial relapse suggesting that long-term treatment or booster sessions at a minimum should be continued for several years (Craske & Barlow, 2014).