Agoraphobia

Agoraphobia is marked fear or avoidance of at least two situations (public transport, open spaces, enclosed spaces, queues or crowds, being outside alone) because escape might be difficult or help unavailable.

• Prevalence 1.7%, onset in late teens to 30s, women 2 to 3 times more affected; frequently follows panic attacks, although it may occur alone.
• Comorbid panic disorder, depression, alcohol or benzodiazepine misuse.
• Can lead to being housebound; chronic without treatment.

• Fear of panic like symptoms, incapacitation or humiliation; avoidance, need for a companion; reliance on safety items.
• Anticipatory anxiety; dependence on family; restricted work and travel.
• Secondary depression and demoralisation.

• DSM-5 criteria: 6 months or more, out of proportion to danger.
• Mobility Inventory for Agoraphobia, Panic and Agoraphobia Scale.
• Exclude specific phobia, social anxiety, PTSD, separation anxiety, psychosis, and medical causes (vestibular disease, cardiac arrhythmia, epilepsy).
• Assess substance use and suicidality.

• CBT with graded in vivo exposure and interoceptive exposure (12 to 20 sessions) is first line.
• SSRIs and SNRIs: sertraline 50 to 200 mg daily, paroxetine 20 to 60 mg, escitalopram 10 to 20 mg, venlafaxine XR 75 to 225 mg; start at half dose to avoid initial jitteriness; continue 12 months or more.
• Clonazepam 0.5 to 2 mg daily or alprazolam short term bridging, not long term.
• Teach breathing control and anxiety management; involve family to reduce accommodation.
• Self help and telehealth exposure programmes for housebound patients.