Agoraphobia Assessment and Treatment
Assessment Approach
Begin with systematic screening using validated anxiety measures, followed by comprehensive diagnostic evaluation to confirm DSM-5 criteria for agoraphobia: excessive fear about being in situations where escape might be difficult or help unavailable. 1
Diagnostic Evaluation Components
Screen systematically using freely available tools like the Pediatric Symptom Checklist or Strengths and Difficulties Questionnaire in primary care settings, or the APA Level 1 Cross-Cutting Symptom Measures in psychiatric settings to identify anxiety concerns before full evaluation 1
Confirm DSM-5 criteria for agoraphobia: excessive fear or worry about being in situations (crowds, enclosed spaces, public transportation, open spaces, being outside the home alone) where the individual may be unable to escape or get help 1
Assess severity and impairment including frequency of avoidance behaviors, degree of distress, and functional impairment in social, occupational, or academic domains 1
Evaluate safety risks including suicidal thoughts, self-harm behaviors, and risk-taking, as these have been associated with anxiety disorders and rarely with antidepressant treatment 1
Rule out medical mimics such as hyperthyroidism, hypoglycemia, cardiac arrhythmias, and caffeine excess through targeted history and laboratory testing (thyroid function, glucose levels) before confirming diagnosis 2, 3
Screen for comorbidities including panic disorder (commonly co-occurs), depression, other anxiety disorders, ADHD, eating disorders, and substance use 2, 3
Gather multi-informant data from patient, family members, and when applicable, school personnel to obtain comprehensive clinical picture 2
Treatment Recommendations
Cognitive-behavioral therapy (CBT) with graduated exposure is the first-line treatment for agoraphobia, with SSRIs as an alternative or adjunctive option, particularly for moderate-to-severe presentations. 1, 4
First-Line Treatment: CBT with Exposure
Initiate CBT structured for 12-20 sessions targeting the three dimensions of anxiety: cognitive (catastrophic thinking about being trapped), behavioral (avoidance of feared situations), and physiologic (autonomic arousal) 1
Graduated exposure is the cornerstone for agoraphobia treatment: patient creates a fear hierarchy of avoided situations (e.g., walking to mailbox → going to small store → using public transportation → being in crowded mall) and masters each step systematically 1
Therapist-guided in situ exposure is superior to therapist-prescribed exposure alone, showing greater reduction in agoraphobic avoidance, improved overall functioning, and sustained panic attack reduction during follow-up 5
Include specific CBT elements: psychoeducation about anxiety, self-monitoring of fear-thought-behavior connections, relaxation techniques (deep breathing, progressive muscle relaxation), cognitive restructuring to challenge catastrophizing and negative predictions, and problem-solving skills 1
Incorporate family interventions to reduce parental anxiety, improve parent-child relationships, strengthen communication skills, and foster anxiety-reducing parenting behaviors (reducing overprotection/overcontrol) 1
Monitor treatment response systematically using standardized symptom rating scales at each session to optimize assessment of progress and remission 1
Pharmacotherapy: SSRIs
When CBT is unavailable, refused, or insufficient, or for moderate-to-severe presentations, initiate SSRI therapy as first-line pharmacological treatment. 4, 3
Start with escitalopram 10-20 mg/day or sertraline 50-200 mg/day as first-line SSRI options for agoraphobia, with paroxetine and fluoxetine as alternatives 4, 6
Begin at subtherapeutic "test" doses (e.g., escitalopram 5 mg, sertraline 25 mg) as initial adverse effects can include increased anxiety or agitation, which may worsen agoraphobic fears 4
Avoid escitalopram doses exceeding 40 mg/day due to QT prolongation risk 4
Paroxetine is FDA-approved for panic disorder with or without agoraphobia, demonstrating efficacy in 10-12 week trials with sustained benefit in relapse prevention studies 6
Monitor closely in first 3 months: schedule follow-up at 2 weeks, then monthly, assessing for worsening anxiety, suicidal ideation (rare but serious risk with antidepressants), medication adherence, and treatment response 3
Combination Treatment
Combination of CBT and SSRI is superior to either treatment alone for moderate-to-severe agoraphobia, providing both immediate symptom relief and durable skills to prevent relapse. 1, 3
Initiate both treatments concurrently for severe presentations with significant functional impairment, as combination therapy shows greater short-term efficacy than monotherapy 1, 3
CBT provides lasting skills that may prevent relapse after medication discontinuation, addressing the limitation that relapse commonly occurs when antidepressants are stopped 3, 7
Treatment Planning Considerations
Prioritize CBT as first-line for mild-to-moderate agoraphobia given its lasting efficacy without medication side effects or relapse upon discontinuation 1, 7
Consider SSRIs first when quality CBT is unavailable, patient refuses psychotherapy, or severe symptoms require rapid intervention 1
Avoid benzodiazepines as they lack evidence for long-term efficacy and carry dependence risks 1
Plan for extended treatment duration: while acute treatment is 12-20 weeks, periodically re-evaluate need for continued treatment, as long-term maintenance may be necessary for sustained benefit 1, 6
Common Pitfalls to Avoid
Do not dismiss avoidance as "just anxiety" without assessing the specific agoraphobic pattern of fear about being trapped or unable to escape 1
Do not overlook panic disorder comorbidity, as agoraphobia frequently develops secondary to panic attacks and requires integrated treatment 6
Do not prescribe exposure without proper graduated hierarchy, as overwhelming exposure can sensitize rather than desensitize patients 1
Do not continue ineffective treatment indefinitely: if no response after 8-12 weeks of adequate-dose SSRI or structured CBT, reassess diagnosis and consider alternative or combination approaches 1