ICD-116B02	AGORAPHOBIA Agoraphobia
ICD-10F40.0	Agoraphobia
DSM-5-TRF40.00	Agoraphobia

1. Definition and nosology

Agoraphobia (ICD-11: 6B02; DSM-5-TR: F40.00) — excessive fear and avoidance of situations from which escape is difficult or help may not be available (public transportation, open spaces, enclosed spaces, crowds, leaving home alone). The patient fears developing panic attacks or other incapacitating symptoms.

2. History

• Westphal C. (1871) “agoraphobia” — Greek “agora” (square) + fear.
• DSM-III (1980) — Together with panic disorder.
• DSM-5 (2013), ICD-11 — agoraphobia formalized as a SEPARATE category from panic disorder (comorbidity possible, but based on separate diagnosis).

3. Epidemiology

• Lifetime prevalence: 1–2.5%.
• Sex: 2 times higher in females.
• Onset: young to middle adulthood.
• Comorbidity: panic disorder 50%, MDD, other anxiety, substance use.

4. Aetiology and pathogenesis

• Heritability ~60% (Mosing M.A. et al. Depress Anxiety 2009;26(11):1004–1011).
• Classical conditioning — fear transfer to a specific situation when a panic attack occurs in that situation.
• Cognitive factors — catastrophizing (“help won't come”).

5. Clinical features

Typical avoided situations:

• Public transportation (bus, train, airplane).
• Open areas (square, bridge, open ground).
• Closed spaces (store, cinema theater).
• Queuing or crowd.
• Leaving home alone.

The patient displays avoidance behaviors, “safety” behaviors (carrying a companion, mobile phone, medication), partial or complete home confinement. In severe cases, housebound.

6. Diagnosis

6.1 Unified diagnostic criteria

A. Significant fear or anxiety in ≥ 2 of the following five categories:

1. Public transportation;
2. Open areas;
3. Closed compartments;
4. Queue or crowd;
5. Leaving home alone.

B. These situations are feared because escape is difficult or help will not be available — in the event of a panic attack or incapacitating symptom.

C. Situations almost always provoke fear.

D. Active avoidance, companion demand, or enduring with acute distress.

E. Fear is disproportionate to the situation.

F. Persistent (≥ 6 months DSM-5-TR).

G. Significant functional impairment.

H. Not better explained by a medical or other mental disorder.

6.2 Source-specific clarifications

• DSM-5-TR / ICD-11 — agoraphobia separate from panic disorder; both diagnoses are given if comorbid.
• NICE CG113 — agoraphobia with panic disorder: similar intervention.

6.3 Diagnostic algorithm

1. Clinical interview — avoided situations, panic attack history, functional burden.
2. SCID-5, MINI.
3. Mobility Inventory for Agoraphobia (MIA) — avoidance severity.
4. Comorbidity (panic, MDD, substance).
5. Medical examination.

6.4 Differential diagnosis

7. Examination and assessment

• MIA, ACQ, BSQ.
• GAD-7, PHQ-9, PDSS comorbidity.

8. Treatment

1. CBT — exposure-based; graded in vivo exposure to avoided situations; cognitive restructuring. First-line; large effect.
2. SSRI or SNRI — first-line pharmacotherapy (as in panic disorder).
3. Benzodiazepine — only short-term.
4. Virtual reality exposure — alternative means; evidence base developing.
5. Treatment duration — ≥ 12 months after remission.

Source-specific specifications

• NICE CG113 — CBT and SSRIs.
• CANMAT 2014 — same.
• Sánchez-Meca J. et al. Clin Psychol Rev 2010 meta-analysis — CBT-based exposure showed large effect.

Treatment methods

1. In vivo exposure — Staged approach — patient enters avoided situations in structured manner; therapist can accompany (therapist-assisted exposure). First-line method.
2. Virtual Reality Exposure Therapy (VRET — Virtual Reality Exposure Therapy) — Virtual environment created in clinical context; alternative to in vivo exposure. Botella C. et al. Behav Res Ther 2007.
3. CBT for panic (Clark, Barlow) — adapted for agoraphobia — Interoceptive + in vivo exposure.
4. Mobility Inventory (MIA) — Chambless (Chambless D.L.) — 27 situations; degree of avoidance alone and with partner.

9. Prognosis

• Exposure CBT — most patients achieve functional recovery.
• Chronicity without early intervention (housebound).
• Comorbid MDD predicts a poor prognosis.

10. Myths and misconceptions

Myth 1: “Patients with agoraphobia should not be placed in situations”

Evidence: Avoidance strengthens the symptoms; exposure is the main therapeutic mechanism.

Myth 2: “Agoraphobia is a ‘subtype’ of panic disorder”

Evidence: DSM-5-TR and ICD-11 — separate diagnostic categories; comorbidity possible, but can occur without the other.

Myth 3: “The patient is ‘lazy’, does not want to leave”

Evidence: Agoraphobia is a neurobiological and behavior-based clinical disorder; not a volitional or character problem.

Myth 4: “Only medication cures agoraphobia, therapy is unnecessary”

Evidence: without exposure-based CBT sustained remission difficult; pharmacotherapy alone does not change avoidance behavior.

Myth 5: “Ordering online or staying in distance education is an appropriate lifestyle for a patient with agoraphobia”

Evidence: Accommodation provides short-term relief but strengthens illness and reduces functional level.

11. Sources

1. WHO. ICD-11. 6B02 Agoraphobia. 2024.
2. APA. DSM-5-TR. 2022.
3. NICE CG113. 2011/2020.
4. Sánchez-Meca J. et al. Psychological treatment of panic disorder with or without agoraphobia: a meta-analysis. Clin Psychol Rev 2010;30(1):37–50.
5. Chambless D.L., Caputo G.C., Jasin S.E. et al. The Mobility Inventory for Agoraphobia. Behav Res Ther 1985;23(1):35–44.
6. Botella C., García-Palacios A., Villa H. et al. Virtual reality exposure in the treatment of panic disorder and agoraphobia. Clin Psychol Psychother 2007;14(3):164–175.