Agoraphobia Without Panic Disorder — Diagnosis and Treatment

Agoraphobia, derived from Greek 'agora' (marketplace) and 'phobia' (fear), originally described fear of public spaces but has been substantially redefined in DSM-5 as a distinct anxiety disorder. Diagnostic criteria require marked fear or anxiety about two or more of five situations: using public transportation, being in open spaces, being in enclosed places, standing in line or being in a crowd, or being outside of the home alone. The fear must arise from thoughts that escape might be difficult or help might be unavailable in the event of developing panic-like or other incapacitating/embarrassing symptoms.

The DSM-5 separation of agoraphobia from panic disorder reflects research showing that agoraphobia can develop without panic attacks (approximately 25-50% of cases), arising instead from fears of physical incapacitation (falling, vomiting, incontinence) or social embarrassment in situations difficult to escape. This recognition is clinically important as treatment approaches differ: pure agoraphobia without panic emphasizes situational exposure without interoceptive exposure to feared bodily sensations.

Lifetime prevalence is approximately 1-2%, with female predominance and onset typically in adolescence or early adulthood. The disorder shows considerable comorbidity with depression, other anxiety disorders, and substance use disorders, with significant functional impairment from progressive avoidance leading to housebound states in severe cases. Evidence-based treatment centers on cognitive-behavioral therapy with graduated in vivo exposure, where patients systematically confront avoided situations from least to most anxiety-provoking with cognitive restructuring of catastrophic predictions. Pharmacotherapy with SSRIs (sertraline, escitalopram, paroxetine) or SNRIs (venlafaxine) provides effective adjunctive treatment, while benzodiazepines should generally be avoided as long-term agents due to dependence risk and interference with exposure-based learning.