Agoraphobia

Essential (Required) Features:

• Marked and excessive fear or anxiety that occurs in, or in anticipation of, multiple situations where escape might be difficult or help might not be available, such as using public transportation, being in crowds, being outside the home alone, in shops, theatres, or standing in line.
• The individual is consistently fearful or anxious about these situations due to a fear of specific negative outcomes such as panic attacks, symptoms of panic, or other incapacitating (e.g., falling) or embarrassing physical symptoms (e.g., incontinence).
• The situations are actively avoided, are entered only under specific circumstances (e.g., in the presence of a companion), or else are endured with intense fear or anxiety.
• The symptoms are not transient, that is, they persist for an extended period of time (e.g., at least several months).
• The symptoms are not better accounted for by another mental disorder (e.g., paranoid ideation in Delusional Disorder; social withdrawal in Depressive Disorders).
• The symptoms result in significant distress about experiencing persistent anxiety symptoms or significant impairment in personal, family, social, educational, occupational, or other important areas of functioning. If functioning is maintained, it is only through significant additional effort.

Additional Clinical Features:

• The experiences feared by individuals with Agoraphobia may include symptoms of a panic attack as described in Panic Disorder (e.g., palpitations or increased heart rate, chest pain, feelings of dizziness or light-headedness) or other symptoms that may be incapacitating, frightening, difficult to manage, or embarrassing (e.g., incontinence, changes in vision, vomiting). It is often important to establish quite specifically the nature of the feared outcome in Agoraphobia, as this may inform the specific choice of treatment strategies.
• It is common for individuals with Agoraphobia to have a history of panic attacks, although they may not currently meet the diagnostic requirements for Panic Disorder or indeed have panic attacks at all because they avoid situations in which panic attacks may occur. Establishing that an individual’s focus of apprehension relates specifically to experiencing the bodily symptoms of a panic attack would be important in considering whether to add components of Panic Disorder treatment (e.g., interoceptive exposure) to the treatment of Agoraphobia, even when there is no current Panic Disorder diagnosis.
• Individuals with Agoraphobia may employ a variety of different behavioural strategies if required to enter feared situations. One such ‘safety’ behaviour is to require the presence of a companion. Other strategies may include going to certain places only at particular times of day or carrying specific materials (e.g., medications, towels) in case of the feared negative outcome. These strategies may change over the course of the disorder and from one occasion to the next. For example, on different occasions in the same situation an individual may insist on having a companion, endure the situation with distress, or use various safety behaviours to cope with their anxiety.
• Although the pattern of symptoms, the severity of the anxiety, and the extent of avoidance are variable, Agoraphobia is one of the most impairing of the Anxiety or Fear-Related Disorders to the extent that some individuals become completely housebound, which has an impact on opportunities for employment, seeking medical care, and the ability to form and maintain relationships.

Boundary with Normality (Threshold):

• Individuals may exhibit transient avoidance behaviours in the context of normal development or in periods of increased stress. These behaviours are differentiated from Agoraphobia because they are limited in duration and do not lead to significant impact on functioning.
• Individuals with disabilities or medical conditions may avoid certain situations because of reasonable concerns about being incapacitated or embarrassed (e.g., a person with a mobility limitation who is concerned that an unfamiliar location won’t be accessible, a person with Crohn’s disease who is concerned about experiencing sudden diarrhoea). Agoraphobia should only be diagnosed if the anxiety and avoidance result in functional impairment that is greater than expected given the disability or heath condition.

Course Features:

• The typical age of onset for Agoraphobia is in late adolescence, with the majority of individuals experiencing onset before age 35 years. However, age of onset is later (during the mid to late 20s) for individuals without a history of panic attacks or pre-existing diagnosis of Panic Disorder. Onset during childhood is considered rare.
• Agoraphobia is generally considered a chronic and persistent condition. The long-term course and outcome of Agoraphobia is associated with increased risk of developing Depressive Disorders, Dysthymic Disorder, and Disorders Due to Substance Use.
• Greater symptom severity (e.g., avoidance of most activities, being housebound) is associated with higher rates of relapse and chronicity, and poorer long-term prognosis.
• The presence of co-occurring disorders, particularly other Anxiety or Fear-Related Disorder, Depressive Disorders, Personality Disorder, and Disorders due to Substance Use has been associated with poorer long-term prognosis.

Developmental Presentations:

• Although the clinical features of Agoraphobia generally remain consistent across the lifespan, specific triggers and related cognitions can vary across age groups. For example, whereas fear of being outside of the home alone or becoming lost are common during childhood, adults are more likely to fear standing in line, being in crowded or open spaces, or experiencing a panic attack. Among older adults, fear of falling is common.
• Similar to adults, children and adolescents with Agoraphobia may demonstrate excessive avoidance of certain situations or locations, or require the presence of a close friend or family member to enter these situations. Children with Agoraphobia are likely to resist leaving the home without a parent or caregiver. A common focus of apprehension is becoming lost and not being able to obtain help. Soliciting information from collateral informants who know the child well can assist in clarifying the child’s focus of apprehension.

Culture-Related Features:

• Assessment of Agoraphobia should incorporate information on cultural and gender norms. For example, fear of leaving the home among populations and contexts in which violence is common should not be assigned this diagnosis unless the fear is in excess of what is culturally normative. Likewise, for individuals in cultures who spend most of their time at home, anxiety when in open areas (e.g., markets) may be expected; the disorder should only be diagnosed when the fear exceeds cultural norms.

Sex- and/or Gender-Related Features:

• Lifetime prevalence of Agoraphobia is approximately twice as high in women. Among children, it is more frequently reported in girls, with symptom onset occurring earlier for girls than boys.
• Men with Agoraphobia are more likely to report co-occurring Disorders due to Substance Use.

Boundaries with Other Disorders and Conditions (Differential Diagnosis):

• Boundary with Panic Disorder: It is common for individuals with Panic Disorder to develop some degree of agoraphobic symptoms over time. If the individual experiences recurrent unexpected panic attacks that are not restricted to particular stimuli or situations, and agoraphobic symptoms do not meet the full diagnostic requirements for Agoraphobia, then Panic Disorder is the appropriate diagnosis. Conversely, many individuals with Agoraphobia have experienced recurrent panic attacks. If an individual with Agoraphobia experiences panic attacks exclusively in the context of the multiple agoraphobic situations without the presence of unexpected panic attacks, an additional diagnosis of Panic Disorder is not warranted and the presence of panic attacks may be indicated using the ‘with panic attacks’ specifier. However, if unexpected panic attacks also occur, an additional diagnosis of Panic Disorder may be assigned.
• Boundary with Specific Phobia: Specific Phobia is differentiated from Agoraphobia because it involves fear of circumscribed situations or stimuli themselves (e.g., heights, animals, blood or injury) rather than fear or anxiety of imminent perceived dangerous outcomes (e.g., panic attacks, symptoms of panic, incapacitation, or embarrassing physical symptoms) that are anticipated to occur in multiple situations where obtaining help or escaping might be difficult.
• Boundary with Social Anxiety Disorder: In Social Anxiety Disorder, symptoms in response to feared social situations (e.g., speaking in public, initiating a conversation) and the primary focus of apprehension is on being negatively evaluated by others.
• Boundary with Separation Anxiety Disorder: Similar to Agoraphobia, individuals with Separation Anxiety Disorder avoid situations but, in contrast, they do so to prevent or limit being away from individuals to whom they are attached (e.g., parent, spouse, or child) for fear of losing them.
• Boundary with Schizophrenia or Other Primary Psychotic Disorders: Individuals with Schizophrenia or Other Primary Psychotic Disorders may avoid situations as a consequence of persecutory or paranoid delusions rather than because of fear or anxiety of imminent perceived dangerous outcomes (e.g., panic attacks, symptoms of panic, incapacitation, or embarrassing physical symptoms) that are anticipated to occur in multiple situations where obtaining help or escaping might be difficult.
• Boundary with Depressive Disorders: In Depressive Disorders, individuals may avoid multiple situations but do so because of loss of interest in previously pleasurable activities or due to lack of energy rather than because of fear or anxiety of imminent perceived dangerous outcomes (e.g., panic attacks, symptoms of panic, incapacitation, or embarrassing physical symptoms) that are anticipated to occur in multiple situations where obtaining help or escaping might be difficult.
• Boundary with Post-Traumatic Stress Disorder: In Post-Traumatic Stress Disorder, the individual deliberately avoids reminders likely to produce re-experiencing of the traumatic event(s). In contrast, situations are avoided in Agoraphobia because of fear or anxiety of imminent perceived dangerous outcomes (e.g., panic attacks, symptoms of panic, incapacitation, or embarrassing physical symptoms) that are anticipated to occur in multiple situations where obtaining help or escaping might be difficult.
• Boundary with Oppositional Defiant Disorder: Irritability, anger, and noncompliance are sometimes associated with anxiety in children and adolescents. For example, children may exhibit angry outbursts when asked to enter situations that make them feel anxious (e.g., being asked to leave the home without a trusted companion such as a parent or caregiver). If the defiant behaviours only occur when triggered by a situation or stimulus that elicits anxiety, fear, or panic, a diagnosis of Oppositional Defiant Disorder is generally not appropriate.