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Agoraphobia in adults: Epidemiology, pathogenesis, clinical manifestations, course, and diagnosis

Author
Randi E McCabe, PhD
Section Editor
Murray B Stein, MD, MPH
Deputy Editor
Richard Hermann, MD

INTRODUCTION

Agoraphobia is defined in DSM-5 as fear or anxiety about and/or avoidance of situations where help may not be available or where it may be difficult to leave the situation in the event of developing panic-like symptoms or other incapacitating or embarrassing symptoms [1]. Patterns of agoraphobic avoidance may range from just a few situations (eg, driving and crowds) to multiple situations. In severe cases, the individual becomes housebound, rarely leaving the house and, if so, only when accompanied.

Although the likelihood of agoraphobia is increased when panic symptoms are present, agoraphobia can occur alone or concurrently with panic disorder [2-4]. With the revision of DSM-IV to DSM-5, agoraphobia is diagnosed independently of panic disorder [1]. The presence of agoraphobia is associated with significant impairment in functioning, degree of disability, and unemployment [4]. The disorder is treatable with various forms of cognitive behavioral treatment and antidepressant medication. More severe cases of agoraphobia may pose treatment challenges [5].

The epidemiology, pathogenesis, clinical manifestations, course, and diagnosis of agoraphobia in adults are reviewed here. Treatment of agoraphobia is reviewed separately. Specific phobia and panic disorder in adults, and phobias in children, are reviewed separately. (See "Specific phobia in adults: Epidemiology, clinical manifestations, course and diagnosis" and "Panic disorder in adults: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis" and "Overview of fears and phobias in children and adolescents" and "Pharmacotherapy for panic disorder in adults" and "Psychotherapy for panic disorder in adults".)

OVERVIEW

Agoraphobia was considered to be a complication of panic disorder in DSM-IV wherein an individual avoids situations for fear of developing a panic attack (“fear of fear”) [6,7]. The unlinking of panic disorder and agoraphobia in DSM-5 reflects the current conceptualization that agoraphobia is a distinct disorder that exists independently of the presence or absence of panic disorder [1,8,9]. Agoraphobia has also been conceptualized more broadly as a fear of difficulty in escaping [10].

EPIDEMIOLOGY

Agoraphobia most commonly occurs in conjunction with panic disorder with lifetime prevalence rate of 1.1 percent [11]. Lifetime prevalence rate of agoraphobia without panic disorder is lower, estimated at 0.8 percent in a large community survey [11]. However, a prospective longitudinal study targeting an adolescent/young adult sample (representing what is considered to be the high-risk age range for psychopathology development) found a much higher incidence when DSM-IV rules requiring agoraphobia to be diagnosed within the context of panic disorder were not used, compared to when they were (5.3 percent versus 0.6 percent) [2]. (See "Panic disorder in adults: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis".)

                

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Literature review current through: Nov 2016. | This topic last updated: Mon Jun 27 00:00:00 GMT 2016.
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References
Top
  1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), American Psychiatric Association, Arlington, VA 2013.
  2. Wittchen HU, Nocon A, Beesdo K, et al. Agoraphobia and panic. Prospective-longitudinal relations suggest a rethinking of diagnostic concepts. Psychother Psychosom 2008; 77:147.
  3. Fava GA, Rafanelli C, Tossani E, Grandi S. Agoraphobia is a disease: a tribute to Sir Martin Roth. Psychother Psychosom 2008; 77:133.
  4. Wittchen HU, Gloster AT, Beesdo-Baum K, et al. Agoraphobia: a review of the diagnostic classificatory position and criteria. Depress Anxiety 2010; 27:113.
  5. Perugi G, Frare F, Toni C. Diagnosis and treatment of agoraphobia with panic disorder. CNS Drugs 2007; 21:741.
  6. Klein DF. Anxiety reconceptualized. Compr Psychiatry 1980; 21:411.
  7. Grant BF, Hasin DS, Stinson FS, et al. The epidemiology of DSM-IV panic disorder and agoraphobia in the United States: results from the National Epidemiologic Survey on Alcohol and Related Conditions. J Clin Psychiatry 2006; 67:363.
  8. Slade T, Grisham JR. A taxometric investigation of agoraphobia in a clinical and a community sample. J Anxiety Disord 2009; 23:799.
  9. Faravelli C, Cosci F, Rotella F, et al. Agoraphobia between panic and phobias: clinical epidemiology from the Sesto Fiorentino Study. Compr Psychiatry 2008; 49:283.
  10. Bienvenu OJ, Onyike CU, Stein MB, et al.. Primary agoraphobia as a specific phobia: Authors' reply. Br J Psychiatry 2006; 189:471.
  11. Kessler RC, Chiu WT, Jin R, et al. The epidemiology of panic attacks, panic disorder, and agoraphobia in the National Comorbidity Survey Replication. Arch Gen Psychiatry 2006; 63:415.
  12. McCabe L, Cairney J, Veldhuizen S, et al. Prevalence and correlates of agoraphobia in older adults. Am J Geriatr Psychiatry 2006; 14:515.
  13. Regier DA, Boyd JH, Burke JD Jr, et al. One-month prevalence of mental disorders in the United States. Based on five Epidemiologic Catchment Area sites. Arch Gen Psychiatry 1988; 45:977.
  14. Ritchie K, Norton J, Mann A, et al. Late-onset agoraphobia: general population incidence and evidence for a clinical subtype. Am J Psychiatry 2013; 170:790.
  15. Faravelli, C, Furukawa ,TA, Truglia, E. Panic disorder. In: Stress-Induced and Fear Circuitry Disorders. Andrews, G, Charney, DS, Sirovatka, PJ, Regier, DA, (Eds) American Psychiatric Association, Arlington 2009. p.31.
  16. Nocon A, Wittchen HU, Beesdo K, et al. Differential familial liability of panic disorder and agoraphobia. Depress Anxiety 2008; 25:422.
  17. Noyes R Jr, Crowe RR, Harris EL, et al. Relationship between panic disorder and agoraphobia. A family study. Arch Gen Psychiatry 1986; 43:227.
  18. Schreier A, Wittchen HU, Höfler M, Lieb R. Anxiety disorders in mothers and their children: prospective longitudinal community study. Br J Psychiatry 2008; 192:308.
  19. Kendler KS, Karkowski LM, Prescott CA. Fears and phobias: reliability and heritability. Psychol Med 1999; 29:539.
  20. Mosing MA, Gordon SD, Medland SE, et al. Genetic and environmental influences on the co-morbidity between depression, panic disorder, agoraphobia, and social phobia: a twin study. Depress Anxiety 2009; 26:1004.
  21. Torgersen S. Genetic factors in anxiety disorders. Arch Gen Psychiatry 1983; 40:1085.
  22. Wittmann A, Schlagenhauf F, Guhn A, et al. Anticipating agoraphobic situations: the neural correlates of panic disorder with agoraphobia. Psychol Med 2014; 44:2385.
  23. Brown TA. Temporal course and structural relationships among dimensions of temperament and DSM-IV anxiety and mood disorder constructs. J Abnorm Psychol 2007; 116:313.
  24. Bienvenu OJ, Brown C, Samuels JF, et al. Normal personality traits and comorbidity among phobic, panic and major depressive disorders. Psychiatry Res 2001; 102:73.
  25. Bienvenu OJ, Samuels JF, Costa PT, et al. Anxiety and depressive disorders and the five-factor model of personality: a higher- and lower-order personality trait investigation in a community sample. Depress Anxiety 2004; 20:92.
  26. Carrera M, Herrán A, Ramírez ML, et al. Personality traits in early phases of panic disorder: implications on the presence of agoraphobia, clinical severity and short-term outcome. Acta Psychiatr Scand 2006; 114:417.
  27. Rosellini AJ, Lawrence AE, Meyer JF, Brown TA. The effects of extraverted temperament on agoraphobia in panic disorder. J Abnorm Psychol 2010; 119:420.
  28. Bienvenu OJ, Hettema JM, Neale MC, et al. Low extraversion and high neuroticism as indices of genetic and environmental risk for social phobia, agoraphobia, and animal phobia. Am J Psychiatry 2007; 164:1714.
  29. Hirshfeld-Becker DR, Micco JA, Simoes NA, Henin A. High risk studies and developmental antecedents of anxiety disorders. Am J Med Genet C Semin Med Genet 2008; 148C:99.
  30. Hayward C, Wilson KA. Anxiety sensitivity: a missing piece to the agoraphobia-without-panic puzzle. Behav Modif 2007; 31:162.
  31. Bienvenu OJ, Stein MB, Samuels JF, et al. Personality disorder traits as predictors of subsequent first-onset panic disorder or agoraphobia. Compr Psychiatry 2009; 50:209.
  32. White KS, Brown TA, Somers TJ, Barlow DH. Avoidance behavior in panic disorder: the moderating influence of perceived control. Behav Res Ther 2006; 44:147.
  33. Levitan MN, Simoes P, Sardinha AG, Nardi AE. Agoraphobia Related to Unassertiveness in Panic Disorder. J Nerv Ment Dis 2016; 204:396.
  34. Hoffart A. Cognitive mediators of situational fear in agoraphobia. J Behav Ther Exp Psychiatry 1995; 26:313.
  35. Taylor S, Rachman SJ. Stimulus estimation and the overprediction of fear. Br J Clin Psychol 1994; 33 ( Pt 2):173.
  36. Mathews A, MacLeod C. Cognitive vulnerability to emotional disorders. Annu Rev Clin Psychol 2005; 1:167.
  37. Fava GA, Kellner R, Zielezny M, Grandi S. Hypochondriacal fears and beliefs in agoraphobia. J Affect Disord 1988; 14:239.
  38. Marks, JM. Fear, phobias, and rituals. Oxford University Press, New York 1987.
  39. Hood HK, Antony MM, Koerner N, Monson CM. Effects of safety behaviors on fear reduction during exposure. Behav Res Ther 2010; 48:1161.
  40. Salkovskis PM, Clark DM, Hackmann A, et al. An experimental investigation of the role of safety-seeking behaviours in the maintenance of panic disorder with agoraphobia. Behav Res Ther 1999; 37:559.
  41. Goisman RM, Goldenberg I, Vasile RG, Keller MB. Comorbidity of anxiety disorders in a multicenter anxiety study. Compr Psychiatry 1995; 36:303.
  42. Kessler RC, Berglund P, Demler O, et al. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 2005; 62:593.
  43. Tibi L, van Oppen P, Aderka IM, et al. An admixture analysis of age of onset in agoraphobia. J Affect Disord 2015; 180:112.
  44. Emmelkamp, PMG, Wittchen, HU. Specific phobias. In: Stress-Induced and Fear Circuitry Disorders: Refining the Research Agenda for DSM-V. Andrews, G, Charney, DS, Sirovatka, PJ, Regier, DA, (Eds), APA, Arlington 2009. p. 77.
  45. Porter E, Chambless DL. A systematic review of predictors and moderators of improvement in cognitive-behavioral therapy for panic disorder and agoraphobia. Clin Psychol Rev 2015; 42:179.
  46. Hoffart A, Hedley LM, Svanøe K, et al. Agoraphobia With and Without Panic Disorder: A 20-Year Follow-up of Integrated Exposure and Psychodynamic Therapy. J Nerv Ment Dis 2016; 204:100.
  47. First MB, William JB, Karg RS, Spitzer RL. Structured Clinical Interview for DSM-5 Disorders, Clinician Version (SCID-5-CV), American Psychiatric Association, Arlington 2015.
  48. Anxiety and Related Disorders Interview Schedule for DSM-5 (ADIS-5), Brown TA, Barlow DH. (Eds), Oxford University Press, New York 2014.
  49. Marks IM, Mathews AM. Brief standard self-rating for phobic patients. Behav Res Ther 1979; 17:263.
  50. Schmidt NB, Cromer KR. Assessing the clinical utility of agoraphobia in the context of panic disorder. Depress Anxiety 2008; 25:158.
  51. Chambless DL, Caputo GC, Jasin SE, et al. The Mobility Inventory for Agoraphobia. Behav Res Ther 1985; 23:35.
  52. Chambless DL, Sharpless BA, Rodriguez D, et al. Psychometric properties of the mobility inventory for agoraphobia: convergent, discriminant, and criterion-related validity. Behav Ther 2011; 42:689.
  53. Chambless DL, Caputo GC, Bright P, Gallagher R. Assessment of fear of fear in agoraphobics: the body sensations questionnaire and the agoraphobic cognitions questionnaire. J Consult Clin Psychol 1984; 52:1090.
  54. Reiss S, Peterson RA, Gursky DM, McNally RJ. Anxiety sensitivity, anxiety frequency and the prediction of fearfulness. Behav Res Ther 1986; 24:1.