Agoraphobia in adults: Epidemiology, pathogenesis, clinical manifestations, course, and diagnosis
- Randi E McCabe, PhD
Randi E McCabe, PhD
- Associate Professor of Psychiatry & Behavioural Neurosciences
- McMaster University
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 . 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 . The presence of agoraphobia is associated with significant impairment in functioning, degree of disability, and unemployment . The disorder is treatable with various forms of cognitive behavioral treatment and antidepressant medication. More severe cases of agoraphobia may pose treatment challenges .
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 with or without agoraphobia in adults" and "Psychotherapy for panic disorder with or without agoraphobia in adults".)
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 .
Agoraphobia most commonly occurs in conjunction with panic disorder with lifetime prevalence rate of 1.1 percent . Lifetime prevalence rate of agoraphobia without panic disorder is lower, estimated at 0.8 percent in a large community survey . 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) . (See "Panic disorder in adults: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis".)
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- Genetic factors
- Neurobiological factors
- Personality factors
- Cognitive factors
- Social/environmental factors
- CLINICAL MANIFESTATIONS
- Differential diagnosis
- - Specific phobia
- - Separation anxiety disorder
- - Major depressive disorder
- Assessment tools
- SUMMARY AND RECOMMENDATIONS