Agoraphobia is generally known as a fear of open spaces, but is a complex condition that may involve the fear of visiting certain public areas like shopping centers, fear of specific situations like public transit, or a fear of leaving home altogether. Exposure to the feared stimulus usually results in anxiety or a panic attack. Symptoms of a panic attack include rapid heartbeat, hyperventilation, sweating, and nausea.
The newest version of the Diagnostic and Statistical Manual for Mental Disorders, DSM-5, contains some updates on the criteria for agoraphobia. Past versions of the DSM divided agoraphobia into two conditions: agoraphobia with panic attacks and agoraphobia without panic attacks.
That distinction was dropped in DSM-III-R and DSM-IV. The DSM-5 now completely separates panic disorder and agoraphobia. It also adds criteria for distinguishing agoraphobia from specific phobia, adds a 6-month duration requirement, and changes the criteria for panic attacks.
Although agoraphobia was once considered to be characterized by panic attacks, epidemiogical data have shown that agoraphobia exists without panic symptoms to a considerable extent. There is also evidence that agoraphobia without panic attacks can also lead to significant functional limitations, and that agoraphobia is independent of panic disorder (and other disorders) in severity, course, and outcome. Agoraphobia and panic disorder may still co-occur, however.
Agoraphobia and specific phobia
Agoraphobia is based on fear of situations which may be grouped into five categories. Those categories are:
- public transportation
- open spaces
- enclosed public spaces
- crowds or standing in line
- being outside of the home, in general
The fear or anxiety must occur in two of the five situations to meet criteria for agoraphobia. According to the DSM-5, if the individual fears only one situation, the diagnosis is of the specific phobia. Agoraphobia also differs from a specific phobia in terms of the feared consequences. If the situation is feared because of expected anxiety or panic responses alone, it falls into the category of agoraphobia. If the situation is feared for other reasons, then it is more likely a specific phobia.
6 month duration
Agoraphobia symptoms must be present for six months to qualify for a diagnosis of agoraphobia. This is consistent with other criteria for anxiety disorders.
An evaluation of agoraphobia typically begins with an assessment of symptoms. The symptoms would include anxiety or panic in two or more of the situation categories described in the DSM-5 criteria. These situations are avoided altogether or endured with extreme anxiety.
The evaluation may include an in-depth interview with a doctor or psychologist, and a physical examination to rule out other conditions. Agoraphobia may resemble some other disorders such as social phobia, a specific phobia, obsessive-compulsive disorder, post-traumatic stress disorder, or separation anxiety disorder. If the symptoms can be pinpointed to the DSM-5 criteria for agoraphobia and there is no other underlying condition, then a diagnosis of agoraphobia will be made.
Treatment options for agoraphobia include:
- Cognitive therapy: This type of therapy is based on changing patterns of thinking that trigger symptoms.
- Behavioral therapy: The goal of behavioral therapy is to change harmful behaviors. This may be done by gradual exposure to feared situations.
- Cognitive behavioral therapy: In cognitive behavioral therapy, a mix of the two approaches are used.
Reviewed by Liji Thomas, MD.