Diagnosis of Agoraphobia

Agoraphobia is anxiety, fear, or avoidance of situations where the person might feel trapped, helpless, or incapacitated. Sometimes these situations can be endured if the person is accompanied by a trusted companion. Examples includes buses, trains, plains, stadiums, shopping centers, and even just being away from home, and therefore away from sources of support if something should go wrong.

In DSM-IV, agoraphobia was considered to be a specifier for panic disorder. A client with panic disorder would be further diagnosed as panic disorder with agoraphobia or panic disorder without agoraphobia. At the time, it was believed that the anxiety and terror of panic disorder would tend to generalize to any class of situations in which the client found themselves. In other words, panic disorder causes agoraphobia, a natural evolution, so that the presence or absence of agoraphobia tends to mark the severity of panic disorder.

When you talk to clients with panic disorder, you quickly realize that these clients would do almost anything to avoid their panic attacks, including avoiding situations where escape might be difficult if an attack occurs. Such avoidance is the defining feature of agoraphobia.

In DSM-5, however, it was realized that agoraphobia can also occur in the absence of a diagnosis of panic disorder. You can be agoraphobic with no history of panic symptoms. As such, agoraphobia is now broken out as it’s own disorder. Since DSM-5 was published comparatively recently in 2013, it’s a good example of how psychological and psychiatric understanding continues to evolve. In contrast to the periodic table in chemistry, which may be said to have objective existence in nature, the DSM is a human construction.

Diagnostic Features

The DSM-5 notes (p. 218) that “the essential feature of agoraphobia is marked, or intense, fear or anxiety triggered by real or imagined exposure to a wide variety of situations.” The DSM then goes on to list five situations that typically evoke anxiety, two of which are necessary for the diagnosis:

  • Using public transportation
  • Open spaces
  • Enclosed spaces
  • Standing in line, crowds
  • Being alone away from home.

In Criterion B, these situations evoke characteristic cognitions like “I’ll get trapped there” and “I won’t have anyone to help me if something happens.” These cognitions are associated with vulnerability, that is, the wherewithal of the person versus the potential severe consequences of the situation. The severe consequences could be panic symptoms (a full blown panic attack is not required for a diagnosis of agoraphobia), but could also be any incapacitating or embarrassing situation, such a diarrhea or loss of bladder control. So there’s the important difference between DSM-IV and DSM-5 again: Panic is just one pathway to agoraphobia. Incapacitating and embarrassing conditions are additional pathways.

Criterion C requires that fear or anxiety almost always accompany the situations. Presumably, then, anxiety half the time would not qualify.

Criterion D requires that the situations be “actively avoided,” that they require the presence of a helper or companion that might provide assistance, or are otherwise endured with despite intense fear or anxiety.

Criterion E is concerned with proportionality. The fear or anxiety must be out of proportion to the real degree of threat.

Criterion F is persistence. The symptoms must have endured six months or more.

Criterion G is pervasiveness. The symptoms must cause “clinically significant distress” in important life domains, such as social or occupational functioning.

Criterion H is exclusionary. If another medical condition is present, then naturally that might lead to anxiety and avoidance, but an agoraphobia diagnosis requires the anxiety and avoidance to be excessive.

Criterion I is also exclusionary. The symptoms must not be better explained by another mental disorder, such as social anxiety disorder.

If the person falls short of meeting diagnostic criteria, perhaps because intense anxiety accompanies the situations but of the time, but not almost always, then a diagnosis of Other Specified Anxiety Disorder can be made. With “other specified” diagnoses, it is specified within the diagnosis where diagnostic criteria are not met. So, “Agoraphobia with Avoidance of Situations Occurring Most of the Time, But not Almost Always” seems reasonable here.

Case Discussion

Here’s a real case from my practice: A client presented with a fear of embarrassing herself when visiting friends due to inflammatory bowel disease that was frequently accompanied by diarrhea, sometimes explosive diarrhea. When an attack of diarrhea started, she would disappear from her get together with friends and be in the restroom for a half hour or more. In the confidence of the therapy room, she explained that it took that long to clean up afterwards, and that it was often disgusting. Friends would come in ask, “Are you okay?” She visualized her friends looking at her empty seat and wondering what in the world was really wrong with her and what she might be hiding. Moreover, when the diarrhea came on, the need for a restroom could be urgent. If she didn’t make it to a restroom in time, she might not be able to hold the diarrhea and could soil her clothes. Even a little bit was completely humiliating. The client knew every suitable restroom on the routes she frequently travelled. Without a suitable restroom, she refused to leave the home. Even when she was supposed to be having a good time with her friends, she secretly lived in fear of diarrhea, to the point that it undermined any enjoyment of her social engagements. She just tried to paste on a smile and get through it.

Is this agoraphobia? Yes, it is, and panic attacks are not involved. The case qualifies as agoraphobia because it is a fear of multiple situations where the client might be temporarily incapacitated by the diarrhea accompanying her inflammatory bowel disease. If the fear, anxiety, or avoidance accompany a medical diagnosis, then the DSM-5 requires it to be “clearly excessive,” and it is. In fact, it’s likely that the inflammatory bowel disease and the client’s anxiety had become a self-sustaining vicious circle, with the anxiety triggering the diarrhea and the diarrhea triggering the anxiety. This suggested that by treating the shame underlying her condition, we had a chance to make a difference with regard to the diarrhea, as well.

Since agoraphobia in this case is based on being incapacitated or embarrassed by circumstances, the client and I decided to work on the underlying shame. She gradually revealed the secret of her inflammatory bowel disease to significant others in her life. Everyone was enormously supportive, and with that the shameful secret lost its power. To her surprise, her girlfriends shared their own health issues—some of which were more severe than her own—which drew everyone closer. The client also made a few practical changes. She started wearing Depends instead of her regular undergarments, and she carried a few extra Depends in her purse. Yes, she did have some residual anxiety while waiting to see if these life changes would actually work out. Fortunately, they did. No more agoraphobia.