Reaching an accurate diagnosis for agoraphobia is of paramount importance. Not only does it facilitate effective treatment, but it also helps sufferers make sense of their experience, offering clarity in a turbulent period of their lives. To ensure a precise diagnosis, clinicians adhere to standardized diagnostic criteria and employ a suite of assessment tools. Furthermore, a differential diagnosis is carried out to rule out conditions that present similarly to agoraphobia.
Diagnostic Criteria (DSM-V & ICD-10)
DSM-V (Diagnostic and Statistical Manual of Mental Disorders – Fifth Edition):
The DSM-V is the primary diagnostic manual used by mental health professionals in the United States. According to this manual, for a person to be diagnosed with agoraphobia, they must display:
Marked fear or anxiety about two (or more) of the following five situations:
Using public transportation.
Being in open spaces.
Being in enclosed spaces.
Standing in line or being in a crowd.
Being outside of the home alone.
The individual fears these situations due to thoughts that escape might be difficult or help might not be available in the event of developing panic-like symptoms.
The agoraphobic situations almost always induce fear or anxiety.
The agoraphobic situations are actively avoided, require the presence of a companion, or are endured with intense fear or anxiety.
The fear or anxiety is out of proportion to the actual danger posed by the agoraphobic situations and to the sociocultural context.
The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.
The fear, anxiety, or avoidance is not better accounted for by another mental disorder.
ICD-10 (International Classification of Diseases – Tenth Edition):
While the ICD-10, used worldwide, has many parallels with the DSM-V in diagnosing agoraphobia, it has its distinctions. The ICD-10 emphasizes:
Agoraphobia should be diagnosed when symptoms are predominant and disabling.
Panic disorder and agoraphobia can co-exist. If so, both should be diagnosed.
Distinction between agoraphobia with and without a history of panic disorder.
Tools and Assessment Methods
To diagnose agoraphobia, clinicians don’t rely on diagnostic criteria alone. They use a combination of clinical interviews and assessment tools:
a) Clinical Interviews
A thorough discussion with the patient about their fears, situations they avoid, the intensity and duration of symptoms, and the impact on daily life.
b) Panic and Agoraphobia Scale (PAS)
Original Source:
Bandelow, B. (1999). Panic and Agoraphobia Scale (PAS). Seattle, WA: Hogrefe &
Huber Publishers
This is a questionnaire used to assess the severity of panic disorder and agoraphobia. It assesses panic attacks, anticipatory anxiety, agoraphobic avoidance, disability, and worries about health.
The Panic and Agoraphobia Scale (PAS) is designed to track changes in symptoms related to panic. Initially created for monitoring progress in both therapy and medication trials, the PAS is versatile and suits various clinical and research contexts.
There are two versions of the PAS: one that individuals can fill out themselves and another where a clinician observes and rates the responses. Both versions have 13 questions. Each question is scored from 0 to 4, although the specific descriptions for these scores vary depending on the question.
The questions on the PAS cover five main areas:
Frequency and nature of panic attacks.
The extent of avoidance due to agoraphobia.
Levels of anxiety in anticipation of panic attacks.
The impact of symptoms on daily functioning.
Concerns related to health and wellbeing.
Each of these areas has its own subscale score, and there’s also an overall severity score. This score reflects the individual’s condition in the past week.
Completing the PAS generally takes between 5 to 10 minutes. If someone is filling it out for themselves, the clinician should clarify what “panic attack” and “agoraphobia” mean. Though, these terms are also explained within the scale.
To determine the total score, all responses are summed up, excluding the question about the unexpected nature of panic attacks (item U). Scores can be anywhere from 0 to 52.
For the clinician-administered version, scores are interpreted as follows:
0-6: Borderline or in remission
7-17: Mild
18-28: Moderate
29-39: Severe
40 and above: Very severe
For the self-rated version, the interpretation is slightly adjusted:
0-8: Borderline or in remission
9-18: Mild
19-28: Moderate
29-39: Severe
40 and above: Very severe.
Mobility Inventory for Agoraphobia (MI)
Original Source:
Chambless, D.L., Caputo, G. C., Jasin, S. E., Gracely, E. J., & Williams, C. (1985). The
Mobility Inventory for Agoraphobia. Behaviour Research and Therapy, 23, 35–44.
The Mobility Inventory (MI) is a questionnaire meant to understand the behavior and concerns of individuals with agoraphobia. It has four distinct sections and usually takes 5 to 10 minutes to complete. Here’s a more straightforward breakdown:
a) Avoidance Situations (Main Focus in Research)
This section lists 26 common situations that individuals with agoraphobia often avoid.
An additional space allows individuals to specify and rate another situation not listed.
Each of the 26 situations is rated on a scale of 1 (never avoid) to 5 (always avoid) in two contexts:
Avoidance when with someone.
Avoidance when alone.
When research studies refer to MI scores, they’re typically talking about this section.
b) Top Concerns
Here, individuals pinpoint the top five situations from the first section that trouble them the most or have the most significant impact on their lives.
c) Panic Assessment
This section has three questions about recent experiences with panic attacks:
Number of panic attacks in the last week.
Number of panic attacks in the past three weeks.
Severity of the most recent panic attacks on a scale of 1 (very mild) to 5 (extremely severe).
d) Safety Zone
Individuals describe a geographical area where they feel safest, specifying its location and extent. For instance, someone might feel secure within a 2-mile radius of their home.
Instructions and Scoring
While filling out the first section, if certain situations don’t apply to a person’s life, they can skip them. For instance, if there’s no subway system in someone’s city, they can leave that question blank.
However, if someone skips over five or more items, it’s suggested the responses might not offer a valid picture of their experiences.
The scores for the first section are determined by averaging the ratings for the first 26 items, both for when the person is with someone and when they’re alone. Including the 27th (the optional item) in this average is up to the evaluator.
The frequency of panic attacks is simply counted to provide a score for the third section.
Agoraphobia Cognitions Questionnaire (ACQ)
Original Source
Chambless, D. L., Caputo, G. C., Bright, P., & Gallagher, R. (1984). Assessment of ‘fear of fear’ in agoraphobics: The Body Sensations Questionnaire and the Agoraphobic Cognitions Questionnaire. Journal of Consulting and Clinical Psychology, 52, 1090–1097.
The ACQ (Agoraphobia Cognitions Questionnaire) is a self-report questionnaire consisting of 15 items. Patients use it to rate how often specific thoughts occur when they feel anxious or frightened. Items 1 to 14 focus on thoughts commonly associated with panic disorder and agoraphobia. Item 15 allows patients to note and rate any other thoughts they may have. Each item is rated on a scale from 1 (thought never occurs) to 5 (thought always occurs when I am nervous).
Completing the ACQ typically takes 5 to 10 minutes.
To score the ACQ, you can calculate the mean for items 1 through 14. Alternatively, it can yield two subscale scores: one for loss of control (averaging items 6, 8, 9, 11–14) and another for physical concerns (averaging items 1–5, 7, 10). You can also gather additional clinical insights by asking patients to identify their three most frequent panic-related thoughts after completing the questionnaire, although this step is optional.
Body Sensations Questionnaire (BSQ)
Original Source
Chambless, D. L., Caputo, G. C., Bright, P., & Gallagher, R. (1984). Assessment of ‘fear of fear’ in agoraphobics: The Body Sensations Questionnaire and the Agoraphobic Cognitions Questionnaire. Journal of Consulting and Clinical Psychology, 52, 1090–1097.
The Body Sensations Questionnaire (BSQ) is a tool with 18 questions that allows individuals to indicate how much they fear certain physical feelings that arise during moments of anxiety or fear. It typically takes between 5 to 10 minutes to fill out.
The first 17 questions focus on common physical reactions related to anxiety or fear. The final question, number 18, offers an opportunity for individuals to note and rank any additional physical sensations they might experience. Responses are gauged on a scale from 1, meaning “not at all,” to 5, meaning “extremely.”
To score the BSQ, an average is taken from the responses to the first 17 items. After filling out the questionnaire, there’s an optional step where individuals can highlight their top three most distressing sensations.
Agoraphobia Cognitions Scale (ACS)
Original Source:
Hoffart, A., Friis, S., & Martinsen, E. W. (1992). “Assessment of fear of fear among agoraphobic patients: The Agoraphobic Cognitions Scale.” Journal of Psychopathology and Behavioral Assessment, 14, 175–187.
a) Objective
This scale is designed to evaluate fearful thoughts in people suffering from panic disorder and agoraphobia.
b) About the Scale
The ACS is comprised of 10 questions.
Respondents gauge the intensity of specific fearful thoughts.
Responses are based on a scale from 0 (not at all concerned) to 4 (highly concerned).
c) Completion and Scoring
The ACS is quick, taking about 3 minutes to fill out.
It produces three distinct scores based on the responses:
d) Fear of Bodily Incapacitation
Average score of items 1 through 5.
e) Fear of Losing Control
Average score of items 6 and 7.
f) Fear of Embarrassment
Average score of items 8 to 10.
Differential Diagnosis
a) Panic Disorder
Panic disorder is one of the primary differentials for agoraphobia. It is characterized by recurrent, unexpected panic attacks, which may or may not be associated with specific triggers. While agoraphobia often accompanies panic disorder, they can also occur independently. Distinguishing features include:
Panic Attack Focus:
In panic disorder, the primary focus is on the panic attacks themselves, whereas in agoraphobia, the focus is on the fear of specific situations.
Avoidance Patterns:
Individuals with panic disorder may avoid situations only because they have experienced panic attacks in those situations. In contrast, agoraphobia involves a broader range of avoided situations.
b) Social Anxiety Disorder
Social anxiety disorder (also known as social phobia) involves a fear of social situations or scrutiny by others. This can sometimes overlap with agoraphobia, especially when it involves crowded places or public speaking. Key differentiating factors include:
Social Focus:
Social anxiety primarily revolves around fears related to social interactions and judgment, while agoraphobia is more about the fear of specific places or situations.
Avoidance Targets:
Social anxiety often leads to avoidance of social events, while agoraphobia involves avoidance of various public spaces or situations.
c) Specific Phobias
Specific phobias involve intense fear and avoidance of specific objects or situations, such as heights, spiders, or flying. While specific phobias can involve avoidance of public spaces, they differ from agoraphobia in the following ways:
Specific Triggers:
Social anxiety primarily revolves around fears related to social interactions and judgment, while agoraphobia is more about the fear of specific places or situations.
Fear Intensity:
In specific phobias, fear is often tied to the specific object or situation, whereas agoraphobia’s fear tends to be more diffuse and focused on the potential for embarrassment or inability to escape.
d) Generalized Anxiety Disorder (GAD)
Generalized anxiety disorder is characterized by excessive worry and anxiety about various aspects of life. While GAD and agoraphobia can co-occur, differentiating factors include:
Worry Focus:
GAD is characterized by excessive worry about a wide range of topics, while Agoraphobia’s fear is more specific to certain situations.
Avoidance Patterns:
Agoraphobia involves specific avoidance behaviors related to particular places or situations, whereas GAD-related avoidance is not as specific.
e) Obsessive-Compulsive Disorder (OCD)
Obsessive-compulsive disorder is marked by obsessions (intrusive, distressing thoughts) and compulsions (repetitive behaviors or mental acts performed to alleviate distress). OCD and agoraphobia may co-occur, but they can be distinguished by:
Obsessive Nature:
OCD’s primary feature is the presence of obsessions and compulsions, whereas agoraphobia’s focus is on the fear of certain situations.
Compulsion Targets:
Compulsions in OCD are usually unrelated to the situations or places feared in agoraphobia.
f) Post-Traumatic Stress Disorder (PTSD)
Post-traumatic stress disorder can resemble agoraphobia, especially when individuals avoid places or situations reminiscent of their traumatic experiences. Differentiating features include:
Trauma History:
PTSD is rooted in a traumatic event, whereas agoraphobia often develops without a specific traumatic trigger.
Symptom Presentation:
While avoidance may occur in both disorders, the core symptoms of PTSD revolve around reliving traumatic experiences and heightened arousal, which may not be as prominent in agoraphobia.
g) Post-Traumatic Stress Disorder (PTSD)
Post-traumatic stress disorder can resemble agoraphobia, especially when individuals avoid places or situations reminiscent of their traumatic experiences. Differentiating features include:
Trauma History:
PTSD is rooted in a traumatic event, whereas agoraphobia often develops without a specific traumatic trigger.
Symptom Presentation:
While avoidance may occur in both disorders, the core symptoms of PTSD revolve around reliving traumatic experiences and heightened arousal, which may not be as prominent in agoraphobia.
h) Separation Anxiety Disorder
Separation anxiety disorder typically occurs in children but can persist into adulthood. It involves excessive fear or anxiety about separation from attachment figures. While it’s rare in adults, it can sometimes be mistaken for agoraphobia when adults fear leaving their homes due to separation anxiety. Key differentiators include:
Attachment Focus:
Separation anxiety is primarily concerned with being away from attachment figures, while agoraphobia’s fear centers on specific places or situations.
Onset Age:
Separation anxiety typically presents in childhood and may continue into adulthood, whereas agoraphobia typically has an adult onset.
i) Substance-Induced Anxiety Disorder
Separation anxiety disorder tSeparation anxiety disorderCertain substances, including drugs and alcohol, can induce anxiety or panic-like symptoms, which may resemble agoraphobia. Accurate assessment requires a thorough evaluation of the individual’s substance use history and withdrawal symptoms. Differentiating factors include:
Temporal Relationship:
Symptoms of substance-induced anxiety typically occur during or shortly after substance use, while agoraphobia is characterized by more persistent and unrelated anxiety symptoms.
Resolution with Abstinence:
Symptoms of substance-induced anxiety often improve with abstinence, whereas agoraphobia symptoms persist.
j) Medical Conditions
Various medical conditions can mimic or exacerbate agoraphobia-like symptoms. These conditions can include cardiovascular issues, thyroid disorders, and neurological conditions. A thorough medical evaluation is essential to rule out underlying medical causes.
Physical Symptoms:
Medical conditions may manifest with physical symptoms, such as palpitations or shortness of breath, which can be confused with anxiety.
Onset and Course:
Agoraphobia typically has a gradual onset and tends to persist over time, whereas medical conditions may have different patterns.
