Agoraphobia Without History of Panic Disorder

Diagnostic Features
The essential features of Agoraphobia Without History of Panic Disorder are similar to those of Panic Disorder With Agoraphobia except that the focus of fear is on the occurrence of incapacitating or extremely embarrassing panic-like symptoms or limited-symptom attacks rather than full Panic Attacks. Individuals with this disorder have Agoraphobia (Criterion A). The “panic-like symptoms” include any of the 13 symptoms listed for Panic Attack or other symptoms that may be incapacitating or embarrassing (e.g., loss of bladder control, vomiting in public). For example, an individual may fear having a severe headache or cardiac symptoms and not being able to get help.

To qualify for this diagnosis, the full criteria for Panic Disorder must never have been met (Criterion B) and the symptoms must not be due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (Criterion C). If an associated general medical condition is present (e.g., a cardiac condition), the fear of being incapacitated or embarrassed by the development of symptoms (e.g., fainting) is clearly in excess of that usually associated with the condition (Criterion D). When a diagnosis of Agoraphobia Without History of Panic Disorder is being made, it should be ensured that the avoidance is characteristic of Agoraphobia and cannot be better explained by another Axis I disorder (e.g., Specific Phobia or Social Phobia) or Axis II disorder (e.g., Avoidant Personality Disorder).

Specific Culture and Gender Features
Some cultural or ethnic groups restrict the participation of women in public life, and this must be distinguished from Agoraphobia. This disorder is diagnosed far more often in females than in males.

Prevalence
In clinical settings, almost all individuals (over 95%) who present with Agoraphobia also have a current diagnosis (or history) of Panic Disorder. In contrast, the prevalence of Agoraphobia Without History of Panic Disorder in epidemiological samples has been reported to be higher than that for Panic Disorder With Agoraphobia. However, problems with assessment appear to have inflated the rates reported in epidemiological studies. Recently, individuals who were given a diagnosis of Agoraphobia Without History of Panic Disorder in an epidemiological study were reevaluated by clinicians using standard interview schedules. The majority were found to have Specific Phobias, but not Agoraphobia.

Course
Relatively little is known about the course of Agoraphobia Without History of Panic Disorder. Anecdotal evidence suggests that some cases may persist for years and be associated with considerable impairment.

Differential Diagnosis
Agoraphobia Without History of Panic Disorder is distinguished from Panic Disorder With Agoraphobia by the absence of a history of recurrent unexpected Panic Attacks. The avoidance in Agoraphobia Without History of Panic Disorder results from fear of incapacitation or humiliation due to unpredictable, sudden, panic-like symptoms rather than from fear of a full Panic Attack as in Panic Disorder With Agoraphobia. The diagnosis of Panic Disorder With Agoraphobia remains appropriate in cases in which Panic Attacks go into remission but Agoraphobia continues to be experienced.

Other reasons for avoidance must also be distinguished from Agoraphobia Without History of Panic Disorder. In Social Phobia, individuals avoid social or performance situations in which they fear that they might act in a way that is humiliating or embarrassing. In Specific Phobia, the individual avoids a specific feared object or situation. In Major Depressive Disorder, the individual may avoid leaving home due to apathy, loss of energy, and anhedonia. Persecutory fears (as in Delusional Disorder) and fears of contamination (as in Obsessive-Compulsive Disorder) can also lead to widespread avoidance. In Separation Anxiety Disorder, children avoid situations that take them away from home or close relatives.

Individuals with certain general medical conditions may avoid situations due to realistic concerns about being incapacitated (e.g., fainting in an individual with transient ischemic attacks) or being embarrassed (e.g., diarrhea in an individual with Crohn’s disease). The diagnosis of Agoraphobia Without History of Panic Disorder should be given only if the fear or avoidance is clearly in excess of that usually associated with the general medical condition.

Diagnostic criteria for Agoraphobia Without History of Panic Disorder
A. The presence of Agoraphobia related to fear of developing panic-like symptoms (e.g., dizziness or diarrhea).
B. Criteria have never been met for Panic Disorder.
C. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.
D. If an associated general medical condition is present, the fear described in Criterion A is clearly in excess of that usually associated with the condition.

Provided by ArmMed Media
Revision date: July 8, 2011
Last revised: by Sebastian Scheller, MD, ScD