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Running head: AGORAPHOBIA 1

AGORAPHOBIA 21

Agoraphobia

Azurdee Brown

Liberty University

HSMF-687

Abstract

Women face more challenges, responsibilities, and unrealistic expectations in today's world than they have ever experienced in history. They are subjected to a lot of pressure concerning what is expected of them, their appearance, and even space in their social environments. As such, counseling women requires significant experience, awareness, and knowledge about their concerns and issues they experience. Agoraphobia is one problem that is not addressed but critically affects most women. As an anxiety disorder, agoraphobia involves the fears of spaces that are considered unsafe, with individuals feeling not having easy ways to escape in such places or situations. The problem is twice more likely to affect women than it is for men. Even though its symptoms are severe, there are no clear causes of anxiety disorder. Even so, agoraphobia is treatable with a combination of behavioral therapy and medication as essential treatment approaches. Therapists are encouraged to use Biblical teachings to support patients with agoraphobia not only during the treatment process but coping up with the fears and anxiety.

Agoraphobia

One of the major issues that women can bring to counseling involves fear of going to certain open places. People who develop this kind of phobia are scared by certain situations, always feeling overwhelmed with anxiety for being unable to escape or get help. This kind of anxiety disorder is referred to as agoraphobia. Even though it is rare, Kivi (2012) indicates that you become afraid of getting out into the world when you have it. Particularly, agoraphobia involves extreme avoidance of places and situations that may cause panic. According to Bandelow, Domschke, and Baldwin (2013), even though agoraphobia is mostly referred to as the fear of open places, it is more complex. They indicate that it can involve many other fears, including fear of bridges, crowds, public transportation, shopping malls, driving, and even concerts, among many other outside activities. As such, people with this kind of anxiety disorder prefer to avoid situations that may make them feel panicked, helpless, trapped, or even embarrassed.

Current statistics of the problem

In most cases, panic, or anxiety disorders such as agoraphobia usually occur unexpectedly. Bandelow et al. (2013) indicate that even though patients with such conditions need immediate help, it is sometimes hard to obtain. They suggest that agoraphobia, in most cases, emerges in early during adolescence and is more prevalent in adults. More so, agoraphobia is more common in adults experiencing panic disorders. Nevertheless, according to Obioha (2020), about 0.8 percent of adults in the United States and mostly over the age of eighteen have agoraphobia even without having any history of panic attacks.

Generally, this kind of anxiety disorder is more prevalent in women than it is for men. Jacobson (2011) indicates that women are twice more likely to develop agoraphobia compared to men. In most women, agoraphobia mostly develops before the age of thirty-five. Also, certain events in their lives increase the risks of agoraphobia, including being abused, attacked, and during grief when a loved one is dead. Agoraphobia tends to affect people with relatives who have the condition or had it in some time of their lives (Jacobson, 2011). In America, agoraphobia has been diagnosed more in women. There is an 89 percent likelihood that women will have agoraphobia in their life, reflecting on women's experiences in contemporary society (Jacobson, 2011).

According to the American Psychiatric Association, 1 percent to 2 percent of people who have a panic disorder are also likely to suffer from agoraphobia (Obioha, 2020). The prevalence of gender difference in agoraphobia related anxieties emerges from the culturally accepted avoidance behaviors between men and women. In this way, men are more likely to cope with unwanted panic symptoms and anxieties using proactive substances or alcohol than women (Obioha, 2020). In women, agoraphobia is quite disabling. Obioha (2020) indicates that 26.5 percent of women report their avoidance to have interference with their day to day lives. This includes marital problems, interpersonal issues, and other functional difficulties in raising children. Even though agoraphobia can be treated, McIntosh and Legg (2017), observe that some people may still experience some of its symptoms when experiencing stress. Even so, one in three people may eventually overcome agoraphobia and never experience it again. More than half of those diagnosed with the problem may show significant improvement. Unfortunately, sometimes one in five people do not display any increase and are likely to continue living with the condition in their lifetime.

Symptoms of the Problem

People experiencing agoraphobia feel stressed and anxious when thinking about or find themselves in situations or places they cannot find help more readily. They are mostly afraid of open or crowded places, making them find it difficult to get out, feeling embarrassed or threatened because of their safety. As such, anyone with agoraphobia works hard to ensure they do not trigger these feelings. Physical agoraphobic symptoms include increased heart rate, sweating in excess, difficulty breathing, shaking, experiencing chest pains, feeling dizzy and dumb, vomiting and diarrhea, and losing control for fear of dying (Counselling Directory, 2015). Apart from the physical feelings, a person with agoraphobia can feel detached from people, helpless, agitated, stressed by the environment, and even feel their body functioning abnormally. At times, they may experience panic attacks, feeling depressed, and alone.

According to Balaram and Marwaha (2020), DSM-5 considers agoraphobia as a distinct diagnosis that occurs independently from other diagnoses. It is marked with anxiety or fear, either anticipated or actual exposure to public spaces. The symptoms of anxiety and fear occur most of the time for people who experience agoraphobia. As such, for people to be diagnosed with agoraphobia, they have to experience fears and anxieties when in public, feeling shortness of breath, nausea, and chest pains, among many others (Balaram & Marwaha, 2020). Also, individuals may feel not in control of a situation, feel like they are looking bad in front of people who are staring at them, and sometimes always want to go outside or in public places with other people they most trust. A person with agoraphobia may also not want to be alone in the house, at home, or in public.

As a counselor, it is important to explore whether the patient meets the criteria created for clinical diagnosis as per the American Psychiatric Association (APA) guidelines. In the intake interview, the therapist will ask the patient if they feel anxiety or fear when using public transportation, in open places, enclosed spaces, within crowds, or when left in the house alone. According to the Counselling Directory (2015), the counselor will tailor the diagnosis based on what can be done to avoid the situations identified, the proportion of the fear experienced by the patient which exceeds the potential of the imminent danger or if the fear cause problems to the patient's life at home and even at work. Balaram and Marwaha (2020) indicate that every underlying anxiety disorder should be ruled out before the patient is diagnosed with agoraphobia.

Causes of the problem

According to Aqeel, Aqeel, and Tohid (2016), agoraphobia has always emerged from panic attacks when individuals find themselves in certain environments or situations. They become worried of having another panic attack when in similar settings that may trigger symptoms of a panic attack. As such, they avoid these environments and situations in the future. Agoraphobia may be caused by existing mental health conditions, including panic disorders. In this sense, it is a combination of psychological and biological factors that impact an individual's experience in life (Aqeel et al., 2016). In relation to biological factors, agoraphobia is associated with the body's fight or flight reflex naturally to protect oneself from dangerous ad stressful situations. In this case, fear and anxiety may cause the body to release hormones, such as adrenaline, increasing an individual's heart and breathing rate. If the flight and fight reflex is triggered wrongly, it may cause an agoraphobic related panic attack.

Inoue, Kaiya, Hara, and Okazaki (2016) indicate that the imbalance in neurotransmitters levels in the human brain can also cause agoraphobia. This affects an individual's behavior and mood, leading to heightened stress levels that trigger fears and anxieties that can lead to a panic attack. Some people may have a weakened sense of system balance and spatial awareness, causing them to feel disoriented and overwhelmed in public or overcrowded places. Consequently, psychological factors that can cause agoraphobia to include traumatic childhood experiences, past stressful events, drug and alcohol abuse, abusive relationships, and previous histories of mental problems (Inoue et al., 2016). More so, agoraphobia can be triggered by violent experiences such as being a victim of a terrorist attack, abusive marriage, and violent robbery in the house, among other irrational fears. The person might have been infected with a serious illness when in a crowded place or done something embarrassing that they felt judged in a humiliating manner.

Essentially, there is no cause of panic disorder related to agoraphobia. However, the above risk factors are always assessed before the diagnosis is made in the clinical setting. In essence, family genetic history concerning anxiety-related disorders is considered a possible factor toward agoraphobia and other depressive illnesses related to panic disorders. Also, negative experiences in life that someone felt extremely stressful, either during childhood or adolescence, may trigger agoraphobia. The death of a loved one, including family members or friends, is mostly associated with agoraphobia and panic disorders. In others, underlying physical and medical conditions trigger agoraphobia and other associated panic disorders.

Treatment of the problem

Balaram and Marwaha (2020) indicate that although agoraphobia and panic disorder are always differentiated, their diagnostic criteria and treatment at times remain similar. Most individuals who present themselves to a mental specialist are those who developed agoraphobia after a panic disorder. Specialists treat agoraphobia in relation to avoidance behaviors after repeated panic attacks or subsequent fears and anxiety in avoidance situations. Early diagnosis and treatment of agoraphobia can prove effective. However, the mental health specialist should always rule out other mental health disorders and ensure the patient meets the criteria for agoraphobia. As such, the first step to the treatment of agoraphobia is to assess its severity, measuring its impairment levels or distress caused to the patient's life (Balaram & Marwaha, 2020). More so, the diagnosis should be based on the criteria listed by the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) for agoraphobia.

Even though there might be various ways to treat and overcome agoraphobia, most counseling treatment options include psychotherapy and effective medication. In therapy, the focus is always placed on decreasing the anxiety-provoking, self-defeating, and other negative behaviors, and thoughts. According to Gloster et al. (2011), cognitive behavioral therapy is highly effective in treating agoraphobia, especially when it occurs alongside panic disorder. Fundamentally, cognitive behavioral therapy with or without medication has always proved effective in relieving the symptoms of agoraphobia as well as preventing their reoccurrence. Even so, some patients may not respond equally to this kind of treatment (Gloster et al., 2011). Therefore, different patients may require different approaches.

Cognitive-behavioral therapy helps counselors to understand the symptom triggers, changes in behaviors, and coping strategies. In the cognitive behavioral therapy process, the therapist, and the client work together to identify, recognize, and replace the patient's negative thoughts (Gloster et al., 2011). First, the therapist helps in the identification of negative thinking patterns and cognitions. In this sense, the client might be directed to assess themselves, how they feel, or view the world, contemplating how the patient perceives it during a panic attack. While focusing on the underlying negative thoughts, the therapists help the client recognize different thinking perspectives and how they affect and influence specific behaviors.

Moreover, the other activities can be used in the counseling sessions, involving those that increase patient self-awareness. Ideally, exercises have proven significant in replacing negative thoughts, ensuring the patients learn newer and healthier thinking ways. Other homework activities are helpful after sessions to ensure the client continuously recognizes and eliminates prior faulty thinking. According to Gloster et al. (2011), the next step in cognitive behavioral therapy is to build skills and change behaviors. These involve all the strategies for coping and changing maladaptive behaviors. In this phase, the therapist will help the client develop the necessary skills important for reducing stress, circumnavigating panic, and managing anxiety. In the session, the skills can be learned, rehearsed, and practiced during and after the therapy.

Cognitive-behavioral therapy is always accompanied by therapist-guided exposure (Sánchez-Meca et al., 2010). Here, desensitization is used to help the client overcome avoidance behaviors. As such, the therapist can explore systematic desensitization by gradually introducing the patient to anxiety-producing stimuli while teaching how to manage such anxiety feelings. The client is further introduced to fear-inducing situations slowly and helped to develop effective ways to cope with the agoraphobia or panic symptoms in the feared circumstances (Sánchez-Meca et al., 2010). Also, relaxation techniques are used to ensure the client remains calm throughout the anxiety and fear-inducing situations they have learned. The methods may include deep mediation, yoga, muscle relaxation, and deep breathing exercises.

Exposure therapy helps people put themselves in situations that cause agoraphobic anxiety and help them relax as they master to manage those behaviors. The internet has provided an excellent way to carry out the exposure and response prevention process. More people are gaining access to the internet, increasing the significance of exposure-based therapy. According to Bettencourt, Roca-Sánchez, Acosta, Villaverde, and Gracia (2015), combining virtual reality to cognitive behavioral therapy with exposure-based treatment can show significant improvements in the client's ability to change behaviors. Bettencourt et al. (2015) suggest combining medications to cognitive behavioral therapy and virtual reality exposure can significantly improve clients with agoraphobia. Even so, doubts still exist concerning the efficacy of virtual reality in the treatment process.

Besides the effectiveness of cognitive-behavioral therapy in agoraphobia treatment, pharmacotherapy is also considered an effective treatment approach. In this sense, pharmacological treatment is incorporated into the therapy process to improve patient outcomes. Perna, Daccò, Menotti, and Caldirola (2011) indicate that effective compounds in the mediations include selective serotonin reuptake inhibitors, tricyclic antidepressants, serotonin-norepinephrine reuptake inhibitors, benzodiazepines, as well as selective noradrenergic reuptake inhibitors. Other compounds such as citalopram, clomipramine, paroxetine, and sertraline are also highly effective, with fluoxetine, fluvoxamine, and imipramine, having limited efficacy in treating agoraphobia (Perna et al., 2011).

Even so, the side effects of agoraphobia medications have significant side effects that differ from one person to the other. They mostly depend on the drug used either as antidepressants or as an anti-anxiety medication. Some of the experienced side effects might involve sexual dysfunction, dry mouth, stomach upset, nausea, or sometimes having trouble sleeping. Also, the patient can experience blurred vision, dizziness, tremors, and even constipation. In some rare cases, the patient may feel depressed or anxious after taking the medication, and at times could lead to suicide or homicide thoughts. Perna et al. (2011) indicate that children and adolescents are considered highly vulnerable to such agoraphobia medication. Therefore, the therapist needs to work closely with a doctor on deciding which medication is appropriate and has minimal risk to the client. In this sense, the medication will be best, and risk for possible adverse side effects prevented.

While working closely with the doctor, the therapist and the client can monitor side effects. The therapist can be in apposition to either suggest termination, change, or continuation of the medication based on the varying effects, including minor, mild, severe, and even life-threatening side effects. Apart from doctors, the therapist can work with other mental health specialists to treat agoraphobia, including psychiatrists relegated, to manage medication treatment (Perna et al., 2011). These professionals can be involved in the therapy sessions to monitor conditions and offer training. Other mental health practitioners, such as nurses and assistant physicians, can help provide medication management as advised by the therapist. Cognitive-behavioral therapy is more effective when combined with medication, involving psychoanalysts from various disciplines, including social workers, psychologists, and psychiatric nurses, which can be essential in the psychotherapy process.

Moreover, other alternative medicines are sometimes used to treat agoraphobia, including herbal and dietary supplements. In some cases, this kind of treatment has had an impact on anti-anxiety beneficial to patients. Evens so, such supplements always have severe side effects. Therefore, as a therapist, it is important to work closely with a doctor to ensure the prescribed medication for agoraphobia does not threaten the client's health. Mostly, the supplements do not have a prescription, posing critical health risks to the patients. One example of an herbal supplement that is commonly used is known as Kava, which appears promising for anxiety treatment. However, recently they have been reported to cause serious liver damage. In the United States, the Food and Drug Administration has recently issued warnings concerning the use of Kava and any product that contain it (Kivi, 2012). Apart from medication, eye movement desensitization and reprocessing have also been considered an effective agoraphobia treatment. Even so, it has always produced poor results. It is regarded as the last option for therapists if the cognitive-behavioral approaches do not effectively follow trauma-induced agoraphobia. In this way, clients with agoraphobia may benefit from a support system created by the therapist to share their problems, experiences, and achievements.

Biblical perspectives on the problem

The Bible also gives significant teachings concerning the individual ability to overcome fears and anxiety, such as agoraphobia. Wong and Kwong (2010) indicate that fear of things, situations, places, or circumstances appears in the Bible too. In Genesis, Adam told God he heard him and was afraid (Genesis 3:10). Even the disciples, when they saw Jesus walking on water, were terrified (Matthew 14:26). More so, Peter, who also started walking on water towards Jesus, was overcome with fear and started sinking (Matthew 14:30). These examples indicate that people affected by suffering, dangers, and defeats make them fear and anxious (Wong & Kwong, 2010). Particularly, the fear of death makes humans to panic and even afraid certain places or situations, in this sense, agoraphobia.

As such, fear and anxiety are very horrible just like Peter they can sink us, but when we turn to God, we can overcome them, and He will hold our hands through the anxiety (Wong & Kwong, 2010). When we believe in God, all our anxiety can be healed. Therefore, we must be willing to request God's aid in overcoming our fears of the environment and the people and even getting past traumatic experiences in our lives. Apart from seeking professional help, people with agoraphobia should be prayerful and follow Biblical teachings on fear and anxiety escape healable anxiety disorders such as agoraphobia. Therapists should show their clients that when they let agoraphobia overweigh them, they are letting God down.

The Bible teaches us that we should not fear or be afraid despite the testing, suffering, or imprisonment because the crown of life will be given to faithful believers in Jesus Christ even at the point of death. "Do not be afraid of what you are about to suffer… Be faithful, even to the point of death, and I will give you the crown of life" (Revelation 2:10). Therapists should be able to make the client believe God is real and listens to their concerns (Wong & Kwong, 2010). No matter how the person feels, instead of focusing on their fear or anxiety, they should focus on God, who will help change their thoughts—indicating the importance of running to God for comfort and protection rather than trying to figure out on themselves.

The client should also learn to trust in the Lord with all their heart and always acknowledge that He can direct their paths. "Do not be anxious about anything, but in everything, by prayer and petition, with thanksgiving, present your requests to God" (Philippians 4:6-7). The therapist should encourage the client to be always prayerful, constantly communicate with God, and let Him in their presence and the midst of scary situations (Wong & Kwong, 2010). The client can make the Bible be their friend and use it to calm them and relax. Developing a starter prayer can be a significant part of the therapy session, allowing the client to ask God for protection and deliverance from fear and anxiety every time they feel overwhelmed.

Homework Assignments

Homework assignments are a significant part of therapy. Homework encourages a collaborative approach between the client and patient, enabling them to work together in understanding the agoraphobic related panic disorder. In cognitive-behavioral therapy, a wide range of activities can be assigned by the therapist to ensure the client becomes aware of their negative thoughts and behaviors that breed fear. The therapist can give the client homework concerning exercises that are geared at increasing self-awareness. The tasks done at home can include writing journals, maintaining a panic diary, keeping a gratitude journal, or even using affirmations. These are mostly self-monitoring activities that help the client keep records about their behaviors and cognition as related to agoraphobia and help the client get a clearer sense of the extent and nature of the underlying problem. The patients are more likely to learn better when the things discussed in therapy are depicted in the reality of life from the self-monitoring process.

As indicated, to effectively treat and overcome agoraphobia, clients need to be slowly exposed to such fears and anxiety as part of the treatment and healing process. As such, homework assignments become particularly important in the therapeutic process. Therefore, to maximize the effects of the treatment, the therapists should give the client assignments that can have more exposure to their fears. Here, the fears discussed in the therapy session, are brought to the environment with repeated experiences for newer thoughts and belief concerning the place, circumstance, or situation. It can include going to a crowded place, like watching a game in a stadium, going to the supermarket, going to a store alone maybe after every two days or even weekly. The therapist can also help keep the client calm and cope with the changes in thoughts or behaviors by using relaxation techniques off therapy sessions to build skills. In the homework assignments, the patient can be instructed to manage their fear and improve their problem-solving skills by taking relaxation exercises, including yoga, deep breathing exercises, muscle relaxation, and even meditation. Ideally, the therapist assigns tasks that cannot or can be better accomplished without the therapist's presence and give the client increased exposure and various situations.

Additional Information

It critical to note that even though agoraphobia is classified as a panic disorder, it was recently differentiated as an anxiety disorder. Therefore, its term of diagnosis has critically changed. DSM-5 indicates that individuals with agoraphobia do not need to acknowledge the underlying excessiveness of their anxiety relative to the risk phobia factors and causes. The duration for diagnosis has also been extended from people under the age of eighteen to all patients with the symptoms. Also, it is important to note that today the internet has made it easy for people with agoraphobia to seek help. More so, despite the traditional way of visiting the therapist's office, patients can explore options such as online and telephone therapy, treatment sessions, and even home visits where they feel safe. More so, family support is critical in the healing process. The family members should be encouraged to offer the client support and understanding for effective coping and healing.

Apart from medication and seeking therapy, self-help, and individual lifestyle changes can help an individual manage the symptoms of agoraphobia. The affected individual can practice personal stress and anxiety management techniques such as deep breathing, progressive muscle relaxation, and visualization to manage fears. Eating healthy and avoiding drugs and alcohol abuse are also significant ways to manage agoraphobia symptoms. Limiting caffeine and taking exercises, including friends and family support, are things that individuals can do on their own and prove effective. Essentially, self-care is always significant in managing agoraphobia. The therapist should ensure they stress the need for the patient to stick on the treatment plan, learn to relax, face their fears, and stay healthy.

References

Aqeel, N., Aqeel, A., & Tohid, H. (2016). A Strange Case of Agoraphobia: A Case Study. Quality in Primary Care, 24(5), 227-230.

American Psychiatric Association. (n.d.). What Are Anxiety Disorders? Psychiatry.org. Retrieved 4 August 2020, from https://www.psychiatry.org/patients-families/anxiety-disorders/what-are-anxiety-disorders#:~:text=Agoraphobia%20is%20the%20fear%20of,and%20causes%20problems%20in%20functioning.

Balaram, K., & Marwaha, R. (2020). Agoraphobia. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK554387/

Bandelow, B., Domschke, K., & Baldwin, D. (2013). Panic disorder and agoraphobia. Oxford University Press.

Bettencourt, J. M., Roca-Sánchez, M. J., Acosta, L., Villaverde, M. L., & Gracia, R. (2015). The combined use of virtual reality exposure in the treatment of agoraphobia. Actas Esp Psiquiatr, 43(4), 133-41.

Counselling Directory. (2015). Facing the fear of Agoraphobia - 'Lucy's story. Counselling-directory.org.uk. Retrieved 4 August 2020, from https://www.counselling-directory.org.uk/memberarticles/facing-the-fear-of-agoraphobia-lucys-story.

Gloster, A. T., Wittchen, H. U., Einsle, F., Lang, T., Helbig-Lang, S., Fydrich, T., ... & Gerlach, A. L. (2011). Psychological treatment for panic disorder with agoraphobia: a randomized controlled trial to examine the role of therapist-guided exposure in situ in CBT. Journal of Consulting and Clinical Psychology, 79(3), 406.

Inoue, K., Kaiya, H., Hara, N., & Okazaki, Y. (2016). A discussion of various aspects of panic disorder depending on the presence or absence of agoraphobia. Comprehensive Psychiatry, 69, 132-135.

Jacobson, K. (2011). Embodied domestics, embodied politics: Women, home, and agoraphobia. Human Studies, 34(1), 1-21.

Kivi, R. (2012). Agoraphobia: Types, Causes, and Symptoms. Healthline. Retrieved 4 August 2020, from https://www.healthline.com/health/agoraphobia.

McIntosh, J., & Legg, J. T. (2017). Agoraphobia: Symptoms, causes, diagnosis, and outlook. Medicalnewstoday.com. Retrieved 4 August 2020, from https://www.medicalnewstoday.com/articles/162169.

Obioha, C. W. (2020). Social Phobia and Agoraphobia: An Empirical Review and Analysis. A Journal of Consulting and Clinical Psychology (1):102-129

Perna, G., Daccò, S., Menotti, R., & Caldirola, D. (2011). Antianxiety medications for the treatment of complex agoraphobia: pharmacological interventions for a behavioral condition. Neuropsychiatric Disease and Treatment, 7, 621.

Sánchez-Meca, J., Rosa-Alcázar, A. I., Marín-Martínez, F., & Gómez-Conesa, A. (2010). Psychological treatment of panic disorder with or without agoraphobia: a meta-analysis. Clinical Psychology Review, 30(1), 37-50.

Wong, C., & Kwong, A. (2010). A Biblical Perspective on How to Handle Worry and Fear. Xulon Press.

Appendixes

Panic Disorder and Agoraphobia Criteria Changes from DSM-IV to DSM-5

DSM-IV Disorder	DSM-IV Criteria	DSM-5 Disorder	DSM-5 Criteria
Diagnostic Class: Anxiety Disorders	SAME
Panic Attack1	A discrete period of intense fear or discomfort, in which four or more of the following symptoms developed abruptly and reached a peak within 10 minutes · Palpitations, pounding heart, or accelerated heart rate · Sweating · Trembling or shaking · Sensations of shortness of breath or smothering · Feeling of choking · Chest pain or discomfort · Nausea or abdominal distress · Feeling dizzy, unsteady, lightheaded, or faint · Derealization (feelings of unreality) or depersonalization (being detached from oneself) · Fear of losing control or “going crazy” · Fear of dying · Paresthesias (numbness or tingling sensation) · Chills or hot flushes.	Panic Attack1	An abrupt surge of intense fear or intense discomfort that reaches a peak within minutes and during which time four or more of the following symptoms occur. · List is unchanged, except that “hot flushes” has been modified to “heat sensations” and there has been a reordering of symptoms.
Agoraphobia1	Anxiety about being in places or situations from which escape might be difficult (or embarrassing) or in which help may not be available in the event of having an unexpected or situationally predisposed panic attack or panic-like symptoms. Agoraphobic fears typically involve characteristic clusters of situations that include being outside the home alone; being in a crowd or standing in a line; being on a bridge; and traveling in a bus, train, or automobile.	Agoraphobia	A marked fear or anxiety about two (or more) of the following five situations: · Using public transportation · Being in open spaces · Being in enclosed spaces (e.g., shops, theaters, cinemas) · Standing in line or being in a crowd · Being outside the home alone.
	The situations are avoided (e.g., travel is restricted) or else are endured with marked distress or with anxiety about having a panic attack or panic-like symptoms, or require the presence of a companion.		SAME
	N/A		The agoraphobic situations almost always provoke fear or anxiety.
	N/A		The fear or anxiety is out of proportion to the actual danger posed by the agoraphobic situations and to the sociocultural context.
	N/A		The fear, anxiety, or avoidance is persistent, typically lasting 6 months or more.
	N/A		The fear, anxiety, or avoidance causes clinically significant distress or impairment in important areas of functioning.
	The anxiety or phobic avoidance is not better accounted for by another mental disorder.		SAME
Agoraphobia without history of Panic Disorder	The presence of agoraphobia related to fear of developing panic-like symptoms.	Agoraphobia	The individual fears or avoids these situations because of thoughts that escape might be difficult or help might not be available in the event of developing panic-like symptoms or other incapacitating or embarrassing symptoms.
	Criteria for panic disorder have never been met.		DROPPED
	The disturbance not due to the direct physiological effects of a substance (e.g., a drug of abuse or a medication) or a general medical condition		DROPPED
	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.		SAME
Panic Disorder, with/without Agoraphobia	Both: · Recurrent and unexpected panic attacks (see below) · ≥1 attack has been followed by 1 month or more of 1 or more of the following Persistent concern about additional attacks Worry about the implications of the attack or its consequences A significant change in behavior related to the attacks	Panic Disorder	Both: · Recurrent and unexpected panic attacks (see below) · ≥1 attack has been followed by 1 month or more of 1 or both of the following Persistent concern about additional attacks or their consequences A significant maladaptive change in behavior related to the attacks
	The panic attacks are not due to the direct physiological effects of a substance (e.g., a drug of abuse or a medication) or a general medical condition		SAME
	The panic attacks are not better accounted for by another mental disorder.		SAME
	Without agoraphobia: Absence of agoraphobia (see below)		DROPPED
	With agoraphobia: Presence of agoraphobia		DROPPED