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It’s important to explore triggers, as well as functional impact. In agoraphobia, your role is not just to identify feared situations, but to understand what the patient can no longer do and the impact on their life as a result.
Key Knowledge
ICD-11 defines agoraphobia (6B02) as an anxiety disorder characterised by marked fear in situations where escape might be difficult or help unavailable if anxiety or panic symptoms occur. These situations are actively avoided or entered only under specific circumstances (e.g. with a trusted companion).
Examples of situations causing distress include:
• Using public transport
• Being in enclosed places
• Standing in a queue or being in a crowd
• Being outside the home alone
The fear relates to concerns about:
• Having a panic attack
• Losing control
• Falling or becoming unwell
• Embarrassing physical symptoms (e.g. incontinence, fainting)
Key features include:
• Anticipatory anxiety before entering feared situations
• Active avoidance, or endurance only with intense fear
• Reliance on safety behaviours (e.g. staying close to exits, needing a companion)
• Symptoms lasting several months or more
• Significant distress or functional impairment
Agoraphobia may occur with or without panic disorder.
Differential Diagnosis for Agoraphobia
Panic disorder
• Panic attacks are unexpected and spontaneous, not limited to specific situations
• In agoraphobia, panic attacks are situation-specific
Social anxiety disorder
• Fear centres on scrutiny or humiliation by others in social situations (e.g. public speaking, starting a conversation)
• Agoraphobia relates to escape, safety or panic, not social judgement
Depressive disorder
• Withdrawal is driven by low mood, anhedonia, or fatigue, rather than fear
• Anxiety and anticipatory dread are not primary drivers for avoiding certain situations
Obsessive compulsive disorder
• Avoidance is due to obsessions or rituals (e.g. contamination fears)
• Not primarily about escape or panic
Post-traumatic stress disorder
• Avoidance linked to trauma re-experiencing
• Often accompanied by flashbacks, nightmares and emotional numbness
Psychotic disorders
• Avoidance driven by persecutory delusions or paranoid beliefs, not anxiety about panic
Specific phobia
• Fear limited to a single or very narrow trigger (e.g. heights, animals, blood or injury)
• Agoraphobia involves multiple situations where escaping might be difficult
Risk Assessment in Agoraphobia
As with all risk assessments, consider risk to self, others, and from others, with particular attention to functional and psychosocial risk.
Specific considerations include:
To self:
•Functional impairment (not shopping for food and subsequent malnutrition, missing medication or appointments)
•Loss of employment or education
•Self-neglect (poor hygiene, malnutrition)
•Self-harm and suicide
To others:
•Consider carer burden if dependence on family is high
From others:
•Increased vulnerability due to isolation
•Risk of neglect if living alone and unable to access help
Communication Tips
• Explore triggers, avoidance, and safety behaviours
• Probe impact on daily functioning
• Screen for comorbid panic disorder, depression, and substance misuse
• Avoid reinforcing avoidance during the interview
Eliciting symptoms (example questions)
Triggers and avoidance
•“Are there places you specifically avoid?” Why?
•“What happens if you try to go to those places?”
Anticipatory anxiety
•“How do you feel in the hours or days before going out?”
Panic symptoms
•“When the anxiety hits, what do you notice in your body?”
•“Have you ever felt you might collapse, lose control, or embarrass yourself?”
Safety behaviours
•“Do you feel safer if someone goes with you?”
•“Are there routes or places you stick to because they feel ‘safe’?”
Functional impact
•“How has this affected shopping, work, appointments, or seeing friends?”
Comorbidity
•“Have you noticed your mood dipping because of how restricted things have become?”
•“Do you use alcohol or anything else to help manage the anxiety?”
CASC Practice Scenarios
Scenario 1: History Taking
Candidate Instructions:
You are on a home visit to assess Ms. Linda Evans, a retired 49-year-old primary school teacher. Her GP and son are concerned that over the past three months she has become increasingly withdrawn.
Please take a focused psychiatric history to arrive at a diagnosis and assess the impact of her symptoms.
Actor Instructions:
You are Linda Evans, 49 years old. You took early retirement from your job as a primary school teacher 18 months ago, a decision you made to help care for your husband, who was diagnosed with terminal cancer and passed away eight months ago. You are a naturally warm, sociable, independent person, and your life was a whirl of activity: church choir, a weekly bridge club, and volunteering at the local library. You live alone in the house where you and your husband raised your son, who is now 25 and visits weekly.
Three months ago, whilst in the middle of grieving, you were shopping for food when you felt an overwhelming wave of dizziness, breathlessness, chest tightness, and an intense fear you might collapse or die. It felt like a heart attack. You left the shop as quickly as you could, and the feelings subsided as you got into your car. You were utterly terrified. When your son came to visit that evening, you didn’t mention it, brushing it off as a simple dizzy spell.
Since then, you have been consumed by a persistent fear of having another “attack” in public. The thought of being in a situation where you couldn’t escape or get help, such as a crowded market or a church service, is terrifying. You initially made excuses to miss your usual activities, telling friends you were “just tired”. You stopped going to church because you were afraid of being “trapped” in a pew with no quick exit. You cancelled your bridge club and stopped volunteering at the library.
The fear has since generalized; even the thought of leaving the house on your own causes a feeling of dread and physical symptoms (chest tightness, racing heart, shortness of breath).
You rely completely on your son for food shopping and errands. You feel a sense of shame, guilt, and embarrassment. You find yourself standing at the front door, but the rising anxiety always forces you back into your house. You spend most of your time listening to the radio or doing crossword puzzles. You feel restless and frustrated. Your mood is “not bad, as long as I stay home,” but you admit that you miss your friends and your old life.
You deny any thoughts of harming yourself, but you have thoughts about how much easier it would be if you didn’t have to face this fear. You have no history of self-harm.
You deny any flashbacks, nightmares, or intrusive memories about the shopping centre. You have no other compulsions or rituals. You have no concerns that someone is trying to harm you. You have never had a panic attack before, and you have no past psychiatric history. You do not drink, smoke or take illicit drugs.
You are physically well and have no history of heart or lung problems. Your sleep is good at home. You are still managing to eat well as your son brings you food and you are able to look after your personal hygiene well.
Feedback for Scenario 1
Knowledge & Clinical Skills
A good candidate will:
●Take a detailed history of the panic attack, for example:
“Tell me about the day at the food shop. What was the first thing you noticed? How long did the feeling last?”
“What was going through your mind at that moment? Were you worried you were having a heart attack?”
“What did you do after it happened? What gave you relief?”
●Assess the extent of the avoidance
●Assess the impact on her social life
●Risk assessment: Make sure to think about risk to self (suicidality, self-neglect, malnutrition), and as usual, risk to and from others. Consider illicit substances and alcohol misuse.
●Rule out other conditions: Ask about other co-morbidities, such as PTSD (e.g., “Do you have any flashbacks or nightmares?”), depression (e.g., “On a typical day, how would you describe your mood?”) and other forms of anxiety disorders.
Communication
A good candidate will:
●Build trust & empathy: A top candidate will quickly build rapport by acknowledging the difficulty of her situation using open, non-judgmental language. A good starting point would be: “Your GP told me a little bit about what’s been going on. I can see this must be a very difficult time, especially after losing your husband recently.”
●Normalise & reframe: The candidate will conclude by sensitively and concisely summarising the patient’s experience, arriving at the most likely diagnosis.
Video Example
Authors/Reviewers
Dr Damir Rafi is a Psychiatry Speciality registrar in forensics, currently working in London.
Dr Rebecca Goodall is a Psychiatry Specialty Registrar, specialising in children & adolescents.
Dr Mohammad Lalji is a Psychiatry Speciality Registrar specialising in general adult psychiatry..
References and Resources
World Health Organization. (2019). International classification of diseases for mortality and morbidity statistics (11th ed.). https://icd.who.int/browse11/l-m/en
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596
Disclaimer:
This article is intended for use as a learning resource for doctors training in Psychiatry in the UK. It is not intended for patients. If you are looking for information about mental health conditions, please visit www.rcpsych.ac.uk/mental-health to find readable, user-friendly and evidence-based information on mental health problems, treatments and other topics written by qualified psychiatrists, with help from patients and carers. If you are looking for help for a mental health condition, please visit https://www.mind.org.uk/ for information about where help is available.
The article was written by UK doctors and cross-checked against various published sources (see Reference list). We endeavour to keep information up to date, but it should not be relied on for clinical decision making. Consult local guidelines and senior colleagues whenever you are not sure.
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