Panic Disorder 283
Agoraphobic Avoidance
Agoraphobia is the avoidance or endurance with distress of “places or situations from
which escape might be difficult (or embarrassing) or in which help may not be avail-
able in the event of having a panic attack or panic-like symptoms” (DSM-IV-TR; APA,
2000, p. 432). The anxiety usually leads to pervasive avoidance of a variety of situa-
tions such as being at home alone, crowds, department stores, supermarkets, driving,
enclosed places (e.g., elevators), open spaces (e.g., crossing bridges, parking lots), the-
aters, restaurants, public transportation, air travel, and the like. In some cases agora-
phobia is mild and confined to a few specific places, whereas for others it is more severe
in which a “safe zone” may be defined around the home with travel outside this zone
highly anxiety- provoking (Antony & Swinson, 2000a). In extreme cases, the person
may be completely housebound.
Panic attacks most often precede the onset of agoraphobia (Katerndahl & Realini,
1997; Thyer & Himle, 1985) and individuals with panic disorder are more likely to
develop agoraphobic avoidance to situations associated with the first panic attack (Fara-
velli, Pallanti, Biondi, Paterniti, & Scarpato, 1992). Furthermore, the development of
agoraphobic avoidance is less dependent on the frequency and severity of panic attacks
and more likely due to high anticipatory anxiety about the occurrence of panic, elevated
anxiety sensitivity, diminished sense of control over threat, and a tendency to use avoid-
ance as a coping strategy (Craske & Barlow, 1988; Craske, Rapee, & Barlow, 1988;
Craske, Sanderson, & Barlow, 1987; White et al., 2006). The close association between
panic attacks and agoraphobia is also confirmed by the low prevalence of agoraphobia
without panic disorder (AWOPD). In the NCS-R AWOPD had a 12-month prevalence
rate of only 0.8% compared to 2.7% for panic disorder (Kessler et al., 2005) and rates
among treatment- seeking samples may be even lower because individuals with AWOPD
may be less likely to seek professional treatment (e.g., Eaton, Dryman, & Weissman,
1991; Wittchen, Reed, & Kessler, 1998). Although relatively rare, AWOPD may be
more severe and associated with less favorable treatment outcome than panic disorder,
but the studies are divided on whether it is characterized by greater impaired function-
ing (Buller, Maier, & Benkert, 1986; Buller et al., 1991; Ehlers, 1995; Goisman et al.,
1994; Wittchen et al., 1998).
Clinician Guideline 8.4
Expect some form of agoraphobic avoidance in most cases of panic disorder. It can vary from
mild, even f luctuating, forms of situational avoidance to severe cases of being housebound.
The clinician should adopt a broad, dimensional assessment perspective, with a focus on
recording the variety of situations, body sensations, feelings, and experiences that the client
avoids.Diagnostic Features
Table 8.3 presents the DSM-IV-TR (APA, 2000) diagnostic criteria for panic disorder.
There are three possible diagnoses relevant to panic disorder; panic disorder with-
out agoraphobia (300.01), panic disorder with agoraphobia (300.21), and agoraphobia