Clinical Vignette
Patient: "Ms. D," 44-year-old freelance editor, referred by her primary care physician after disclosing that she has not left her neighborhood in 18 months.
Chief Concern: "I'm afraid something terrible will happen to me if I'm too far from home. What if I get dizzy and fall? What if I can't get to a bathroom? I can't be in situations where I can't get out quickly."
History of Present Illness: Ms. D describes a progressive restriction of her activities over 3 years. It began with avoidance of highways (feared being 'trapped' in traffic). This expanded to avoidance of public transportation, then shopping malls, then movie theaters, then restaurants. For the past 18 months, she has confined herself to her home neighborhood (a 4-block radius). She orders groceries online and has not entered a store in over a year. Her fears center on situations where escape would be difficult or help unavailable if she experienced dizziness, gastrointestinal distress, or felt overwhelmed. She has NEVER had a spontaneous panic attack. She has never experienced the sudden surge of intense fear with peak symptoms within minutes. Her anxiety is anticipatory and gradually escalating (not sudden-onset), and she avoids situations before anxiety becomes severe. She denies fearing social judgment or embarrassment (ruling out social anxiety). She fears the SITUATIONS themselves, not how others perceive her.
Past Psychiatric History: Briefly saw a therapist at age 30 for 'stress.' No prior diagnosis. No medication history.
Family History: Mother: agoraphobia (housebound for 10 years). Sister: panic disorder.
Mental Status Exam: Interviewed at home (was unable to come to office). Alert, cooperative. Speech normal. Mood 'trapped.' Affect anxious but composed. No panic symptoms during interview. Thought content: pervasive avoidance cognitions centered on inability to escape situations. No psychotic symptoms. No depressive symptoms. Insight present.
Step 1: Agoraphobia DSM-5-TR Criteria
Criterion A: Marked fear or anxiety about 2+ of 5 situations: (1) public transportation, (2) open spaces, (3) enclosed places, (4) standing in line or being in a crowd, (5) being outside the home alone.
(1) Public transportation: avoids buses, trains, subways. (2) Open spaces: avoids parking lots, bridges. (3) Enclosed places: avoids stores, theaters, restaurants. (4) Lines/crowds: avoids shopping during busy hours. (5) Being outside home alone: confined to 4-block radius. All 5 situation types involved. MET (5/5 situations).
Criterion B: The individual fears these situations because of thoughts that escape might be difficult or help unavailable in the event of panic-like symptoms or other incapacitating/embarrassing symptoms.
Fears dizziness, GI symptoms, or feeling overwhelmed in situations where escape is difficult. Fear is about the inability to exit, not about specific objects or social judgment. MET.
Criterion C: Situations almost always provoke fear or anxiety.
Anticipatory anxiety begins when contemplating leaving her neighborhood. Actual confrontation with feared situations produces escalating anxiety (though not sudden panic). MET.
Criterion D: Situations are actively avoided, require companion, or endured with intense anxiety.
Active avoidance of all 5 situation categories. Has not left neighborhood in 18 months. MET.
Criterion E: Out of proportion to actual danger.
The feared scenarios (dizziness in a store, needing a bathroom in a theater) are disproportionate to the degree of restriction (complete neighborhood confinement). MET.
Criterion F: Duration ≥6 months.
Progressive restriction over 3 years. MET.
Criterion G: Clinically significant distress or impairment.
Housebound for 18 months. Cannot attend medical appointments. Social life eliminated. Career restricted to remote work only. MET.
Step 2: Confirming Absence of Panic Disorder
DSM-5-TR separates Agoraphobia from Panic Disorder. They can co-occur, but each can be diagnosed independently. Ms. D's presentation is Agoraphobia WITHOUT Panic Disorder.
| Feature | Agoraphobia with Panic | Agoraphobia WITHOUT Panic | This Patient |
|---|---|---|---|
| Panic attacks | Recurrent, unexpected panic attacks present | No spontaneous panic attacks | NO spontaneous panic attacks ever |
| Fear onset | Sudden surge (peaks in minutes) | Gradual, anticipatory buildup | Gradual anticipatory anxiety |
| Avoidance motivation | Prevent panic attacks from occurring | Prevent being trapped/unable to escape if symptoms occur | Fear of being trapped |
| Physical symptoms | Full DSM panic criteria (4+ symptoms peaking in minutes) | Anticipatory somatic symptoms (dizziness, GI) not meeting panic criteria | Gradual dizziness/GI worry, not sudden panic |
Diagnostic Precision
Ms. D has never experienced a sudden, unexpected surge of intense fear with 4+ symptoms peaking within minutes. Her anxiety is anticipatory and situation-dependent, not spontaneous and paroxysmal. Agoraphobia is diagnosed independently without Panic Disorder.
Diagnostic Formulation
Diagnostic Conclusion
Agoraphobia Without Panic Disorder (F40.00): All 7 DSM-5-TR criteria met. All 5 agoraphobic situation types involved. Progressive restriction over 3 years with current 18-month confinement to neighborhood. No comorbid Panic Disorder (no spontaneous panic attacks). Family history of agoraphobia (mother). Treatment: CBT with graduated in vivo exposure as first-line, SSRI as adjunctive pharmacotherapy.
Teaching Points
- DSM-5-TR separated Agoraphobia from Panic Disorder as independent diagnoses. Previously (DSM-IV), Agoraphobia could only be diagnosed in relationship to Panic Disorder. This change recognized that many individuals with agoraphobic avoidance have never experienced a panic attack.
- Agoraphobia without Panic Disorder is often more severe in terms of avoidance and functional impairment than panic disorder alone. Patients may become completely housebound because their avoidance is not limited to preventing panic but extends to any feared symptom.
- The five agoraphobic situation types in DSM-5-TR capture the common thread: situations where escape is perceived as difficult or help unavailable. The patient does not need to fear all 5, but ≥2 are required. Ms. D fears all 5, indicating severe generalization.
- Treatment with graduated in vivo exposure is the gold standard. Because these patients have often been avoidant for years, exposure must be carefully graded, starting with situations closest to existing comfort (edge of the 4-block radius) and expanding progressively.
- Family history of agoraphobia is a risk factor. Ms. D's mother was housebound for 10 years, suggesting genetic vulnerability. Her sister's panic disorder demonstrates that the underlying anxiety vulnerability can manifest as different disorders within a family.