Specific Phobia
Diagnostic Criteria
A. Marked fear or anxiety about a specific object or situation (e.g., flying, heights, animals,
receiving an injection, seeing blood).
Note: In children, the fear or anxiety may be expressed by crying, tantrums, freezing,
or clinging.
B. The phobic object or situation almost always provokes immediate fear or anxiety.
C. The phobic object or situation is actively avoided or endured with intense fear or anxiety.
D. The fear or anxiety is out of proportion to the actual danger posed by the specific object
or situation and to the sociocultural context.
E. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.
F. The fear, anxiety, or avoidance causes clin ically significant distress or impairment in
social, occupational, or other important areas of functioning.
G. The disturbance is not better explained by the symptoms of another mental disorder,
including fear, anxiety, and avoidance of situations associated with panic-like symptoms
or other incapacitating symptoms (as in agoraphobia); objects or situations related to
obsessions (as in obsessive-compulsive disorder); reminders of traumatic events (as in
posttraumatic stress disorder); separation from home or attachment figures (as in sep-
aration anxiety disorder); or social situations (as in social anxiety disorder).


198 Anxiety Disorders
Specify if:
Code based on the phobic stimulus:
300.29 (F40.218)  Animal (e.g., spiders, insects, dogs).
300.29 (F40.228) Natural environment  (e.g., heights, storms, water).
300.29 (F40.23x) Blood-injection-injury  (e.g., needles, invasive medical procedures).
Coding note: Select specific ICD-10-CM code as follows: F40.230 fear of blood;
F40.231 fear of injections and transfusions; F40.232  fear of other medical care; or
F40.233 fear of injury.
300.29 (F40.248) Situational  (e.g., airplanes, elevators, enclosed places).
300.29 (F40.298) Other  (e.g., situations that may lead to choking or vomiting; in chil-
dren, e.g., loud sounds or costumed characters).
Coding note:  When more than one phobic stimulus is present, code all ICD-10-CM codes
that apply (e.g., for fear of snakes and flying, F40.218 specific phobia, animal, and
F40.248 specific phobia, situational).
Specifiers
It is common for individuals to have multiple  specific phobias. The average individual with
specific phobia fears three objects or situatio ns, and approximately 75% of individuals with
specific phobia fear more than on e situation or object. In such cases, multiple specific phobia
diagnoses, each with its own diagnostic code reflecting the phobic stimulus, would need to be
given. For example, if an individual fears thunderstorms and flying , then two diagnoses
would be given: specific phobia, natural en vironment, and specific phobia, situational.


Diagnostic Features
A key feature of this disorder is that the fear or anxiety is circumscribed to the presence of a
particular situation or object (Criterion A), which may be termed the phobic stimulus.  The cat-
egories of feared situations or objects are provi ded as specifiers. Many individuals fear objects
or situations from more than one category, or  phobic stimulus. For th e diagnosis of specific
phobia, the response must differ from normal, transient fears that commonly occur in the pop-
ulation. To meet the criteria for a diagnosis, the fear or anxiety must be intense or severe (i.e.,
“marked”) (Criterion A). The amount of fear experienced may vary wi th proximity to the
feared object or situation and may occur in anticipa tion of or in the actual presence of the object
or situation. Also, the fear or anxiety may take the form of a full or limited symptom panic at-
tack (i.e., expected panic attack). Another characteri stic of specific phobias is that fear or anxi-
ety is evoked nearly every time the individual  comes into contact with the phobic stimulus
(Criterion B). Thus, an indivi dual who becomes anxious only occasionally upon being con-
fronted with the situation or object (e.g., become s anxious when flying only on one out of every
five airplane flights) would not be diagnosed with specific phobia. However, the degree of fear
or anxiety expressed may vary (from anticipatory anxiety to a full panic attack) across different
occasions of encountering the phobic object or situation because of various contextual factors
such as the presence of others, duration of exposure, and other threat ening elements such as
turbulence on a flight for indi viduals who fear flying. Fear and anxiety are often expressed dif-


ferently between children and adults. Also, the fear  or anxiety occurs as soon as the phobic ob-
ject or situation is encountered (i.e., immediately rather than being delayed).
The individual actively avoids the situation, or  if he or she either is unable or decides
not to avoid it, the situation or object evok es intense fear or anxiety (Criterion C). Active
avoidance  means the individual intentionally behave s in ways that are designed to prevent
or minimize contact with phobic objects or situ ations (e.g., takes tunnels instead of bridges
on daily commute to work for fear of heights; avoids entering a dark room for fear of spi-
ders; avoids accepting a job in a locale wh ere a phobic stimulus is more common). Avoid-


Specific Phobia 199
ance behaviors are often obvious (e.g., an indi vidual who fears blood refusing to go to the
doctor) but are sometimes less obvious (e.g., an individual who fears snakes refusing to
look at pictures that resemble  the form or shape of snakes).  Many individuals with specific
phobias have suffered over many years and have changed their living circumstances in
ways designed to avoid the phobic object or si tuation as much as possible (e.g., an indi-
vidual diagnosed with specific phobia, animal , who moves to reside in an area devoid of
the particular feared animal). Therefore, they no longer experience fear or anxiety in their
daily life. In such instances, avoidance behavi ors or ongoing refusal to engage in activities
that would involve exposure to the phobic object or situation (e.g., repeated refusal to ac-
cept offers for work-related travel because of fear of flying) may be  helpful in confirming
the diagnosis in the absence of overt anxiety or panic.
The fear or anxiety is out of proportion to th e actual danger that the object or situation
poses, or more intense than is deemed necess ary (Criterion D). Although individuals with
specific phobia often recognize their reactions as disproportionate, th ey tend to overesti-
mate the danger in their feared situations, an d thus the judgment of being out of propor-
tion is made by the cl inician. The individual ’s sociocultural contex t should also be taken
into account. For example, fears of the dark may be reasonable in a context of ongoing
violence, and fear of insects may be more di sproportionate in settings where insects are
consumed in the diet. The fear, anxiety, or avoidance is persistent, typically lasting for
6 months or more (Criterion E), which helps distinguish the disorder from transient fears


6 months or more (Criterion E), which helps distinguish the disorder from transient fears
that are common in the popu lation, particularly among children. However, the duration
criterion should be used as a general guide,  with allowance for so me degree of flexibility.
The specific phobia must cause clinically sign ificant distress or impairment in social, oc-
cupational, or other important areas of functioning in order for the disorder to be diag-
nosed (Criterion F).
Associated Features Supporting Diagnosis
Individuals with specific phobia typically experience an increase in physiological arousal
in anticipation of or during exposure to a phobic object or situation. However, the physi-
ological response to the feared situation or object varies. Whereas individuals with situa-
tional, natural environment, an d animal specific phobias are likely to show sympathetic
nervous system arousal, individuals with bloo d-injection-injury specific phobia often
demonstrate a vasovagal fainting or near-faint ing response that is marked by initial brief
acceleration of heart rate an d elevation of blood pressure followed by a deceleration of
heart rate and a drop in blood pressure. Curr ent neural systems models for specific phobia
emphasize the amygdala and related structures, much as in other anxiety disorders.
Prevalence
In the United States, the 12-month community prevalence estimate for specific phobia is
approximately 7%–9%. Prevalence  rates in European countrie s are largely similar to those
in the United States (e.g., about 6%), but rate s are generally lower in  Asian, African, and
Latin American countries (2%–4%). Prevalence  rates are approximately 5% in children and
are approximately 16% in 13- to 17-year-olds. Prevalence rates are lower in older individ-


uals (about 3%–5%), possibly reflecting diminishing severity to subclinical levels. Females
are more frequently affected than males, at a rate of approximately 2:1, although rates vary
across different phobic stimuli. That is, animal, natural envi ronment, and situational spe-
cific phobias are predominantly experienced by females, whereas blood-injection-injury
phobia is experienced nearly equally by both genders.
Development and Course


cific phobias are predominantly experienced by females, whereas blood-injection-injury
phobia is experienced nearly equally by both genders.
Development and Course
Specific phobia sometimes develops following  a traumatic event (e.g., being attacked by
an animal or stuck in an elevat or), observation of others going through a traumatic event (e.g.,


200 Anxiety Disorders
watching someone drown), an unexpected panic attack in the to be feared situation (e.g.,
an unexpected panic attack while on the subway), or informational transmission (e.g., ex-
tensive media coverage of a plane crash). However, many individuals with specific phobia
are unable to recall the specific reason for the onset of their phobias. Specific phobia usu-
ally develops in early childho od, with the majority of case s developing prior to age 10
years. The median age at onset is between 7 and 11 years, with the mean at about 10 years.
Situational specific phobias tend to have a later age at onset than natural environment, an-
imal, or blood-injection-injury specific phob ias. Specific phobias that develop in child-
hood and adolescence are likely to wax and wane during that period. However, phobias
that do persist into adulthood are unlikely to remit for the majority of individuals.
When specific phobia is being diagnosed in children, two issues sh ould be considered.
First, young children may express their fear and anxiety by crying, tantrums, freezing,
or clinging. Second, young children typically are not able to understand the concept of
avoidance. Therefore, the clinician should assemble additional information from parents,
teachers, or others who know  the child well. Excessive fears are quite common in young
children but are usually transitory and only m ildly impairing and thus considered devel-
opmentally appropriate. In such cases a diag nosis of specific phobia would not be made.
When the diagnosis of specific phobia is being considered in a child, it is important to
assess the degree of im pairment and the duration of the fear, anxiety, or avoidance, and


whether it is typical for the child’s  particular developmental stage.
Although the prevalence of specific phobia is lower in older populations, it remains
one of the more commonly experienced disorders in late life. Several issues should be con-
sidered when diagnosing specific phobia in  older populations. Fi rst, older individuals
may be more likely to endorse natural envi ronment specific phobias, as well as phobias of
falling. Second, specific phobia (like all anxiet y disorders) tends to co-occur with  medical
concerns in older individuals, including co ronary heart disease and chronic obstructive
pulmonary disease. Third, older individuals may be more likely to attribute the symptoms
of anxiety to medical conditions. Fourth, olde r individuals may be more likely to manifest
anxiety in an atypical manner (e.g., involvin g symptoms of both anxiety and depression)
and thus be more likely to warrant a diagnosis of unspecified anxiety disorder. Addition-
ally, the presence of specific phobia in olde r adults is associated with decreased quality of
life and may serve as a risk factor for major neurocognitive disorder.
Although most specific phobias develop in ch ildhood and adolescence, it is possible for a
specific phobia to develop at any age, often as the result of expe riences that are traumatic. For
example, phobias of choking almost always follow a near-choking event at any age.
Risk and Prognostic Factors
Temperamental. Temperamental risk factors for specif ic phobia, such as negative affec-
tivity (neuroticism) or behavioral inhibition, are risk factors for ot her anxiety disorders as
well.
Environmental. Environmental risk factors for specif ic phobias, such as parental over-


Environmental. Environmental risk factors for specif ic phobias, such as parental over-
protectiveness, parental loss and separation, and physical and sexual abuse, tend to pre-
dict other anxiety disorders as well. As note d earlier, negative or traumatic encounters
with the feared object or situation sometime s (but not always) precede the development of
specific phobia.
Genetic and physiological. There may be a genetic suscepti bility to a certain category of
specific phobia (e.g., an individual with a first-degree relative with a specific phobia of an-


Genetic and physiological. There may be a genetic suscepti bility to a certain category of
specific phobia (e.g., an individual with a first-degree relative with a specific phobia of an-
imals is significantly more likely to have the same specific phobia than any other category
of phobia). Individuals with blood-injection- injury phobia show a unique propensity to
vasovagal syncope (fainting) in th e presence of the phobic stimulus.


Specific Phobia 201
Culture-Related Diagnostic Issues
In the United States, Asians and Latinos report  significantly lower rates of specific phobia
than non-Latino whites, African Americans, an d Native Americans. In addition to having
lower prevalence rates of specific phobia, some  countries outside of the United States, par-
ticularly Asian and African countries, show differing phobia content, age at onset, and
gender ratios.
Suicide Risk
Individuals with specific phobia are up to 60 % more likely to make a suicide attempt than
are individuals without the diagnosis. However, it is likely that these elevated rates are
primarily due to como rbidity with personality disorder s and other anxiety disorders.
Functional Consequences of Specific Phobia
Individuals with specific phobia show simi lar patterns of impairment in psychosocial
functioning and decreased quality of life as individuals with other anxiety disorders and
alcohol and substance use disorders, includ ing impairments in occupational and inter-
personal functioning. In older adults, impair ment may be seen in caregiving duties and
volunteer activities. Also, fear of falling in older adults can lead to reduced mobility and
reduced physical and social functioning, an d may lead to receiving formal or informal
home support. The distress and impairment caused by specif ic phobias tend to increase
with the number of feared objects and situat ions. Thus, an individual who fears four ob-
jects or situations is likely to have more im pairment in his or her occupational and social
roles and a lower quality of life than an indivi dual who fears only one object or situation.
Individuals with blood-injection-injury specif ic phobia are often reluctant to obtain med-
ical care even when a medical concern is present. Additionally, fear of vomiting and chok-
ing may substantially reduce dietary intake.


ing may substantially reduce dietary intake.
Differential Diagnosis
Agoraphobia. Situational specific phobia may resemble agoraphobia in its clinical pre-
sentation, given the overlap in feared situations (e.g., flying, enclosed places, elevators). If
an individual fears only one of the agorapho bia situations, then sp ecific phobia, situa-
tional, may be diagnosed. If two or more agoraphobic situations are feared, a diagnosis of
agoraphobia is likely warranted. For example,  an individual who fears airplanes and ele-
vators (which overlap with the “public transportation” ag oraphobic situation) but does
not fear other agoraphobic situations would be diagnosed with specific phobia, situa-
tional, whereas an individual who fears airplanes, elevators, and crowds (which overlap
with two agoraphobic situations, “using public transportation” and “standing in line and
or being in a crowd”) would be diagnosed wi th agoraphobia. Criterion B of agoraphobia
(the situations are feared or avoided “because of thoughts that escape might be difficult or
help might not be available in the event of developing panic-like symptoms or other inca-
pacitating or embarrassing symptoms”) can also  be useful in differentiating agoraphobia
from specific phobia. If the situations are fe ared for other reasons, such as fear of being
harmed directly by the object or situations (e.g ., fear of the plane crashing, fear of the an-
imal biting), a specific phobia diagnosis may be more appropriate.
Social anxiety disorder. If the situations are feared because of negative evaluation, so-
cial anxiety disorder should be di agnosed instead of  specific phobia.
Separation anxiety disorder. If the situations are feared because of separation from a


Separation anxiety disorder. If the situations are feared because of separation from a
primary caregiver or attachment figure, separation anxiety disorder should be diagnosed
instead of specific phobia.


202 Anxiety Disorders
Panic disorder. Individuals with specific phobia may experience panic attacks when con-
fronted with their feared situation or object. A diagnosis of specific phobia would be given if
the panic attacks only occurred in response to the specific obje ct or situation, whereas a di-
agnosis of panic disorder woul d be given if the individual also experienced panic attacks
that were unexpected (i.e., not in response to  the specific phobia object or situation).
Obsessive-compulsive disorder. If an individual’s primary fear or anxiety is of an ob-
ject or situation as a result of  obsessions (e.g., fear of bloo d due to obsessive thoughts about
contamination from blood-borne pathogens [i.e., HIV]; fear of  driving due to obsessive im-
ages of harming others), and if other diagnostic criteria for obsess ive-compulsive disorder
are met, then obsessive-compulsive disorder should be diagnosed.
Trauma- and stressor-related disorders. If the phobia develops following a traumatic
event, posttraumatic stress disorder (PTSD) should be considered as a diagnosis. How-
ever, traumatic events ca n precede the onset of PTSD and sp ecific phobia. In this case, a di-
agnosis of specific phobia would be assigned only if all of the criteria for PTSD are not met.
Eating disorders. A diagnosis of specific phobia is not given if the avoidance behavior is
exclusively limited to avoidance of food and food-related cues, in which case a diagnosis
of anorexia nervosa or bulimia nervosa should be considered.
Schizophrenia spectrum and other psychotic disorders. When the fear and avoidance
are due to delusional thinking (as in schizo phrenia or other schizophrenia spectrum and
other psychotic disorders), a diagnosis of specific phobia is not warranted.
Comorbidity


other psychotic disorders), a diagnosis of specific phobia is not warranted.
Comorbidity
Specific phobia is rarely seen in medical-clinical settings in the absence of other psycho-
pathology and is more frequently seen in nonm edical mental health settings. Specific pho-
bia is frequently associated with a range of ot her disorders, especially depression in older
adults. Because of early onset, specific phobia is typically the temporally primary disorder.
Individuals with specific phobia are at incr eased risk for the development of other dis-
orders, including other anxiety disorders, de pressive and bipolar disorders, substance-
related disorders, somatic symptom and relate d disorders, and personality disorders (par-
ticularly dependent personality disorder).
Social Anxiety Disorder (Social Phobia)
Diagnostic Criteria 300.23 (F40.10)
A. Marked fear or anxiety about one or more social situations in which the individual is
exposed to possible scrutiny by others. Examples include social interactions (e.g., hav-
ing a conversation, meeting unfamiliar people), being observed (e.g., eating or drink-
ing), and performing in front of others (e.g., giving a speech).
Note:  In children, the anxiety must occur in peer settings and not just during interac-
tions with adults.
B. The individual fears that he or she will act in a way or show anxiety symptoms that will
be negatively evaluated (i.e., will be humiliating or embarrassing; will lead to rejection
or offend others).
C. The social situations almost always provoke fear or anxiety.
Note:  In children, the fear or anxiety may be expressed by crying, tantrums, freezing,
clinging, shrinking, or failing to speak in social situations.
D. The social situations are avoided or  endured with intense fear or anxiety.


Social Anxiety Disorder (Social Phobia) 203
E. The fear or anxiety is out of proportion to t he actual threat posed by the social situation
and to the sociocultural context.
F. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.
G. The fear, anxiety, or avoidance causes clin ically significant distress or impairment in
social, occupational, or other important areas of functioning.
H. The fear, anxiety, or avoidance is not attributable to the physiological effects of a sub-
stance (e.g., a drug of abuse, a medication) or another medical condition.
I. The fear, anxiety, or avoidance is not better explained by the symptoms of another
mental disorder, such as panic disorder, bod y dysmorphic disorder, or autism spectrum
disorder.
J. If another medical condition (e.g., Parkinson’ s disease, obesity, disfigurement from burns
or injury) is present, the fear, anxiety, or avoidance is clearly unrelated or is excessive.
Specify if:
Performance only: If the fear is restricted to speaking or performing in public.
Specifiers
Individuals with the performanc e only type of social anxiety disorder have performance
fears that are typically most impairing in thei r professional lives (e.g., musicians, dancers,
performers, athletes) or in roles that requir e regular public speaking. Performance fears
may also manifest in work, school, or academic  settings in which regular public presenta-
tions are required. Individuals with performance only social anxiety disorder do not fear
or avoid nonperformanc e social situations.
Diagnostic Features
The essential feature of social an xiety disorder is a marked, or in tense, fear or anxiety of so-
cial situations in which the individual may be scrutinized by others. In children the fear or


cial situations in which the individual may be scrutinized by others. In children the fear or
anxiety must occur in p eer settings and not just during in teractions with adults (Criterion
A). When exposed to such social situations, the individual fears that he or she will be neg-
atively evaluated. The individu al is concerned that he or she will be judged as anxious,
weak, crazy, stupid, boring, intimidating, dirt y, or unlikable. The individual fears that
he or she will act or appear in a certain way or show anxiety symptoms, such as blushing,
trembling, sweating, stumbling over one’s words, or staring, that will be negatively eval-
uated by others (Criterion B). Some individuals fear offending others or being rejected as
a result. Fear of offending others—for exampl e, by a gaze or by showing anxiety symp-
toms—may be the predominant fear in individu als from cultures with strong collectivistic
orientations. An individual with fear of tr embling of the hands ma y avoid drinking, eat-
ing, writing, or pointing in public; an individual with fear of sweating may avoid shaking
hands or eating spicy foods; and an individual with fear of blushing may avoid public per-
formance, bright lights,  or discussion about intimate to pics. Some individuals fear and
avoid urinating in public restrooms when other individuals are present (i.e., paruresis, or
“shy bladder syndrome”).
The social situations almost always provoke fear or anxiety (Criterion C). Thus, an in-
dividual who becomes anxious only occasionally in the social situatio n(s) would not be di-
agnosed with social anxiety di sorder. However, the degree an d type of fear and anxiety
may vary (e.g., anticipatory anxiety, a panic attack) across different occasions. The antici-


patory anxiety may occur sometimes far in adva nce of upcoming situations (e.g., worrying
every day for weeks before attending a social ev ent, repeating a speech for days in advance).
In children, the fear or anxiety may be expre ssed by crying, tantrums, freezing, clinging, or
shrinking in social situations. The individual will often avoid the feared social situations.
Alternatively, the situations are endured with intense fear or anxiety (Criterion D). Avoid-


204 Anxiety Disorders
ance can be extensive (e.g., not going to partie s, refusing school) or subtle (e.g., overpre-
paring the text of a speech, diverting at tention to others, limiting eye contact).
The fear or anxiety is judged to be out of proportion to the actual risk of being nega-
tively evaluated or to the consequences of su ch negative evaluation  (Criterion E). Some-
times, the anxiety may not be judged to be excessive, because it is related to an actual
danger (e.g., being bullied or tormented by ot hers). However, individuals with social anx-
iety disorder often overestimate the negative  consequences of social situations, and thus
the judgment of being out of proportion is ma de by the clinician. The individual’s socio-
cultural context needs to be taken into account when this judgment is being made. For ex-
ample, in certain cultures, behavior that mi ght otherwise appear socially anxious may be
considered appropriate in social situations (e .g., might be seen as a sign of respect).
The duration of the disturbance is typically at least 6 months (Criterion F). This dura-
tion threshold helps distinguish the disorder from transient social fears that are com-
mon, particularly among children and in the community. However, th e duration criterion
should be used as a general guide, with allowance for some degree of flexibility. The fear,
anxiety, and avoidance must interfere significa ntly with the individual’s normal routine,
occupational or academic functioning, or social activities or relation ships, or must cause
clinically significant distress or impairment in social, occupational, or other important ar-
eas of functioning (Criterion G). For example, an individual who is afraid to speak in pub-
lic would not receive a diagnosis of social anxi ety disorder if this activity is not routinely


lic would not receive a diagnosis of social anxi ety disorder if this activity is not routinely
encountered on the job or in classroom work, an d if the individual is not significantly dis-
tressed about it. However, if the individual avoi ds, or is passed over for, the job or educa-
tion he or she really wants because of so cial anxiety symptoms, Criterion G is met.
Associated Features Supporting Diagnosis
Individuals with social anxiety disorder may be inadequately assertive or excessively sub-
missive or, less commonly, highly controlling of the conversation. They may show overly
rigid body posture or inadequate eye contact, or  speak with an overly soft voice. These in-
dividuals may be shy or withdrawn, and they may be less open in conversations and dis-
close little about themselves. They may seek em ployment in jobs that  do not require social
contact, although this is not the case for indi viduals with social anxiety disorder, perfor-
mance only. They may live at home longer. Men may be delayed in marrying and having
a family, whereas women who would want to work outside the home may live a life as
homemaker and mother. Self-medication with substances is common (e.g., drinking be-
fore going to a party). Social anxiety among older adults may also include exacerbation of
symptoms of medical illnesses, such as increa sed tremor or tachycardia. Blushing is a hall-
mark physical response of social anxiety disorder.
Prevalence
The 12-month prevalence estimate of social an xiety disorder for the United States is ap-
proximately 7%. Lower 12-month prevalence esti mates are seen in much of the world us-
ing the same diagnostic instrument, clusteri ng around 0.5%–2.0%; median prevalence in


Europe is 2.3%. The 12-month prevalence rates in children and adolescents are comparable
to those in adults. Prevalence rates decrease  with age. The 12-mont h prevalence for older
adults ranges from 2% to 5%. In general, high er rates of social anxiety disorder are found
in females than in males in the general popu lation (with odds ratios ranging from 1.5 to
2.2), and the gender difference in prevalen ce is more pronounced in adolescents and
young adults. Gender rates are equivalent or slightly higher for males in clinical samples,


2.2), and the gender difference in prevalen ce is more pronounced in adolescents and
young adults. Gender rates are equivalent or slightly higher for males in clinical samples,
and it is assumed that gender roles and social  expectations play a significant role in ex-
plaining the heightened help-seeking behavior  in male patients. Prevalence in the United
States is higher in American Indians and lowe r in persons of Asian, Latino, African Amer-
ican, and Afro-Caribbean descent compared with non-Hispanic whites.


Social Anxiety Disorder (Social Phobia) 205
Development and Course
Median age at onset of social anxiety disorder  in the United States is 13 years, and 75% of
individuals have an age at onset between 8 and 15 years. The disord er sometimes emerges
out of a childhood history of social inhibition or shyness in U.S. and European studies. On-
set can also occur in early childhood. Onset of  social anxiety disorder may follow a stress-
ful or humiliating experience (e.g., being bu llied, vomiting during a public speech), or it
may be insidious, developing slowly. First onse t in adulthood is relatively rare and is more
likely to occur after a stressful or humiliating event or after life changes that require new
social roles (e.g., marrying someone from a different social class, receiving a job promo-
tion). Social anxiety disorder may diminish after an individual with fear of dating marries
and may reemerge after divorce. Among individu als presenting to clinical care, the disor-
der tends to be particularly persistent.
Adolescents endorse a broader pattern of fe ar and avoidance, including of dating,
compared with younger children . Older adults express social anxiety at lower levels but
across a broader range of situations, whereas younger adults express higher levels of so-
cial anxiety for specific situations. In older adults, social anxiet y may concern disability
due to declining sensory functioning (hearing , vision) or embarrassment about one’s ap-
pearance (e.g., tremor as a symptom of Parkin son’s disease) or functioning due to medical
conditions, incontinence, or cogn itive impairment (e.g., forgetting people’s names). In the
community approximately 30% of individuals with social anxiety disorder experience re-


community approximately 30% of individuals with social anxiety disorder experience re-
mission of symptoms within 1 year, and about 50% expe rience remission within a few
years. For approximately 60% of individuals wi thout a specific treatment for social anxiety
disorder, the course takes several years or longer.
Detection of social anxiety disorder in olde r adults may be challenging because of sev-
eral factors, including a focus on somatic symptoms, comorbid me dical illness, limited
insight, changes to social environment or roles that may obscure impairment in social
functioning, or reticence about de scribing psychological distress.
Risk and Prognostic Factors
Temperamental. Underlying traits that predispose individuals to social anxiety disor-
der include behavioral inhibition and fear of negative evaluation.
Environmental. There is no causative role of increa sed rates of childhood maltreatment or
other early-onset psychosocial adversity in th e development of social anxiety disorder. How-
ever, childhood maltreatment an d adversity are risk factors for social anxiety disorder.
Genetic and physiological. Traits predisposing individual s to social anxiety disorder,
such as behavioral inhibition, are strongly genetically influenced. The genetic influence is
subject to gene-environment interaction; that is, children with high behavioral inhibition
are more susceptible to environmental influe nces, such as socially anxious modeling by
parents. Also, social anxiety disorder is heritable (but performance-only anxiety less so).
First-degree relatives have a two to six times greater chance of having social anxiety dis-
order, and liability to the disord er involves the interplay of di sorder-specific (e.g., fear of
negative evaluation) and nonspecific (e.g., neuroticism) genetic factors.
Culture-Related Diagnostic Issues


Culture-Related Diagnostic Issues
The syndrome of taijin kyofusho  (e.g., in Japan and Korea) is often characterized by social-
evaluative concerns, fulfilling criteria for social anxiety di sorder, that are associated with
the fear that the individual makes other  people uncomfortable (e.g., “My gaze upsets peo-
ple so they look away and avoid me”), a fear that is at times experienced with delusional
intensity. This symptom may also be found in non-Asian settings.  Other presentations


ple so they look away and avoid me”), a fear that is at times experienced with delusional
intensity. This symptom may also be found in non-Asian settings.  Other presentations
of taijin kyofusho  may fulfill criteria fo r body dysmorphic disorder  or delusional disorder.


206 Anxiety Disorders
Immigrant status is associated with significan tly lower rates of social anxiety disorder in
both Latino and non-Latino white groups. Prev alence rates of social anxiety disorder may
not be in line with self-reported social anxiety levels in the same cult ure—that is, societies
with strong collectivistic orientations may report high levels of social anxiety but low prev-
alence of social anxiety disorder.
Gender-Related Diagnostic Issues
Females with social anxiety disorder report a greater number of social fears and comorbid
depressive, bipolar, and anxiety disorders, wh ereas males are more likely to fear dating,
have oppositional defiant disorder or conduct disorder, and use alcohol and illicit drugs to
relieve symptoms of the disorder. Paruresis is more common in males.
Functional Consequences of  Social Anxiety Disorder
Social anxiety disorder is asso ciated with elevated rates of  school dropout and with de-
creased well-being, employment , workplace productivity, soci oeconomic status, and quality
of life. Social anxiety disorder  is also associated with being single, unmarried, or divorced
and with not having children, particularly amon g men. In older adults, there may be impair-
ment in caregiving duties and volunteer activi ties. Social anxiety disorder also impedes lei-
sure activities. Despite the extent of distress  and social impairment associated with social
anxiety disorder, only about half  of individuals with the diso rder in Western societies ever
seek treatment, and they tend to do so only after 15–20 years of experiencing symptoms. Not
being employed is a strong predictor for th e persistence of social anxiety disorder.
Differential Diagnosis
Normative shyness. Shyness (i.e., social reticence) is a common personality trait and is
not by itself pathological. In some societies, shyness is even evaluated positively. How-


not by itself pathological. In some societies, shyness is even evaluated positively. How-
ever, when there is a significant adverse impa ct on social, occupational, and other impor-
tant areas of functioning, a di agnosis of social anxiety disord er should be considered, and
when full diagnostic criteria for social anxiety disorder are met, the disorder should be di-
agnosed. Only a minority (12%) of self-identif ied shy individuals in the United States have
symptoms that meet diagnostic crit eria for social anxiety disorder.
Agoraphobia. Individuals with agoraphobia may fear an d avoid social situations (e.g., go-
ing to a movie) because escape might be difficult or help might not be available in the event of
incapacitation or panic-like sy mptoms, whereas individuals with  social anxiety disorder are
most fearful of scrutiny by others. Moreover, in dividuals with social anxiety disorder are likely
to be calm when left entirely alone, wh ich is often not the case in agoraphobia.
Panic disorder. Individuals with social anxiety disord er may have panic attacks, but the
concern is about fear of negative evaluati on, whereas in panic disorder the concern is
about the panic attacks themselves.
Generalized anxiety disorder. Social worries are common in generalized anxiety disorder,
but the focus is more on the nature of ongoing relationships rather than  on fear of negative
evaluation. Individuals with generalized anxiety disorder, particularly children, may have ex-
cessive worries about the quality of their social performance, bu t these worries also pertain to
nonsocial performance and when the individual is not being evaluated by others. In social anx-
iety disorder, the worries focus on social performance and others’ evaluation.
Separation anxiety disorder. Individuals with separation anxiety disorder may avoid


Separation anxiety disorder. Individuals with separation anxiety disorder may avoid
social settings (including school refusal) because of concerns about being separated from
attachment figures or, in childre n, about requiring the presence of a parent when it is not
developmentally appropriate. Individuals with separation anxiety disorder are usually


attachment figures or, in childre n, about requiring the presence of a parent when it is not
developmentally appropriate. Individuals with separation anxiety disorder are usually
comfortable in social settings when their attachment figure is present or when they are at


Social Anxiety Disorder (Social Phobia) 207
home, whereas those with social anxiety diso rder may be uncomforta ble when social sit-
uations occur at home or in the presence of attachment figures.
Specific phobias. Individuals with specific phobias may fear embarrassment or humil-
iation (e.g., embarrassment about fainting wh en they have their blood drawn), but they do
not generally fear negative evalua tion in other social situations.
Selective mutism. Individuals with selective mutism ma y fail to speak because of fear of
negative evaluation, but they do not fear nega tive evaluation in social situations where no
speaking is required (e.g., nonverbal play).
Major depressive disorder. Individuals with major depre ssive disorder may be con-
cerned about being negatively evaluated by ot hers because they feel they are bad or not
worthy of being liked. In contrast, individuals with social anxiety disorder are worried
about being negatively evaluated because of ce rtain social behaviors or physical symptoms.
Body dysmorphic disorder. Individuals with body dysmorphic disorder are preoccu-
pied with one or more perceived defects or fl aws in their physical appearance that are not
observable or appear slight to others; this preoccupation often causes social anxiety and
avoidance. If their social fears and avoidance are caused only by their beliefs about their
appearance, a separate diagnosis of soci al anxiety disorder is not warranted.
Delusional disorder. Individuals with delusional disorder may have nonbizarre delu-
sions and/or hallucinations related to the delu sional theme that focus on being rejected by
or offending others. Although extent of insi ght into beliefs about social situations may
vary, many individuals with social anxiety diso rder have good insight that their beliefs are
out of proportion to the actual th reat posed by the social situation.


out of proportion to the actual th reat posed by the social situation.
Autism spectrum disorder. Social anxiety and social comm unication deficits are hall-
marks of autism spectrum disorder. Individu als with social anxiety disorder typically
have adequate age-appropriate social relationships and social communication capacity,
although they may appear to have impairment in these areas when first interacting with
unfamiliar peers or adults.
Personality disorders. Given its frequent onset in childhood and its persistence into and
through adulthood, social anxiety disorder may resemble a personality disorder. The most
apparent overlap is with avoidant personalit y disorder. Individuals with avoidant person-
ality disorder have a broader avoidance pattern than those with social anxiety disorder.
Nonetheless, social anxiety disorder is typica lly more comorbid with avoidant personality
disorder than with other personality disorders, and avoidant personality disorder is more
comorbid with social anxiety disorder  than with other anxiety disorders.
Other mental disorders. Social fears and discomfort can occur as part of schizophrenia,
but other evidence for psychotic symptoms is usually present. In individuals with an eat-
ing disorder, it is important to determine th at fear of negative evaluation about eating
disorder symptoms or behaviors (e.g., purging and vomiting) is not the sole source of so-
cial anxiety before applying a diagnosis of social anxiety disorder. Similarly, obsessive-
compulsive disorder may be asso ciated with social anxiety, but the additional diagnosis of
social anxiety disorder is used only when social fears and avoidance are independent of
the foci of the obsessions and compulsions.
Other medical conditions. Medical conditions may produce symptoms that may be em-
barrassing (e.g. trembling in Parkinson’s dise ase). When the fear of negative evaluation
due to other medical conditions  is excessive, a diagnosis of social anxiety disorder should
be considered.


be considered.
Oppositional defiant disorder. Refusal to speak due to oppo sition t o authorit y figures


due to other medical conditions  is excessive, a diagnosis of social anxiety disorder should
be considered.
Oppositional defiant disorder. Refusal to speak due to oppo sition t o authorit y figures
should be differentiated from failure to speak due to fear of negative evaluation.


208 Anxiety Disorders
Comorbidity
Social anxiety disorder is often comorbid wi th other anxiety disorders, major depressive
disorder, and substance use diso rders, and the onset of social anxiety disorder generally
precedes that of the other disorders, except for specific phobia and separation anxiety dis-
order. Chronic social isolation in the course of  a social anxiety disorder may result in major
depressive disorder. Comorbidity with depression is high also in older adults. Substances
may be used as self-medication for social fe ars, but the symptoms of substance intoxica-
tion or withdrawal, such as trembling, may also be a source of (further) social fear. Social
anxiety disorder is frequently comorbid with  bipolar disorder or body dysmorphic disor-
der; for example, an individual has body dysmorphic disorder co ncerning a preoccupa-
tion with a slight irregularity of her nose, as  well as social anxiety disorder because of a
severe fear of sounding unintelligent. The mo re generalized form of social anxiety disor-
der, but not social anxiety di sorder, performance only, is often comorbid with avoidant
personality disorder. In children, comorbidities with high-functioning autism and selec-
tive mutism are common.
Panic Disorder
Diagnostic Criteria 300.01 (F41.0)
A. Recurrent unexpected panic attacks. A panic attack is 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:
Note:  The abrupt surge can occur from a calm state or an anxious state.
1. Palpitations, pounding heart, or accelerated heart rate.
2. Sweating.
3. Trembling or shaking.


2. Sweating.
3. Trembling or shaking.
4. Sensations of shortness of breath or smothering.
5. Feelings of choking.
6. Chest pain or discomfort.
7. Nausea or abdominal distress.
8. Feeling dizzy, unsteady, light-headed, or faint.
9. Chills or heat sensations.
10. Paresthesias (numbness or tingling sensations).
11. Derealization (feelings of unreality) or depersonalization (being detached from one-
self).
12. Fear of losing control or “going crazy.”
13. Fear of dying.
Note: Culture-specific symptoms (e.g., tinnitus, neck soreness, headache, uncontrol-
lable screaming or crying) may be seen. Such symptoms should not count as one of
the four required symptoms.
B. At least one of the attacks has been followed by 1 month (or more) of one or both of
the following:
1. Persistent concern or worry about additional panic attacks or their consequences
(e.g., losing control, having a heart attack, “going crazy”).
2. A significant maladaptive change in behavior related to the attacks (e.g., behaviors
designed to avoid having panic attacks, such as avoidance of exercise or unfamiliar
situations).


Panic Disorder 209
C. The disturbance is not attributable to the physiological effects of a substance (e.g., a
drug of abuse, a medication) or another medi cal condition (e.g., hyperthyroidism, car-
diopulmonary disorders).
D. The disturbance is not better explained by another mental disorder (e.g., the panic at-
tacks do not occur only in response to feared social situations, as in social anxiety dis-
order; in response to circumscribed phobic objec ts or situations, as in specific phobia;
in response to obsessions, as in obsessive-compulsive disorder; in response to re-
minders of traumatic events, as in posttraumatic stress disorder; or in response to sep-
aration from attachment figures, as in separation anxiety disorder).
Diagnostic Features
Panic disorder  refers to recurrent unexpected panic attacks (Criterion A). A panic attack is
an abrupt surge of intense fear or intense di scomfort that reaches a peak within minutes,
and during which time four or more of a lis t of 13 physical and cognitive symptoms occur.
The term recurrent  literally means more than one un expected panic attack. The term unex-
pected  refers to a panic attack for which there is no obvious cue or trigger at the time of oc-
currence—that is, the attack appears to occu r from out of the blue, such as when the
individual is relaxing or emerging from sleep (nocturnal panic attack). In contrast, expected
panic attacks are attacks for which there is an ob vious cue or trigger, such as a situation in
which panic attacks typically occur. The determination of whether panic attacks are ex-
pected or unexpected is made by the clinicia n, who makes this judgment based on a com-
bination of careful questioning as to the sequence of events preceding or leading up to the


bination of careful questioning as to the sequence of events preceding or leading up to the
attack and the individual’s own judgment of wh ether or not the attack seemed to occur for
no apparent reason. Cultural interpretation s may influence the assignment of panic at-
tacks as expected or unexpected (see section “Culture-Related Diagnostic Issues” for this
disorder). In the United States and Europe , approximately one-half  of individuals with
panic disorder have expected panic attacks as  well as unexpected panic attacks. Thus, the
presence of expected panic attacks does not rule out the diagnosis of panic disorder. For
more details regarding expected versus unexpected panic attacks, see the text accompa-
nying panic attacks (pp. 214–217).
The frequency and severity of panic attacks vary widely. In terms of frequency, there
may be moderately frequent a ttacks (e.g., one per week) for months at a time, or short
bursts of more frequent attacks (e.g., daily) separated by weeks or months without any at-
tacks or with less frequent attacks (e.g., two per month) over many years. Persons who
have infrequent panic attacks resemble person s with more frequent panic attacks in terms
of panic attack symptoms, demographic charac teristics, comorbidity with other disorders,
family history, and biological data. In terms of severity, individuals with panic disorder
may have both full-symptom (four or more symptoms) and limited-symptom (fewer than
four symptoms) attacks, and the number and type of panic attack symptoms frequently
differ from one panic attack to  the next. However, more th an one unexpected full-symp-
tom panic attack is required for the diagnosis of panic disorder.
The worries about panic attacks or their co nsequences usually pertain to physical con-


The worries about panic attacks or their co nsequences usually pertain to physical con-
cerns, such as worry that panic attacks refl ect the presence of life-threatening illnesses
(e.g., cardiac disease, seizure disorder); social concerns, such  as embarrassment or fear of
being judged negatively by others because of visible panic symptoms; and concerns about
mental functioning, such as “going crazy” or  losing control (Criterion B). The maladaptive
changes in behavior represent attempts to mi nimize or avoid panic attacks or their conse-


mental functioning, such as “going crazy” or  losing control (Criterion B). The maladaptive
changes in behavior represent attempts to mi nimize or avoid panic attacks or their conse-
quences. Examples include avoiding physical exertion, reorganizing daily life to ensure
that help is available in the event of a pani c attack, restricting usual daily activities, and
avoiding agoraphobia-type situations, such as  leaving home, using pu blic transportation,
or shopping. If agoraphobia is present, a separate diagnosis of agoraphobia is given.


210 Anxiety Disorders
Associated Features Supporting Diagnosis
One type of unexpected panic attack is a nocturnal panic attack (i.e., waking from sleep in
a state of panic, which differs from panicking after fully waking from sleep). In the United
States, this type of panic attack has been es timated to occur at leas t one time in roughly
one-quarter to one-third of individuals with  panic disorder, of whom the majority also
have daytime panic attacks. In addition to  worry about panic attacks and their conse-
quences, many individuals with panic disorder report constant or intermittent feelings of
anxiety that are more broadly related to heal th and mental health concerns. For example,
individuals with panic disorder often antici pate a catastrophic outc ome from a mild phys-
ical symptom or medication side effect (e.g., thinking that they may have heart disease or
that a headache means presence of a brain tumo r). Such individuals often are relatively in-
tolerant of medication side effects. In ad dition, there may be pe rvasive concerns about
abilities to complete daily tasks or withstand daily stressors, excessive use of drugs (e.g.,
alcohol, prescribed medications or illicit drugs)  to control panic attacks, or extreme behav-
iors aimed at controlling panic attacks (e.g., seve re restrictions on food intake or avoidance
of specific foods or medications because of concerns about physical symptoms that pro-
voke panic attacks).
Prevalence
In the general population, the 12-month prevalen ce estimate for panic disorder across the
United States and several European countries is about 2%–3% in adults and adolescents. In
the United States, significantly lower rates of  panic disorder are reported among Latinos,
African Americans, Caribbean blacks, and As ian Americans, compared with non-Latino


African Americans, Caribbean blacks, and As ian Americans, compared with non-Latino
whites; American Indians, by contrast, have significantly higher rates. Lower estimates
have been reported for Asian,  African, and Latin American countries, ranging from 0.1%
to 0.8%. Females are more frequently affected than males, at a rate of approximately 2:1. The
gender differentiation occurs in adolescence and is already observable before age 14 years.
Although panic attacks occur in children, the overall prevalence  of panic disorder is low
before age 14 years (<0.4%). The rates of panic disorder show a gradua l increase during ad-
olescence, particularly in females, and possibly following the onset of puberty, and peak dur-
ing adulthood. The prevalence rates decline in older individuals (i.e., 0.7% in adults over
the age of 64), possibly reflecting diminishing severity to subclinical levels.
Development and Course
The median age at onset for panic disorder in the United States is 20–24 years. A small
number of cases begin in childhood, and onse t after age 45 years is unusual but can occur.
The usual course, if the disorder is untreated,  is chronic but waxing and waning. Some in-
dividuals may have episodic outbreaks with years of remission in between, and others
may have continuous severe symptomatology. Only a minority of individuals have full
remission without subsequent relapse within a few years. The course of panic disorder
typically is complicated by a range of other disorders, in particular other anxiety disor-
ders, depressive disorders, and substance us e disorders (see section “Comorbidity” for
this disorder).
Although panic disorder is very rare in child hood, first occurrence of “fearful spells” is


often dated retrospectively back to childhood. As in adults, panic disorder in adolescents
tends to have a chronic course and is frequent ly comorbid with othe r anxiety, depressive,
and bipolar disorders. To date, no differences in the clinical presentation between adoles-
cents and adults have been fo und. However, adolescents may be less worried about addi-
tional panic attacks than are young adults. Lower prevalence of panic disorder in older


cents and adults have been fo und. However, adolescents may be less worried about addi-
tional panic attacks than are young adults. Lower prevalence of panic disorder in older
adults appears to be attributable to age- related “dampening” of the autonomic nervous
system response. Many older individuals with  “panicky feelings” are observed to have a
“hybrid” of limited-symptom panic attacks and generalized anxiety. Also, older adults


Panic Disorder 211
tend to attribute their panic attacks to certai n stressful situations, such as a medical pro-
cedure or social setting. Older individuals may retrospectively endorse explanations for
the panic attack (which would preclude the diagnosis of panic disorder), even if an attack
might actually have been unexpected in the moment (and thus qualify as the basis for a
panic disorder diagnosis). This may result in under-endorsem ent of unexpected panic at-
tacks in older individuals. Thus, careful questioning of older adults is required to assess
whether panic attacks were expected before entering the situation,  so that unexpected
panic attacks and the diagnosis of panic disorder are not overlooked.
While the low rate of panic disorder in child ren could relate to difficulties in symptom
reporting, this seems unlikely given that child ren are capable of reporting intense fear or
panic in relation to separation and to phobic objects or phobic si tuations. Adolescents
might be less willing than adul ts to openly discuss panic a ttacks. Therefore, clinicians
should be aware that unexpected  panic attacks do occur in adolescents, much as they do in
adults, and be attuned to this possibility when encountering adolescents presenting with
episodes of intense fear or distress.
Risk and Prognostic Factors
Temperamental. Negative affectivity (neuroticism) (i .e., proneness to experiencing neg-
ative emotions) and anxiety sensitivity (i.e., the disposition to believe that symptoms of
anxiety are harmful) are risk factors for the onset of panic attacks and, separately, for
worry about panic, although thei r risk status for the diagnosis of panic disorder is un-
known. History of “fearful spe lls” (i.e., limited-symptom atta cks that do not meet full cri-


teria for a panic attack) may be a risk factor for later panic attacks and panic disorder.
Although separation anxiety in childhood, espe cially when severe, may precede the later
development of panic disorder, it is not a consistent risk factor.
Environmental. Reports of childhood experiences of  sexual and physical abuse are more
common in panic disorder than in certain othe r anxiety disorders. Smoking is a risk factor
for panic attacks and panic disorder. Most individuals report identifiable stressors in the
months before their first panic attack (e.g., interpersonal stressors and stressors related to
physical well-being, such as negative experiences with illicit or prescription drugs, dis-
ease, or death in the family).
Genetic and physiological. It is believed that multiple genes confer vulnerability to panic
disorder. However, the exact genes, gene prod ucts, or functions related to the genetic re-
gions implicated remain unknown. Current ne ural systems models for panic disorder em-
phasize the amygdala and related structures, mu ch as in other anxiety disorders. There is
an increased risk for panic d isorder among offspring of pare nts with anxiety, depressive,
and bipolar disorders. Respiratory disturbance, such as asthma, is associated with panic
disorder, in terms of past history, comorbidity, and family history.
Culture-Related Diagnostic Issues
The rate of fears about mental and somatic symptoms of anxiety ap pears to vary across
cultures and may influence the rate of panic attacks and panic disorder. Also, cultural ex-
pectations may influence the classification of panic attacks as expected or unexpected. For
example, a Vietnamese individual who has a panic attack after walking out into a windy
environment ( trúng gió;  “hit by the wind”) may attribut e the panic attack to exposure to


wind as a result of the cultural  syndrome that links these two experiences, resulting in clas-
sification of the panic attack as expected. Various other cultural syndromes are associated
with panic disorder, including ataque de nervios  (“attack of nerves”) among Latin Ameri-
cans and khyâl  attacks and “soul loss” among Cambodians. Ataque de nervios  may involve


with panic disorder, including ataque de nervios  (“attack of nerves”) among Latin Ameri-
cans and khyâl  attacks and “soul loss” among Cambodians. Ataque de nervios  may involve
trembling, uncontrollable screaming or crying , aggressive or suicidal behavior, and deper-
sonalization or derealization, which may be ex perienced longer than the few minutes typical


212 Anxiety Disorders
of panic attacks. Some c linical presentations of ataque de nervios  fulfill criteria for condi-
tions other than panic attack (e.g., other spec ified dissociative disorder). These syndromes
impact the symptoms and frequency of panic disorder, including the individual’s attribu-
tion of unexpectedness, as cultural syndromes may create fear of certain situations, rang-
ing from interpersonal arguments (associated with ataque de nervios), to types of exertion
(associated with khyâl  attacks), to atmospheri c wind (associated with trúng gió  attacks).
Clarification of the details of cultural attributions may aid in distinguishing expected and
unexpected panic attacks. For more information regarding cultural syndromes, refer to the
“Glossary of Cultural Concepts of Distress” in the Appendix.
The specific worries about panic attacks or their consequences are likely to vary from
one culture to another (and across different age groups and gender). For panic disorder,
U.S. community samples of non- Latino whites have significantly less functional impair-
ment than African Americans. There are also hi gher rates of objectively defined severity in
non-Latino Caribbean blacks with panic disord er, and lower rates of panic disorder over-
all in both African American and Afro-Carib bean groups, suggesting that among individ-
uals of African descent, the criteria for pa nic disorder may be met only when there is
substantial severity and impairment.
Gender-Related Diagnostic Issues
The clinical features of panic disorder do not appear to differ between males and females.
There is some evidence for sexual dimorphi sm, with an association between panic disor-
der and the catechol-O-methyltransferase (COMT) gene in females only.
Diagnostic Markers


Diagnostic Markers
Agents with disparate mechanisms of action, such as sodium lactate, caffeine, isoprotere-
nol, yohimbine, carbon dioxide, and cholecys tokinin, provoke panic attacks in individuals
with panic disorder to a much greater extent than in healthy control subjects (and in some
cases, than in individuals with other anxiet y, depressive, or bipo lar disorders without
panic attacks). Also, for a proportion of indi viduals with panic disorder, panic attacks are
related to hypersensitive medullary carbon di oxide detectors, resulting in hypocapnia and
other respiratory irregularities . However, none of these labo ratory findings are consid-
ered diagnostic of panic disorder.
Suicide Risk
Panic attacks and a diagnosis of panic disorder in the past 12 months are related to a higher
rate of suicide attempts and suicidal ideation in the past 12 months even when comorbid-
ity and a history of childhood abuse and other suicide risk factors are taken into account.
Functional Consequences of Panic Disorder
Panic disorder is associated with high levels of social, occupational, and physical disabil-
ity; considerable economic co sts; and the highest number of medical visits among the anx-
iety disorders, although the effects are st rongest with the presence of agoraphobia.
Individuals with panic disorder may be freque ntly absent from work or school for doctor
and emergency room visits, which can lead to  unemployment or dropping out of school.
In older adults, impairment may be seen in caregiving duties or volunteer activities. Full-
symptom panic attacks typically are associated with greater morbidity (e.g., greater health
care utilization, more disabilit y, poorer quality of  life) than limited-symptom attacks.
Differential Diagnosis
Other specified anxiety disorder or unspecified anxiety disorder. Panic disorder should


Differential Diagnosis
Other specified anxiety disorder or unspecified anxiety disorder. Panic disorder should
not be diagnosed if full-symptom  (unexpected) panic attacks ha ve never been experienced. In


Panic Disorder 213
the case of only limited-symptom unexpected panic attacks, an other specified anxiety dis-
order or unspecified anxiety disord er diagnosis should be considered.
Anxiety disorder due to another medical condition. Panic disorder is not diagnosed if
the panic attacks are judged to be a direct physiological consequence of another medical
condition. Examples of medica l conditions that can cause panic attacks include hyperthy-
roidism, hyperparathyroidism, pheochromocytoma, vestibular  dysfunctions, seizure dis-
orders, and cardiopulmonary conditions (e.g., arrhythmias, supraventricular tachycardia,
asthma, chronic obstructive pulmonary diseas e [COPD]). Appropriate laboratory tests
(e.g., serum calcium levels for hyperparathy roidism; Holter monitor for arrhythmias) or
physical examinations (e.g., for cardiac conditions) may be helpful in determining the eti-
ological role of another medical condition.
Substance/medication-induced anxiety disorder. Panic disorder is not diagnosed if
the panic attacks are judged to be a direct physiological consequence of a substance. In-
toxication with central nervou s system stimulants (e.g., co caine, amphetamines, caffeine)
or cannabis and withdraw al from central nervous system depressants (e.g., alcohol, bar-
biturates) can precipitate a panic attack. Howe ver, if panic attacks continue to occur out-
side of the context of substance use (e.g., long after the effects of intoxication or withdrawal
have ended), a diagnosis of panic disorder should be cons idered. In addition, because
panic disorder may precede substance use in some individuals and may be associated
with increased substance use, especially for pu rposes of self-medicat ion, a detailed history


should be taken to determine if the individual had panic at tacks prior to excessive sub-
stance use. If this is the case, a diagnosis of pa nic disorder should be considered in addition
to a diagnosis of substance use disorder. Features such as onset after age 45 years or the
presence of atypical symptoms during a panic attack (e.g., vertigo, loss of consciousness,
loss of bladder or bowel control, slurred speech, amnesia) suggest the possibility that an-
other medical condition or a substance may be causing the panic attack symptoms.
Other mental disorders with panic attacks as an associated feature (e.g., other anxiety
disorders and psychotic disorders). Panic attacks that occur as a symptom of other anx-
iety disorders are expected (e.g., triggered by social situations in social anxiety disorder, by
phobic objects or situations in specific phobia  or agoraphobia, by worry in generalized anx-
iety disorder, by separation from home or atta chment figures in separation anxiety disorder)
and thus would not meet crit eria for panic disorder. ( Note: Sometimes an unexpected panic
attack is associated with the onset of another anxi ety disorder, but then the attacks become
expected, whereas panic disorder is characterized by recurrent unexpected panic attacks.) If
the panic attacks occur only in response to spec ific triggers, then only the relevant anxiety
disorder is assigned. However,  if the individual experiences unexpected panic attacks as
well and shows persistent concern and worry or  behavioral change because of the attacks,
then an additional diagnosis of pa nic disorder should be considered.
Comorbidity
Panic disorder infrequently occurs in clinic al settings in the absence of other psychopa-
thology. The prevalence of panic disorder is elevated in individuals with other disorders,
particularly other anxiety disorders (and espe cially agoraphobia), major depression, bipo-


lar disorder, and possibly mild alcohol use di sorder. While panic disorder often has an ear-
lier age at onset than the comorbid disorder(s), onset sometimes occurs after the comorbid
disorder and may be seen as a severi ty marker of the comorbid illness.
Reported lifetime rates of comorbidity between major depressive disorder and panic


disorder and may be seen as a severi ty marker of the comorbid illness.
Reported lifetime rates of comorbidity between major depressive disorder and panic
disorder vary widely, ranging from 10% to 65%  in individuals with panic disorder. In ap-
proximately one-third of indivi duals with both disorders, the depression precedes the on-
set of panic disorder. In the remaining two-th irds, depression occurs coincident with or
following the onset of panic disorder. A subset of individuals with panic disorder develop
a substance-related disorder, wh ich for some represents an a ttempt to treat their anxiety


214 Anxiety Disorders
with alcohol or medications. Comorbidity wi th other anxiety disorders and illness anxiety
disorder is also common.
Panic disorder is significantly comorbid  with numerous general medical symptoms
and conditions, including, but not limited to, dizziness, ca rdiac arrhythmias, hyperthy-
roidism, asthma, COPD, and ir ritable bowel syndrome. However, the nature of the asso-
ciation (e.g., cause and effect) between pani c disorder and these conditions remains
unclear. Although mitral valve prolapse and thyroid disease are more common among in-
dividuals with panic disorder than in the ge neral population, the differences in prevalence
are not consistent.
Panic Attack Specifier

Note: Symptoms are presented for the purpose of identifying a panic attack; however,
panic attack is not a mental disorder and cannot be coded. Panic attacks can occur in the
context of any anxiety disorder as well as other mental disorders (e.g., depressive disor-
ders, posttraumatic stress disorder, substanc e use disorders) and some medical condi-
tions (e.g., cardiac, respiratory, vestibular, gastrointestinal). When the presence of a panic
attack is identified, it should be noted as a specifier (e.g., “posttraumatic stress disorder
with panic attacks”). For panic disorder, the pr esence of panic attack is contained within
the criteria for the disorder and panic attack is not used as a specifier.
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:
Note:  The abrupt surge can occur from a calm state or an anxious state.
1. Palpitations, pounding heart, or accelerated heart rate.
2. Sweating.
3. Trembling or shaking.


2. Sweating.
3. Trembling or shaking.
4. Sensations of shortness of breath or smothering.
5. Feelings of choking.
6. Chest pain or discomfort.
7. Nausea or abdominal distress.
8. Feeling dizzy, unsteady, light-headed, or faint.
9. Chills or heat sensations.
10. Paresthesias (numbness or tingling sensations).
11. Derealization (feelings of unreality) or de personalization (being detached from oneself).
12. Fear of losing control or “going crazy.”
13. Fear of dying.
Note: Culture-specific symptoms (e.g., tinnitus, neck soreness, headache, uncontrollable
screaming or crying) may be seen. Such sym ptoms should not count as one of the four
required symptoms.
Features
The essential feature of a panic attack is an abru pt surge of intense fear or intense discomfort
that reaches a peak within minutes and during wh ich time four or more of 13 physical and cog-
nitive symptoms occur. Eleven of these 13 sy mptoms are physical (e.g., palpitations, sweat-
ing), while two are cognitive (i.e., fear of losing control or going crazy, fe ar of dying). “Fear of
going crazy” is a colloquialism often used by indivi duals with panic atta cks and is not in-
tended as a pejorative or diagnostic term. The term within minutes  means that the time to peak


Panic Attack Specifier 215
intensity is literally only a few minutes. A panic attack can arise from either a calm state or an
anxious state, and time to peak intensity shou ld be assessed independently of any preceding
anxiety. That is, the start of the panic attack is the point at which there is an abrupt increase in
discomfort rather than the point at which anxiet y first developed. Likew ise, a panic attack can
return to either an anxious state or a calm stat e and possibly peak again. A panic attack is dis-
tinguished from ongoing anxiety by its time to pe ak intensity, which occurs within minutes; its
discrete nature; and its typically greater severity. Attacks that meet all other criteria but have
fewer than four physical and/or cogn itive symptoms are referred to as limited-symptom attacks.
There are two characteristic types of pa nic attacks: expected and unexpected. Expected
panic attacks  are attacks for which there is an obvious cue or trigger, such as situations in
which panic attacks have typically occurred. Unexpected panic attacks  are those for which
there is no obvious cue or trigger at the time  of occurrence (e.g., wh en relaxing or out of
sleep [nocturnal panic attack]). The determination of whether panic attacks are expected
or unexpected is made by the clinician, who makes this judgment based on a combination
of careful questioning as to the sequence of events preceding or leading up to the attack
and the individual’s own judgment of whether or not the attack seemed  to occur for no ap-
parent reason. Cultural interp retations may influence their determination as expected or
unexpected. Culture-specific symptoms (e.g., tinnitus, neck soreness, headache, uncon-
trollable screaming or crying) may be seen; however, such symptoms  should not count as


trollable screaming or crying) may be seen; however, such symptoms  should not count as
one of the four required symptoms. Panic attacks can occur in the context of any mental
disorder (e.g., anxiety disorder s, depressive disorders, bipola r disorders, eating disorders,
obsessive-compulsive and related disorders, personality di sorders, psychotic disorders,
substance use disorders) and some medical cond itions (e.g., cardiac,  respiratory, vestibu-
lar, gastrointestinal), with the majority ne ver meeting criteria for panic disorder. Recur-
rent unexpected panic attacks are requir ed for a diagnosis of panic disorder.
Associated Features
One type of unexpected panic attack is a nocturnal panic attack  (i.e., waking from sleep in a
state of panic), which differs from panicking after fully waking from sleep. Panic attacks
are related to a higher rate of  suicide attempts and suicidal ideation even when comorbid-
ity and other suicide risk fa ctors are taken into account.
Prevalence
In the general population, 12-month prevalen ce estimates for panic attacks in the United
States is 11.2% in adults. Twelve-month preval ence estimates do not appear to differ sig-
nificantly among African Americans, Asian Americans, and Latinos. Lower 12-month
prevalence estimates for European countries ap pear to range from 2.7% to 3.3%. Females
are more frequently affected than males, al though this gender difference is more pro-
nounced for panic disorder. Panic attacks can oc cur in children but are relatively rare until
the age of puberty, when the prevalence rates increase. The prevalence rates decline in
older individuals, possibly reflecting diminishing severity to subclinical levels.
Development and Course
The mean age at onset for panic attacks in the United States is approximately 22–23 years


The mean age at onset for panic attacks in the United States is approximately 22–23 years
among adults. However, the course of panic at tacks is likely influenced by the course of
any co-occurring mental disorder(s) and stre ssful life events. Panic attacks are uncommon,
and unexpected panic attacks are rare, in preadolescent children . Adolescents might be
less willing than adults to openly discuss panic attacks, even though they present with ep-
isodes of intense fear or discom fort. Lower prevalence of pani c attacks in older individuals


less willing than adults to openly discuss panic attacks, even though they present with ep-
isodes of intense fear or discom fort. Lower prevalence of pani c attacks in older individuals
may be related to a weaker autonomic response to emotional states re lative to younger in-
dividuals. Older individuals may be less inclin ed to use the word “fear” and more inclined


216 Anxiety Disorders
to use the word “discomfort” to describe pa nic attacks. Older individuals with “panicky
feelings” may have a hybrid of limited-sym ptom attacks and generalized anxiety. In
addition, older individuals tend  to attribute panic attacks to  certain situations that are
stressful (e.g., medical procedures, social se ttings) and may retrospectively endorse expla-
nations for the panic attack even if it was un expected in the moment. This may result in un-
der-endorsement of unexpected panic attacks in older individuals.
Risk and Prognostic Factors
Temperamental. Negative affectivity (neuroticism) (i .e., proneness to experiencing neg-
ative emotions) and anxiety sensitivity (i.e., the disposition to believe that symptoms of
anxiety are harmful) are risk factors for the onset of panic attacks. History of “fearful
spells” (i.e., limited-symptom attacks that do not meet full criteria for a panic attack) may
be a risk factor for later panic attacks.
Environmental. Smoking is a risk factor for panic atta cks. Most individu als report iden-
tifiable stressors in the months before their first panic attack (e.g., interpersonal stressors
and stressors related to physical well-being,  such as negative experiences with illicit or
prescription drugs, disease,  or death in the family).
Culture-Related Diagnostic Issues
Cultural interpretations may in fluence the determination of panic attacks as expected or
unexpected. Culture-specific symptoms (e.g., tinnitus, neck soreness, headache, and un-
controllable screaming or crying) may be seen ; however, such symptoms should not count
as one of the four required symptoms. Frequency of each of the 13 symptoms varies cross-


as one of the four required symptoms. Frequency of each of the 13 symptoms varies cross-
culturally (e.g., higher rates of paresthesias in African Americans and of dizziness in sev-
eral Asian groups). Cultural syndromes also influence the cross-cultural presentation of
panic attacks, resulting in different symptom profiles across different cultural groups. Ex-
amples include khyâl  (wind) attacks, a Cambodian cultural syndrome involving dizziness,
tinnitus, and neck soreness; and trúng gió  (wind-related) attacks,  a Vietnamese cultural
syndrome associated with headaches. Ataque de nervios (attack of nerves) is a cultural syn-
drome among Latin Americans that may invo lve trembling, uncontrollable screaming or
crying, aggressive or suicidal behavior, and depersonalization or derealization, and which
may be experienced for longer than only a few minutes. Some clinical presentations of
ataque de nervios fulfill criteria for conditions other than panic attack (e.g., other specified
dissociative disorder). Also, cu ltural expectations may influe nce the classification of panic
attacks as expected or unexpected, as cultural syndromes may create fear of certain situa-
tions, ranging from interpersonal arguments (associated with ataque de nervios ), to types of
exertion (associated with khyâl attacks), to atmospheric wind (associated with trúng gió  at-
tacks). Clarification of the details of cultural  attributions may aid in distinguishing ex-
pected and unexpected panic attacks. For more information ab out cultural syndromes, see
“Glossary of Cultural Concepts of Distress” in the Appendix to this manual.
Gender-Related Diagnostic Issues
Panic attacks are more common in  females than in males, but clinical features or symp-


Panic attacks are more common in  females than in males, but clinical features or symp-
toms of panic attacks do not di ffer between males and females.
Diagnostic Markers
Physiological recordings of naturally occurring panic attacks in individuals with panic
disorder indicate abrupt surges  of arousal, usually of heart rate, that reach a peak within
minutes and subside within minu tes, and for a proportion of  these individu als the panic
attack may be preceded by cardiorespiratory instabilities.


Agoraphobia 217
Functional Consequenc es of Panic Attacks
In the context of co-occurring mental disord ers, including anxiety disorders, depressive
disorders, bipolar disorder, substance use disorders, psychoti c disorders, and personality
disorders, panic attacks are associated with  increased symptom severity, higher rates of
comorbidity and suicidality, and poorer trea tment response. Also, full-symptom panic at-
tacks typically are associated wi th greater morbidity (e.g., gr eater health care utilization,
more disability, poorer quality of life) than limited-symptom attacks.
Differential Diagnosis
Other paroxysmal episodes (e.g., “anger attacks”). Panic attacks should not be diag-
nosed if the episodes do not involve the essent ial feature of an abrupt surge of intense fear
or intense discomfort, but rather other emotional states (e.g ., anger, grief).
Anxiety disorder due to another medical condition. Medical conditions that can cause
or be misdiagnosed as panic attacks include hyperthyroidism, hyperparathyroidism, pheo-
chromocytoma, vestibular dysfunctions, se izure disorders, and cardiopulmonary con-
ditions (e.g., arrhythmias, supraventricular  tachycardia, asthma, chronic obstructive
pulmonary disease). Appropriate laboratory tests (e.g., serum calcium levels for hyperpara-
thyroidism; Holter monitor for arrhythmias) or  physical examinations (e.g., for cardiac con-
ditions) may be helpful in determining the etiological role of another medical condition.
Substance/medication-induced anxiety disorder. Intoxication with central nervous
system stimulants (e.g., coca ine, amphetamines, caffeine) or cannabis and withdrawal


from central nervous system depressants (e.g ., alcohol, barbiturat es) can precipitate a
panic attack. A detailed histor y should be taken to determin e if the indivi dual had panic
attacks prior to excessiv e substance use. Features such as  onset after age 45 years or the
presence of atypical symptoms during a panic attack (e.g., vertigo, loss of consciousness,
loss of bladder or bowel contro l, slurred speech, or amnesia)  suggest the possibility that a
medical condition or a substance may be causing the panic attack symptoms.
Panic disorder. Repeated unexpected panic attacks are required but are no t sufficient for
the diagnosis of panic disorder (i .e., full diagnostic criteria fo r panic disorder must be met).
Comorbidity
Panic attacks are associated with increased likelihood of various comorbid mental dis-
orders, including anxiety disorders, depressi ve disorders, bipolar disorders, impulse-
control disorders, and substanc e use disorders. Panic attacks are associated with increased
likelihood of later developing anxiety disorder s, depressive disorders, bipolar disorders,
and possibly other disorders.
Agoraphobia
Diagnostic Criteria 300.22 (F40.00)
A. Marked fear or anxiety about two (or more) of the following five situations:
1. Using public transportation (e.g., automobiles, buses, trains, ships, planes).
2. Being in open spaces (e.g., parking lots, marketplaces, bridges).
3. Being in enclosed places (e.g., shops, theaters, cinemas).
4. Standing in line or being in a crowd.
5. Being outside of the home alone.
B. 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 symp-


218 Anxiety Disorders
toms or other incapacitating or embarrassing symptoms (e.g., fear of falling in the el-
derly; fear of incontinence).
C. The agoraphobic situations almost always provoke fear or anxiety.
D. The agoraphobic situations are actively avoi ded, require the presence of a companion,
or are endured with intense fear or anxiety.
E. The fear or anxiety is out of proportion to the actual danger posed by the agoraphobic
situations and to the sociocultural context.
F. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.
G. The fear, anxiety, or avoidance causes clin ically significant distress or impairment in
social, occupational, or other important areas of functioning.
H. If another medical condition (e.g., inflammato ry bowel disease, Parkinson’s disease)
is present, the fear, anxiety, or avoidance is clearly excessive.
I. The fear, anxiety, or avoidance is not better explained by the symptoms of another men-
tal disorder—for example, the symptoms are not confined to specific phobia, situational
type; do not involve only social situations (as in social anxiety disorder); and are not re-
lated exclusively to obsessions (as in obsessive-compulsive disorder), perceived defects
or flaws in physical appearance (as in body dysmorphic disorder), reminders of traumatic
events (as in posttraumatic stress disorder), or fear of separation (as in separation anx-
iety disorder).
Note: Agoraphobia is diagnosed irrespective of the presence of panic disorder. If an indi-
vidual’s presentation meets criteria for panic disorder and agoraphobia, both diagnoses
should be assigned.
Diagnostic Features
The essential feature of agoraphobia is marked, or intense, fear or anxiety triggered by the


real or anticipated exposure to a wide range of situations (Criterion A). The diagnosis re-
quires endorsement of symptoms occurring in at least two of the following five situations:
1) using public transporation, such as automobiles, buses, trains, ships, or planes; 2) being
in open spaces, such as parking lots, marketplac es, or bridges; 3) being in enclosed spaces,
such as shops, theaters, or cine mas; 4) standing in line or being in a crowd; or 5) being out-
side of the home alone. The examples for each situation are not exha ustive; other situations
may be feared. When experienci ng fear and anxiety cued by such situations, individuals
typically experience thoughts that something terrible might happen (Criterion B). Individ-
uals frequently believe that esca pe from such situations might be difficult (e.g., “can’t get
out of here”) or that help might be unavaila ble (e.g., “there is nobody to help me”) when
panic-like symptoms or other incapacitating or embarrassing symptoms occur. “Panic-like
symptoms” refer to any of the 13 symptoms incl uded in the criteria for panic attack, such as
dizziness, faintness, and fear of dying. “Other incapacitating or  embarrassing symptoms”
include symptoms such as vomiting and inflammatory bowel symptoms, as well as, in
older adults, a fear of falling or, in children, a sense of disorientation and getting lost.
The amount of fear experience d may vary with proximity to the feared situation and
may occur in anticipation of or  in the actual presence of the agoraphobic situation. Also,
the fear or anxiety may take the form of a full- or limited-symp tom panic attack (i.e., an ex-


pected panic attack). Fear or anxiety is evoked nearly every time the individual comes into
contact with the feared situation (Criterion C). Thus, an individual who becomes anxious
only occasionally in an agoraphobic situation (e.g., becomes anxious when standing in line
on only one out of every five occasions) would not be diagnosed with agoraphobia. The in-
dividual actively avoids the situation or, if he or she either is unable or decides not to avoid
it, the situation evokes intense fear or anxiety (Criterion D). Active avoidance  means the in-


dividual actively avoids the situation or, if he or she either is unable or decides not to avoid
it, the situation evokes intense fear or anxiety (Criterion D). Active avoidance  means the in-
dividual is currently behaving in ways that are intentionally designed to prevent or min-
imize contact with agoraphobi c situations. Avoidance can be behavioral (e.g., changing


Agoraphobia 219
daily routines, choosing a job nearby to avoi d using public transportation, arranging for
food delivery to avoid entering shops and su permarkets) as well as cognitive (e.g., using
distraction to get through agoraphobic situations) in nature. The avoidance can become so
severe that the person is completely homebound. Often, an individual is better able to con-
front a feared situation when accompanied by a companion, such as a partner, friend, or
health professional.
The fear, anxiety, or avoidance must be out of proportion to the actual danger posed by
the agoraphobic situations and to the sociocul tural context (Criterion E). Differentiating
clinically significant agoraphobic fears from  reasonable fears (e.g., leaving the house dur-
ing a bad storm) or from situations that ar e deemed dangerous (e.g ., walking in a parking
lot or using public transportation in a high-cri me area) is important for a number of reasons.
First, what constitutes av oidance may be difficul t to judge across cult ures and sociocultural
contexts (e.g., it is sociocultu rally appropriate for orthodox Muslim women in certain parts
of the world to avoid leaving the house alone,  and thus such avoidance would not be con-
sidered indicative of agoraphobia). Second, older adults are likely to overattribute their
fears to age-related constraints and are less likely to judge their fears as being out of pro-
portion to the actual risk. Th ird, individuals with agoraphobia are likely to overestimate
danger in relation to panic-like or other bodily symptoms. Agora phobia should be diag-
nosed only if the fear, anxiety, or avoidance pers ists (Criterion F) and if it causes clinically


significant distress or impairment in social, occupational, or other important areas of func-
tioning (Criterion G). Th e duration of “typically lasting for 6 months or more” is meant to
exclude individuals with short-lived, transien t problems. However, the duration criterion
should be used as a general guide, with allowance for some degree of flexibility.
Associated Features Supporting Diagnosis
In its most severe forms, agoraphobia can ca use individuals to become completely home-
bound, unable to leave their home and dependent on others for services or assistance to pro-
vide even for basic needs. Demoralization and depressive symptoms, as well as abuse of
alcohol and sedative medication as inappropriate self-medication st rategies, are common.
Prevalence
Every year approximately 1.7% of adolescents and adults have a diagnosis of agoraphobia.
Females are twice as likely as males to expe rience agoraphobia. Agoraphobia may occur in
childhood, but incidence peaks in late ad olescence and early adulthood. Twelve-month
prevalence in individuals older than 65 year s is 0.4%. Prevalence rates do not appear to
vary systematically across cultural/racial groups.
Development and Course
The percentage of individuals with agorapho bia reporting panic attacks or panic disorder
preceding the onset of agoraphobia ranges fr om 30% in community samples to more than
50% in clinic samples. The majority of individuals with panic disorder show signs of anx-
iety and agoraphobia before the onset of panic disorder.
In two-thirds of all cases of agoraphobia, initial onset is before age 35 years. There is a
substantial incidence risk in late adolescence and early adulthood, with indications for


substantial incidence risk in late adolescence and early adulthood, with indications for
a second high incidence risk phase after age 40 years. First onset in childhood is rare. The
overall mean age at onset for agoraphobia is 17 years, although the age at onset without
preceding panic attacks or panic disorder is 25–29 years.
The course of agoraphobia is typically pers istent and chronic. Complete remission is
rare (10%), unless the agoraphobia is treated. With more severe agoraphobia, rates of full
remission decrease, whereas rates of relapse and chronicity increase. A range of other dis-


rare (10%), unless the agoraphobia is treated. With more severe agoraphobia, rates of full
remission decrease, whereas rates of relapse and chronicity increase. A range of other dis-
orders, in particular other anxiety disorders,  depressive disorders, substance use disor-
ders, and personality disorders, may complicat e the course of agoraphobia. The long-term


220 Anxiety Disorders
course and outcome of agoraphobia are associate d with substantially elevated risk of sec-
ondary major depressive disorder, persistent  depressive disorder (dysthymia), and sub-
stance use disorders.
The clinical features of agoraphobia are rela tively consistent across the lifespan, although
the type of agoraphobic situations  triggering fear, anxiety, or avoidance, as well as the type of
cognitions, may vary. For example, in children, being outside of the home alone is the most fre-
quent situation feared, whereas in older adults, being in shops, standing in line, and being in
open spaces are most often feared. Also, cognitio ns often pertain to beco ming lost (in children),
to experiencing panic-like symptoms (in adults), to falling (in older adults).
The low prevalence of agoraphobia in childre n could reflect difficulties in symptom re-
porting, and thus assessments in young child ren may require solicitation of information
from multiple sources, includ ing parents or teachers. Adolescents, particularly males,
may be less willing than adults to openly discuss agoraphobic fears and avoidance; how-
ever, agoraphobia can occur prior to adulthood and should be assessed in children and
adolescents. In older adults, comorbid somatic symptom disord ers, as well as motor dis-
turbances (e.g., sense of fall ing or having medical compli cations), are frequently men-
tioned by individuals as the reason for their fear  and avoidance. In these instances, care is
to be taken in evaluating whether the fear and avoidance are out of proportion to the real
danger involved.
Risk and Prognostic Factors
Temperamental. Behavioral inhibition and neurotic disposition (i.e., negative affectivity


Temperamental. Behavioral inhibition and neurotic disposition (i.e., negative affectivity
[neuroticism] and anxiety sensit ivity) are closely associated with agoraphobia but are rel-
evant to most anxiety disorders (phobic disord ers, panic disorder, generalized anxiety dis-
order). Anxiety sensitivity (t he disposition to believe that symptoms of anxiety are
harmful) is also characteristic of individuals with agoraphobia.
Environmental. Negative events in childhood (e.g., se paration, death of parent) and other
stressful events, such as being attacked or mugge d, are associated with the onset of agorapho-
bia. Furthermore, individuals with agoraphobia describe the family climate and child-rearing
behavior as being characterized by redu ced warmth and increased overprotection.
Genetic and physiological. Heritability for agoraphobia is 61%. Of the various phobias,
agoraphobia has the strongest and most specific association with the genetic factor that
represents proneness to phobias.
Gender-Related Diagnostic Issues
Females have different patterns of comorbid disorders than males. Consistent with gender
differences in the prevalence of mental diso rders, males have higher rates of comorbid
substance use disorders.
Functional Consequences of Agoraphobia
Agoraphobia is associated with considerable  impairment and disability in terms of role
functioning, work productivity, and disability days. Agoraphobia severity is a strong de-
terminant of the degree of disab ility, irrespective of the pres ence of comorbid panic disor-
der, panic attacks, and other comorbid cond itions. More than one- third of individuals
with agoraphobia are completely homebound and unable to work.
Differential Diagnosis


Differential Diagnosis
When diagnostic criteria for agoraphobia and an other disorder are full y met, both diagnoses
should be assigned, unless the fear, anxiety, or av oidance of agoraphobia is  attributable to the
other disorder. Weighting of crit eria and clinical judgment may be helpful in some cases.


Agoraphobia 221
Specific phobia, situational type. Differentiating agoraphobia from situational specific
phobia can be challenging in some cases, because these conditions share several symptom
characteristics and criteria. Specific phobia, sit uational type, should be diagnosed versus ago-
raphobia if the fear, anxiety, or avoidance is limited to one of the agoraphobic situations.
Requiring fears from two or more of the agorapho bic situations is a robust means for differen-
tiating agoraphobia from specific phobias, partic ularly the situational subtype. Additional dif-
ferentiating features include the cognitive ideati on. Thus, if the situation is feared for reasons
other than panic-like symptoms or other incapaci tating or embarrassing symptoms (e.g., fears
of being directly harmed by the situation itself, such as fear of  the plane crashing for individ-
uals who fear flying), then a diagnosis of  specific phobia may be more appropriate.
Separation anxiety disorder. Separation anxiety disorder can be best differentiated
from agoraphobia by examining cognitive ideation. In separation anxiety disorder, the
thoughts are about detachment from signific ant others and the home environment (i.e.,
parents or other attachment figures), whereas in agoraphobia the focus is on panic-like
symptoms or other incapacitating or embarr assing symptoms in the feared situations.
Social anxiety disorder (social phobia). Agoraphobia should be differentiated from so-
cial anxiety disorder based primarily on the si tuational clusters that trigger fear, anxiety,
or avoidance and the cognitive ideation. In soci al anxiety disorder, the focus is on fear of
being negatively evaluated.
Panic disorder. When criteria for panic disorder are met, agoraphobia should not be di-


agnosed if the avoidance behaviors associated wi th the panic attacks do not extend to avoid-
ance of two or more agoraphobic situations.
Acute stress disorder and post traumatic stress disorder. Acute stress disorder and
posttraumatic stress disorder (PTSD) can be differentiated from agoraphobia by examin-
ing whether the fear, anxiety, or avoidance is related only to situations that remind the
individual of a traumatic event. If the fear, anxiety, or avoidanc e is restricted to trauma re-
minders, and if the avoidance behavior does not extend to two or more agoraphobic situ-
ations, then a diagnosis of agoraphobia is not warranted.
Major depressive disorder. In major depressive disorder, the individual may avoid leav-
ing home because of apathy, loss of energy, low self-esteem, and anhe donia. If the avoid-
ance is unrelated to fears of panic-like or other incapacitating or embarrassing symptoms,
then agoraphobia should not be diagnosed.
Other medical conditions. Agoraphobia is not diagnosed if the avoidance of situations
is judged to be a physiological consequence of  a medical condition. This determination is
based on history, laboratory findings, and a physical examination. Other relevant medical
conditions may include neurod egenerative disorders with associated moto r disturbances
(e.g., Parkinson’s disease, multiple sclerosis), as well as cardiovascular disorders. Individ-
uals with certain medical conditions may av oid situations because of realistic concerns
about being incapacitate d (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 should be given only when the fear or avoidance is clearly in excess of that
usually associated with these medical conditions.
Comorbidity


usually associated with these medical conditions.
Comorbidity
The majority of individuals with agoraphobia also have other mental  disorders. The most
frequent additional diagnoses are other anxiety disorders (e.g., specific phobias, panic dis-
order, social anxiety disorder), depressive disorders (major depre ssive disorder), PTSD,
and alcohol use disorder. Where as other anxiety disorders (e.g., separation anxiety disor-


order, social anxiety disorder), depressive disorders (major depre ssive disorder), PTSD,
and alcohol use disorder. Where as other anxiety disorders (e.g., separation anxiety disor-
der, specific phobias, panic disorder) frequent ly precede onset of agoraphobia, depressive
disorders and substance use disorders ty pically occur secondary to agoraphobia.