URJHS Volume 12

Predictors of Agoraphobia

Keshia Wagers
Jonathan S. Gore*
Eastern Kentucky University

Abstract

Separation anxiety disorder, school phobia, and gender have all been implicated in being able to predict the onset of agoraphobia. This study tested the hypothesis that separation anxiety disorder, school phobia, and gender would predict unique variance in the symptoms of agoraphobia both with a close companion and when alone. One hundred students at Eastern Kentucky University completed a survey that assessed their separation anxiety disorder symptoms, school phobia symptoms experienced during childhood, and agoraphobia symptoms. Symptoms of school phobia predicted symptoms of agoraphobia when the individual was with someone, and both school phobia and separation anxiety disorder symptoms predicted symptoms of agoraphobia when the individual was alone. Gender was not a significant predictor of agoraphobia symptoms. These results imply that more factors may influence the expression of agoraphobia symptoms when an individual is alone compared to when they are with someone else.

Predictors of Agoraphobia

Anxiety is common for most people in some aspect of their lives and most people easily recognize the emotional and physical symptoms associated with it. However, once anxiety begins to interfere in a person's life, it can become a serious problem. Separation anxiety disorder is one of the most common anxiety disorders among children, and school phobia, or school refusal, is often associated with this disorder (Mash & Wolfe, 2010). Separation anxiety disorder and school phobia both involve fear of either situations or of being separated from home or parents. Agoraphobia is also an anxiety disorder, and it is characterized by a fear of specific places or situations, especially if the feared situation occurs without a close friend or family member (Mash & Wolfe, 2010). It is estimated that approximately 5 percent of the United States has been diagnosed with agoraphobia, with 40 percent of those cases being classified as severe. Severe agoraphobia can cause serious impairment and interfere with individuals' lives greatly. The purpose of this study was to examine the degree to which several factors predict agoraphobia symptoms and how these differ depending on whether or not the person experiences the symptoms with someone else present.

Previous research suggested that school phobia is somewhat common for adults with agoraphobia. One study that examined the relationship found that nearly a quarter of 786 women with agoraphobia had school phobia during childhood. This number was similar to that found in a significantly smaller sample of individuals without agoraphobia, but school phobia seemed to predict earlier onset of agoraphobia and more severe symptoms (Berg, Marks, McGuire, & Lipsedge, 1974). Although school phobia seems to be a very significant predictor of agoraphobia, other factors have also been suggested as predicters of onset of the disorder.

A significant amount of research has also been devoted to understanding the relationship between separation anxiety disorder and agoraphobia. Although some results have been mixed, most indicate a positive relationship between separation anxiety disorder and agoraphobia. In a group of both clinical and community samples, individuals were tested, retrospectively, for separation anxiety disorder. The only group who had a high degree of separation anxiety disorder symptoms was the group with agoraphobia (Manicavasagar, Silove, & Hadzi-Pavlovic, 1998). When analyzing retrospective occurrences of separation anxiety disorder, women with higher scores of separation anxiety disorder were more likely to have agoraphobia than generalized anxiety disorder or phobic disorders (Silove, Harris, Morgan, & Boyce, 1995). Researchers also suggested that separation anxiety disorder may serve as a risk factor for the development of agoraphobia. It may also be possible, however, that separation anxiety serves as a risk factor for anxiety disorders in general (Masi, Mucci, Millepiedi, 2001). Therefore, it may be possible that both school phobia and separation anxiety disorder may be used to predict the development of agoraphobia; however, they may not be equally effective at predicting the disorder.Another study focused on school phobia, separation anxiety disorder, and agoraphobia within a family spanning three generations and found that the children in the family often displayed symptoms of all three disorders. This finding suggests that these disorders may best be viewed as existing on a continuum of anxiety disorders that appears differently over the course of an individual's development (Deltito & Hahn, 1993).

Gender may also predict the development of agoraphobia. Females with agoraphobia have displayed significantly higher rates of separation anxiety disorder during childhood than simple or social phobias. Males with agoraphobia, however, did not show significant rates of separation anxiety disorder, simple phobias, or social phobias (Zitrin & Ross, 1988). Most of the research involving these disorders studied females, so it is difficult to know whether separation anxiety disorder can be used to predict agoraphobia in males as well.

Due to the similarities between childhood separation anxiety disorder and the development of agoraphobia in adolescence and young adulthood, it has been suggested that early separation anxiety disorder may be a predictor of agoraphobia. It has also been suggested that both separation anxiety disorder and school phobia may be able to predict agoraphobia, especially in females (Zitrin & Ross, 1988). To date, no one has examined all three predictors of agoraphobia nor have they distinguished between the onset of symptoms with and without close others nearby. In addition, few studies have examined agoraphobic symptoms in the general population. The present research extends previous work by examining each predictor's contribution to agoraphobic symptoms in a group of nonclinical young adults. Therefore, I hypothesize that school phobia, separation anxiety symptoms, and gender each predict unique variance in symptoms of agoraphobia.

Method

Participants

The 100 participants in this study were all undergraduate students in either an introductory or statistical-experimental psychology class at Eastern Kentucky University. These classes are required for Psychology majors at EKU. The participants are required to earn six outside credits for these courses and half of one credit was offered as incentive to participate in the data collection. They gave consent by reading the consent form and continuing with the online survey. They were also told that they could stop participating or omit a section if they felt uncomfortable with any of the questions. Upon completion of the questionnaire, participants were given a debriefing form that provided past research and the explanation for the current research.

Materials

This study examined the relationship between symptoms of school phobia and separation anxiety disorder displayed in childhood, gender, and current symptoms of agoraphobia. To assess school phobia, separation anxiety disorder, and agoraphobia, a questionnaire was used with three scales. The participants' gender was also requested.

School Phobia. Birmaher, Brent, Chiappetta, Bridge, Monga, and Baugher's (1999) Screen for Child Anxiety Related Disorders was used to assess symptoms of school phobia experienced in childhood. The questionnaire asked participants to rate how often they felt upset or worried about going to school. This scale measured replies from 0 (not true or hardly ever true) to 2 (very true or often true). The mean of the items was obtained for an overall score (Cronbach's Alpha = .70).

Separation Anxiety Disorder. Birmaher, Brent, Chiappetta, Bridge, Monga, and Baugher's (1999) Screen for Child Anxiety Related Disorders was also used to assess symptoms of separation anxiety disorder experienced in childhood. The scale asked participants to rate how often they were worried about being away from home or being separated from their parents. The scale measured responses from 0 (not true or hardly ever true) to 2 (very true or often true). The mean of the items was obtained to create an overall score (Cronbach's Alpha = .72.

Agoraphobia. Chambless, Caputo, Jasin, Gracely, and Williams' (1985) Mobility Inventory was used to assess symptoms of agoraphobia. The scale asked participants to rate how often they avoided certain places when accompanied with a trusted friend and when alone. Responses were measured from 1 (never avoid) to 5 (always avoid). Two means were obtained to create separate scores for agoraphobia symptoms that were experienced while accompanied by a close other (Cronbach's alpha = .92) and symptoms that were experienced while alone (Cronbach's alpha = .93).

Gender. The participants were also asked to indicate their gender as part of the questionnaire.

Procedure

After making an account with the online experiment management system, each participant was given an identification number that was unique. Participants were then instructed as to what would be required to complete this study. They were given a consent statement to read and reminded that they could stop participation at any time without penalty if they felt uncomfortable. The participants were given an online questionnaire, and they then proceeded to answer questions about school phobia, separation anxiety disorder, gender, and agoraphobia.

Results

Preliminary Analyses

To test the associations among the variables, a bivariate correlation analysis was conducted including all variables from the current study. The results of this analysis revealed that school phobia was positively correlated with symptoms of agoraphobia, both when accompanied (r = .48, p < .05) and when alone (r = .41, p < .05). Separation anxiety symptoms were also positively correlated with symptoms of agoraphobia, both when accompanied (r = .32, p < .05) and when alone (r = .39, p < .05). There were no other significant correlations (ps > .05).

Hypothesis Test

To test the hypothesis that school phobia and separation anxiety disorder symptoms and gender will predict symptoms of agoraphobia, a linear regression analysis was conducted with school phobia, separation anxiety disorder, and gender entered as the independent variables and agoraphobia symptoms while accompanied and while alone were entered separately as the dependent variables. The results revealed that school phobia in childhood predicted agoraphobia symptoms when the individual was accompanied by a close other (β = .41, p < .05), but neither separation anxiety symptoms nor gender predicted agoraphobia while accompanied by a close other (bs = .11 and .13, ns). The results also revealed that school phobia and separation anxiety symptoms in childhood predicted agoraphobia symptoms when the individual was alone in a situation (βs = .29 and.24, p<.05). Gender did not predict this form of agoraphobia either (β = .09, ns). Therefore, the hypothesis that school phobia, separation anxiety disorder, and gender predict unique variance in agoraphobia was only partially supported in that school phobia predicted both types of agoraphobia, separation anxiety disorder only predicted agoraphobia while alone, and gender did not predict either type of agoraphobia.

Discussion

Upon examination of the results of this study, one could determine that the hypothesis was partially supported. School phobia predicted symptoms of agoraphobia when an individual was accompanied in a situation, but separation anxiety symptoms and gender did not. School phobia and separation anxiety symptoms predicted symptoms of agoraphobia when alone, but gender did not.

Limitations and Future Directions

Although the hypothesis was partially supported, limitations existed that may have affected the results. The study included 100 nonclinical participants. This was a significant sample size, but more participants would be needed in order to have more convincing results. The sample was made up of students from one university, so variability within the sample was limited as well. This sample was also nonclinical, whereas most previous research had been conducted with clinical samples. Although it is important to note that results were found to be significant in a nonclinical sample, the relationship may have been stronger in a clinical sample of individuals with diagnosed separation anxiety disorder or agoraphobia.

This study was also limited by its correlational design. Due to the design of the study, an individual could not claim that school phobia or separation anxiety disorder somehow causes the development of agoraphobia later in life. Based on the results of this study, one could only claim that the disorders, or symptoms of the disorders, are correlated.

Also related to the design of the study was the method by which data was collected. Although the measures used to assess the variables are validated measures, they rely on self-report. Although there would have likely been little motivation for the participants to provide incorrect answers purposefully, participants may have provided answers that were not entirely accurate due to problems with remembering events.

The results of this study could be used as a basis for further research, and the design of the study could also be altered to include more variability and therefore improve generalizability to other samples. Further research could additionally include a clinical sample in order to observe whether the results would remain consistent when clinical samples were studied, as opposed to nonclinical samples. The design of this study could also be altered in order to eliminate previously mentioned limitations to improve the validity of the research. Future researchers may also wish to follow individuals using a longitudinal design in order to eliminate the issue related to self-report.

The hypothesis of this study was partially supported and these results, paired with results from previous research, seem to suggest that school phobia, separation anxiety disorder, and agoraphobia are linked. Future research could focus on finding whether these disorders develop along a continuum or if having one predisposes an individual to the other. It may also be worth studying whether other factors, such as parental attachment, are also useful in predicting the onset of agoraphobia.

Gender has frequently been implicated in being able to predict the onset of agoraphobia; however, gender was not a significant predictor in this study. Much of the research devoted to agoraphobia has focused on females, so future research could examine the relationship between agoraphobia and gender to better understand that link.

Implications   

This study examined the relationship between school phobia, separation anxiety disorder, gender, and agoraphobia symptoms. The relationship between all four of these factors has rarely been tested and most of the research devoted to these disorders has been conducted with clinical samples. Previous research has largely demonstrated positive relationships between school phobia, separation anxiety disorder, gender, and agoraphobia (Deltito & Hahn, 1993; Silove, Harris, Morgan, & Boyce, 1995; Zitrin & Ross, 1988). The current study found somewhat similar results as previous research; however, there were also findings from previous research that were not replicated in this research.

The results of the current study show a positive correlation between school phobia and agoraphobia, both when an individual was alone and accompanied, and between separation anxiety disorder and agoraphobia, when an individual was alone. Similar to previous research, school phobia and separation anxiety disorder were found to predict some symptoms of agoraphobia; however, school phobia appeared to be able to predict agoraphobia in a wider variety of situations. Due to the fact that separation anxiety disorder only predicted agoraphobia when the individual was alone, separation anxiety disorder may only be related to certain symptoms of agoraphobia.

Previous research has found significant relationships between gender and agoraphobia; however, it has largely focused on solely on females in relation to the development of agoraphobia. In contrast with most previous research, both males and females were surveyed and gender did not appear to be a significant factor in relation to agoraphobia. Therefore, it is possible that gender does not play as large of a role in the development of agoraphobia as previously considered.

The current study focused on a nonclinical sample, as opposed to previous research, and observed the specified relationship among college students who had likely not been diagnosed with one of the studied disorders but may have experienced symptoms of the disorders. This finding suggests that even mild symptoms of school phobia and separation anxiety disorder can predict symptoms of agoraphobia and that this relationship would likely only be stronger in a clinical sample.

Based on the results of this study, it may be possible to create a screening tool for the development of agoraphobia using school phobia and separation anxiety disorder. Agoraphobia can have a significant impact on an individual's life. With this and past research pointing to school phobia and separation anxiety disorder as risk factors of agoraphobia, it may be useful to think of these disorders as risk factors for agoraphobia. If a clinician were to have a client with school phobia or separation anxiety disorder, they may be at a heightened risk of developing agoraphobia. Once realized, the clinician could then create a treatment program that targeted both school phobia or separation anxiety disorder as well as early symptoms of agoraphobia in order to lessen the severity of the disorder.

Conclusion

Current estimates suggest that approximately 5 percent of individuals in the United States have been diagnosed with agoraphobia and nearly 40 percent of those cases are classified as severe. Individuals living with severe agoraphobia are greatly impacted and the disorder can cause significant impairment. Although this current line of research suggests that school phobia and separation anxiety disorder may both be able to play a part in predicting agoraphobia, school phobia may be the most significant warning sign of developing agoraphobia.

References

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Chambless, D. L., Caputo G. C., Jasin, S. E., Gracely, E. J., Williams, C. (1985). The mobility inventory for agoraphobia. Behavior Research and Therapy, 23, 35-44.

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Mash, E. J., & Wolfe, D. A. (2010). Abnormal child psychology (4th ed.). Belmont, CA: Wadsworth.

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Zitrin, C. M., & Ross, D. C. (1988). Early separation anxiety and adult agoraphobia. Journal of Nervous And Mental Disease, 176, 621-625.