What is the Agoraphobic Cognitions Questionnaire (ACQ)?

The Agoraphobic Cognitions Questionnaire (ACQ) is a 14-item self-report measure designed to assess catastrophic thoughts and beliefs that commonly occur during panic attacks and episodes of intense anxiety. It specifically targets the cognitive component of panic disorder and agoraphobia, helping clinicians identify maladaptive thought patterns that contribute to the maintenance of these conditions.

Who developed the ACQ and when?

Developed by Paul Salkovskis, David Clark, and Michael Gelder in 1996 as part of their cognitive-behavioral model of panic disorder. The ACQ was created to provide a reliable and valid measure of the catastrophic cognitions that are central to the cognitive theory of panic disorder, complementing behavioral measures of agoraphobic avoidance.

What type of assessment is the ACQ?

The ACQ is a self-report questionnaire that uses a 5-point Likert scale format. It takes approximately 5-10 minutes to complete and can be administered in clinical settings, research environments, or for self-assessment purposes. The scale is designed for adults with anxiety disorders, particularly those with panic disorder and agoraphobia.

What does the ACQ assess?

• Physical Catastrophe Fears: Thoughts about having heart attacks, strokes, brain tumors, or other medical emergencies
• Mental/Cognitive Concerns: Fears about losing control, going crazy, or being unable to control one's behavior
• Social Embarrassment: Worries about others noticing anxiety symptoms or acting inappropriately
• Loss of Control Thoughts: Fears about completely losing behavioral or emotional control

How many items and what format?

The ACQ consists of 14 items rated on a 5-point scale from 1 ("Thought never occurs") to 5 ("Thought always occurs"), creating a total possible score range of 14-70. Each item represents a common catastrophic thought that occurs during panic or anxiety episodes.

How is the ACQ scored and interpreted?

Total scores are calculated by summing all item responses:

• 14-24: Minimal catastrophic thinking (within normal range)
• 25-34: Mild catastrophic thinking (occasional concerns)
• 35-49: Moderate catastrophic thinking (significant concerns)
• 50-70: Severe catastrophic thinking (intense and frequent)

Clinical Cutoff Points:

• ≥35: Suggests clinically significant catastrophic thinking that may contribute to panic symptoms
• ≥50: Indicates severe catastrophic cognitions that are likely maintaining panic disorder
• ≥60: Very high catastrophic thinking requiring immediate clinical attention

Unique Features and Advantages

• Cognitively Focused: Specifically targets the cognitive component of panic disorder
• Theory-Driven: Based on established cognitive-behavioral models of anxiety
• Treatment Sensitive: Responsive to changes during cognitive-behavioral therapy
• Clinically Useful: Helps identify specific cognitive targets for intervention
• Research Validated: Extensive research base supporting its clinical applications
• Brief Format: Quick administration suitable for clinical practice

Research Applications and Validation

The ACQ has been extensively used in research:

• Clinical trials evaluating cognitive-behavioral therapy for panic disorder
• Longitudinal studies of panic disorder development and maintenance
• Comparative studies of different anxiety disorder treatments
• Assessment of treatment outcomes and cognitive changes
• Cross-cultural studies of catastrophic thinking patterns
• Epidemiological research on anxiety disorder prevalence

Populations and Special Considerations

The ACQ has been validated for use with:

• Adults diagnosed with panic disorder (primary population)
• Individuals with agoraphobia and panic attacks
• Clinical populations receiving CBT for anxiety disorders
• Research participants in anxiety disorder studies
• Diverse cultural and ethnic groups
• Individuals with comorbid anxiety and mood disorders

Special Considerations:

• Most appropriate for individuals who experience panic attacks
• Cultural differences in catastrophic thinking should be considered
• May be less sensitive for individuals with very low insight
• Self-report format may be affected by current anxiety state
• Should be interpreted within broader clinical assessment

Clinical Applications

• Diagnostic Assessment: Supporting evidence for panic disorder diagnosis
• Treatment Planning: Identifying specific cognitive targets for CBT
• Progress Monitoring: Tracking changes in catastrophic thinking during treatment
• Outcome Evaluation: Measuring cognitive improvements post-treatment
• Risk Assessment: Identifying individuals at risk for panic symptom escalation
• Research: Standardized measurement in clinical trials and studies

Strengths and Limitations

Strengths:

• Strong psychometric properties with excellent reliability and validity
• Directly measures cognitive component of panic disorder
• Brief and easy to administer in clinical settings
• Sensitive to treatment-related cognitive changes
• Extensive research base supporting clinical utility
• Theory-driven items based on cognitive-behavioral model

Limitations:

• Self-report format may be subject to recall and response bias
• Does not assess behavioral avoidance or physical symptoms
• May not capture all types of catastrophic thinking
• Cultural differences in cognitive patterns may affect interpretation
• Should be supplemented with behavioral measures and clinical interview

Integration with Other Assessments

The ACQ is often used alongside complementary measures:

• Mobility Inventory (MI): Assessment of agoraphobic avoidance behaviors
• Body Sensations Questionnaire (BSQ): Fear of physical symptoms
• Panic Disorder Severity Scale (PDSS): Overall panic symptom severity
• Beck Anxiety Inventory (BAI): General anxiety symptom assessment
• Hamilton Anxiety Rating Scale: Clinician-rated anxiety assessment

Factor Structure and Subscales

Research has identified distinct factors within the ACQ:

• Physical Concerns (7 items): Fears about physical catastrophes and medical emergencies
• Mental Concerns (5 items): Fears about losing mental control or cognitive functioning
• Social Concerns (2 items): Worries about social embarrassment and others noticing
• Loss of Control (4 items): Fears about completely losing behavioral control

Subscale analysis helps identify specific cognitive domains that may require targeted intervention, allowing for more personalized treatment approaches.