Agoraphobia

Nature

Agoraphobia is not, as many people believe, just about open spaces.

It is really a fear of being in any place or situation where the sufferer does not feel safe, where they feel trapped, or where escape may be difficult or embarrassing. A person with agoraphobia may avoid a range of situations, e.g. queues, public transport, large crowded shops, supermarkets, shopping centers. In these situations, the person feels anxious with panic feelings (butterflies in the stomach, palpitations i.e. increased heart rate, hyperventilation etc.). The sufferer feels that when they panic something ‘bad’ will happen. These fears are usually about a fear of illness and harm (e.g. having a heart attack, dying, stopping breathing) or a fear of public scrutiny and embarrassment (e.g. falling and “making a fool” of oneself). Panic-like symptoms might include typical symptoms of panic (e.g. dizziness, faintness, and fear of dying), or “other intrusive, uncomfortable or embarrassing symptoms” such as vomiting, fainting, sweating, falling, or, in children, a sense of disorientation, getting lost, or being kidnapped are more common.

Experience

Agoraphobia is ‘a fear of being in situations where escape might be difficult or that help wouldn’t be available if things go wrong.’

A patient articulated agoraphobia well: “It’s a fear that’s vague enough that it can apply to anything, anywhere – any situation or location. It can dictate where you go, demand control of every tiny detail, and it steals the fun out of life under the pretense of protecting you. I’ve been living with agoraphobia for seven years now. It started with panic attacks and evolved into a constant fear of having a panic attack away from the only place I knew I wouldn’t; my home. The intense and relentless stress had a rapid effect on my brain and body, and over time I felt I’d be only safe if I stayed inside my house. I became terrified, and sometimes completely unable, to step out of my front door. The simplest of tasks, everything I once took for granted, became impossible.”

When experiencing fear and anxiety cued by such situations, individuals typically experience thoughts that something terrible might happen, and believe that escape from such situations might be difficult. Individuals will likely experience acute anxiety, and thus avoid using public transportation, such as automobiles, buses, trains, ships, or planes being in open spaces such as parking lots, marketplaces, or bridges; an enclosed space such as shops, theaters, or cinemas, standing in line or being in a crowd, getting their haircut, being outside of the home alone.

Impact

Agoraphobia makes sufferers behave in ways to intentionally prevent or minimize contact with agoraphobic situations or symptoms of panic.

Avoidance can be behavioral (e.g., changing daily routines, choosing a school closer to home, arranging for food delivery to avoid entering a grocery store) as well as cognitive in nature (e.g., using distraction to get through agoraphobic situations). Often, an individual is better able to confront a feared situation when accompanied by a companion, such as a partner, friend, or health professional, and if left untreated the sufferer can become completely housebound.

Prevalence of Agoraphobia

The lifetime prevalence of Agoraphobia is estimated at 5%-12%. The average age of onset is 20 years old, typically occurring between age 15 and age 35. The prevalence of agoraphobia is higher for females than for males.

Treatment

Overcoming agoraphobia is possible, but it requires a deliberate, goal orientated CBT approach with a heavy focus on exposure therapy.

Exposure means gradually facing your fear until anxiety decreases enough to make the situation, at a minimum, tolerable. The treatment of agoraphobia, graded exposure therapy is the most effective intervention. Graded refers to the pace at which the feared situation is confronted which is done is a gradual, deliberate manner.

The Anxiety Institute developed and utilizes a treatment approach termed Exposure-Focused CBT, which is a model designed to make the process more gradual, where treatment begins by deliberate discussion of the anxiety provoking situation (Conversational Exposure), followed by imagining the situation vividly (Guided Imaginal Exposure), prior to exposing oneself to the situations virtually (Virtual Reality Exposure), and in real life (In-Vivo Exposure). The Anxiety Institute’s 4 step process is expanded across social, family, and school domains to assure that the scope of recovery matches the scope of impairment.

There are four essential rules in making EfCBT effective, each of which should be maintained until the anxiety is tolerable.

Rule 1: Repeated Exposures: it is important to practice the exposure in same situation multiple times until the anxiety level (SUDS score) consistently diminishes with repetition. Once mastered, practice the same exposure in a different situation or location. Practice a minimum of 30-60 minutes each day.

Rule 2: Prolonged Exposures: it is important to stay in the anxiety provoking situation long-enough until the fear decreases, typically 30-60 minutes. Allow enough time during each exposure for you to habituate to the situation or the sensation.

Rule 3:   Focused Exposures: It is important that the person in the exposure focus

on the situation and sensation as fully as possible. They should not distract, avoid or use safety cues to avoid the discomfort nor should another person “rescue” them from the anxiety as this will interfere with the effectiveness of the intervention.

Rule 4:  Monitored Exposures: After each exposure write down your anxiety level during the exposure. Pay attention to patterns. If anxiety has not decreased over a number of repetitions, ask yourself if you are using any of the maintaining factors or distractions. If your anxiety has decreased congratulate yourself.

Resources

AnxietyBC;
https://www.anxietybc.com/adults/agoraphobia

Anxiety and Depression Association of America, ADAA;
https://adaa.org/understanding-anxiety/agoraphobia

Mayo Clinic;
https://www.mayoclinic.org/diseases-conditions/agoraphobia/symptoms-causes/syc-20355987

National Institute of Mental Health (NIMH): An organization with the National Institute of health dedicated to mental health research;
https://www.nimh.nih.gov/health/statistics/agoraphobia.shtml