Agoraphobia is an anxiety disorder that causes patients to experience extreme bouts of panic when in open areas. Often this related to a fear of having a panic attack in an open space which could be embarrassed, though in some cases it is caused more by a fear of being physically attacked by others. Usually the condition is exacerbated when in crowded areas and when the location has no means of ‘escape’. This often results in patients locking themselves away for long periods of time and becoming isolated, or in experiencing considerable distress including sweating and trembling when they leave the house.
Such a condition is obviously fairly crippling and can prevent an individual from getting the most out of their life. Agoraphobia treatment then is important for sufferers, and there are various types of treatment available.
The first agoraphobia treatment is ‘cognitive behavioural therapy’, or ‘CBT’, which attempts to look at mental disorders as originating from both unhealthy thought patterns and damaging ‘associations’. These unhealthy thought patterns for example might involve the individual thinking that they’re going to have a panic attack, or thinking that people would laugh or point if they did. Such thoughts are detached from reality and are damaging to the individual, but can be hard to prevent once they’ve become second nature. In cognitive behavioural therapy then, the patient is taught to practice ‘mindfulness’, where they are encouraged to use a form of meditation where they ‘watch’ thoughts pass by ‘like clouds’ without engaging in them. This way they are able to view the contents of their mind from an objective standpoint and to spot thoughts that might be damaging. Then, once they’re in an uncomfortable situation, they should be able to notice the thoughts and stop them. They can also try to replace these negative thoughts with positive affirmations, such as ‘if I have a panic attack, there are lots of people here who can help and they’ll understand and sympathise’, or simply ‘there is no reason for me to have a panic attack here’. This is called ‘cognitive restructuring’, whereby the contents of the patient’s mind are altered to be more conducive to being outdoors. This may also take the form of keeping a diary, wherein they will note down thoughts and feelings that they can later read back and that the therapist can look at for unproductive thoughts.
Another CBT agoraphobia treatment is exposure treatment, or re-association. This aims to try and remove the harmful association they have made between crowded places and a stressful response. As every time they’re in a crowded place they begin to panic, they then begin to associate crowds with panic and the reaction can become in-built and occur on its own without logical reasoning.
In some cases a single traumatic event – such as falling over in public or being mugged – can be enough for the patient to associate being outdoors with pain and again humiliation of falling in public. This then causes the patient to experience the fear of falling with being outside, in a manner similar to the mechanism by which Pavlov trained dogs to salivate at the sound of a bell. Through exposure treatment then, the aim is to gradually demonstrate that the stressor – in this case public spaces, and the feeling of panic, do not necessarily go hand in hand. As an agoraphobic patient will generally avoid open spaces they will receive no evidence that their fear is unfounded and can continue in their faulty associations. By gradually being reintroduced to larger and larger spaces however, they can start to see that there’s nothing to fear and begin to associate the outdoors with these new, pleasurable experiences.
The final CBT agoraphobia treatment is to teach sufferers relaxation techniques and coping strategies to help them recognise and deal with the symptoms of their anxiety disorder. When an agoraphobic patient steps outside they will likely begin to suffer an increased heart-rate, profuse sweating and panting for breath – which can actually cause a full blown panic attack in itself. By learning relaxation techniques then, the sufferer can prevent this from occurring and return themselves to a more relaxed state making the exposure more bearable. These relaxation techniques will involve controlled breathing, meditation, visualisation and focussing. In some cases they will be taught using ‘biofeedback’, in which the patient will be provided with a heart rate monitor so that they might be able to get immediate feedback on how well their relaxation techniques are working so that they can find which techniques work best for them and accurately monitor progress. The monitor might be set to warn them when their heart rate becomes too rapid with a beep, and they will then have the task of returning it to a normal level. Eventually they will begin to get an innate feel for how fast their heart is beating and how to control it themselves.
Other schools of therapy such as psychotherapy and family oriented approaches look at other potential causes for agoraphobia – that intend to explain how these negative thought patterns and associations arise in certain people in the first place. As such, seeing another therapist will result in a different agoraphobia treatment. In psychotherapy the agoraphobia is believed to stem from an unrelated repressed memory that can be addressed through various methods of reaching subconscious thoughts including dream analysis and free association. Agoraphobia has also been linked to attachment styles in infancy. When a child is insecurely attached, they can’t stand being separated from their care giver for even short periods of time. As such, when they grow older they will display this trait as being unable to separate themselves from their ‘base’ without anxiety – that being their home.
While family systems therapy and psychotherapy have proven to be successful in some cases, they are also expensive and difficult to maintain and organise. Psychotherapy for example requires an intensive course with the patient meeting with the therapist multiple times each week and making complex notes based on their experiences. This is expensive for the patient or for the health service, and can also be psychological draining for patients and some will prove resistant to this form of agoraphobia treatment. Cognitive behavioural therapy meanwhile has proven successful as it can be taught and understood over a relatively short space of time and minimal expense. CBT therapy can also take place in an ‘e-mail course’, which is particularly practical for patients who may find it difficult to leave the house to seek treatment.
Psychopharmaceutical options represent the last agoraphobia treatment and these should be reserved as the last resort for patients with extreme cases or who fail to respond to therapy. The main medications prescribed are anti-depressants from the SSRI class (selective serotonin reuptake inhibitors) which work by leaving more free serotonin in the brain (serotonin being one of the ‘feel good’ hormones that creates a positive mood). These include sertaline, paroxetine and fluoxetine. Benzodiazepines are also commonly prescribed, though this could be a mistake, as Benzodiazepines in large quantities have actually also been linked to agoraphobia as a possible cause. This example demonstrates just how risky it can be to alter the chemistry of your brain and how in some cases it can actually exacerbate rather than treat mental disorders. Additionally, psychopharmaceutical agrophobia treatments are not curative and instead will only help to maintain the condition. They can be expensive for the patient and in some cases addictive. Furthermore they are not directly treating the symptoms of the anxiety disorder, but instead addressing anxious moods as a whole and possibly preventing panic attacks.
The best form of agoraphobia treatment then will likely be cognitive behavioural therapy (though individuals and cases vary) and basic self help and self awareness. By training a patient to change their thought patterns and to use necessary skills to control and understand their responses, it’s possible to give them the tools they need to learn to cope without drugs or in depth therapeutic sessions.