Psychological therapy for agoraphobia: what is it and how does it work?
We explain what methods exist to reduce the negative impact of this anxiety disorder
Agoraphobia is an anxiety disorder characterized by anticipatory anxiety due to the fear of having a panic attack in public. The person also fears being in a public place and not being able to "run away". That is why psychological therapy for agoraphobia should be very focused on treating the cognitive variables that influence the perpetuation of the disorder.
In this article, in addition to explaining the general characteristics of agoraphobia, we will learn what cognitive behavioral therapy for agoraphobia (considered a first-choice treatment) consists of, how it works and what its six fundamental components are.
Agoraphobia: what is it?
Agoraphobia is an anxiety disorder that involves fear of being in public places or in situations where it is difficult or embarrassing to escape. It also appears a fear of being in places where it is difficult to get help in case of a panic attack or similar symptoms. That is to say, the fear occurs in public places, and not so much out in the open, as is often thought.
Thus, because of this fear, situations that involve being in these places are avoided or resisted with great discomfort; in the event that they are faced, the person with agoraphobia is usually accompanied. On the other hand, two characteristic components that are usually included in the concept of agoraphobia are: multiphobia (having several phobias at the same time) and phobophobia (being "afraid of fear", or fear of one's own anxiety).
Classification in the manuals
Regarding its location in the different reference manuals, agoraphobia is a disorder that has undergone certain changes in the editions of the DSM (Diagnostic Manual of Mental Disorders). Thus, in the third edition (DSM-III) and in the ICD-10 (International Classification of Diseases), agoraphobia was classified as an independent disorder, and may or may not be accompanied by panic disorder (generally in severe cases).
In DSM-III-R and DSM-IV-TR, however, agoraphobia is now part of a more global panic disorder. Finally, in the current DSM-5, agoraphobia and panic disorder become independent of each other for the first time, and become two distinct disorders.
Psychological therapy for agoraphobia
There are three treatments of choice for treating agoraphobia: live exposure, cognitive behavioral therapy, and pharmacotherapy (use of Selective Serotonin Reuptake Inhibitors [SSRIs]). In this article we will focus on psychological therapy for agoraphobia from a cognitive-behavioral perspective, and that is why we will discuss the second treatment of choice mentioned: cognitive behavioral therapy.
This type of therapy is considered well-established for treating agoraphobia, according to the reference manuals of treatment efficacy; that is, research results support it as an effective and safe therapy. Thus, it provides positive results for treating this disorder.
Components
Psychological therapy for agoraphobia from a cognitive-behavioral orientation, usually includes a number of specific components. Let's see what they are and what they consist of.
Psychoeducation
Psychoeducation consists of "educating" the patient about his or her pathology that is to say, to provide him/her with the appropriate information so that he/she can understand his/her disorder, the etiology of the disorder, what factors are favoring its continuation, etc. Thus, in the psychological therapy for agoraphobia, this education will deal mainly with anxiety and panic.
The objective is to provide the patient with the necessary information so that he/she can understand why this is happening to him/her, and to learn to differentiate some concepts that can sometimes be confusing. This information can help reduce their uncertainty and help them feel calmer.
Breathing techniques
Breathing is an essential factor in anxiety disorders. Learning to control it can greatly help to reduce anxious symptoms. In agoraphobia this is especially important, since precisely what is feared is to suffer a panic attack in places where it is difficult to receive help; these panic attacks are characterized by a large number of physical and neurophysiological symptoms related to anxiety.
That is why having strategies to breathe better, and to be able to exercise controlled breathing, can help the patient to prevent the anxious symptoms characteristic not only of the panic attack, but also of agoraphobia itself, since agoraphobic patients begin to think that they will suffer a panic attack and this causes them anxious symptoms.
3. Cognitive restructuring
Cognitive restructuring is another key element in the psychological therapy for agoraphobia, as it helps to modify the patient's dysfunctional and unrealistic thoughts about the belief that he/she could suffer a panic attack at any moment (or the moment he/she is exposed to a public place).
That is to say, cognitive restructuring will be focused on modifying these thoughts and beliefs, and also on correcting the distortions and distortions of the patient and also to correct the patient's cognitive distortions (e.g. thinking "if I take the bus and have a panic attack, I will die right there, because no one will be able to help me", or "if I go to the party and have a panic attack, I will be very embarrassed, because I will be overwhelmed and I will not be able to get out of there".
The objective is that the patient learns to elaborate more realistic alternative thoughts that help him/her to face situations in a more adaptive way, and that contribute to reduce his/her anxiety or anticipatory discomfort.
4. Interoceptive exposure
Interoceptive exposure consists of the patient being exposed to the anxious symptoms that a panic attack originates, but through other mechanisms (e.g., through a different type of exposure) but through other mechanisms (i.e. artificially produced, simulating them). These symptoms are induced in the patient (in fact, the patient usually induces them himself) through different strategies, such as turning in a chair (to obtain the sensation of dizziness), doing Cardiovascular exercises (to increase the heart rate), inhaling carbon dioxide, hyperventilating, etc.
The aim of interoceptive exposure is to weaken the association between the patient's specific bodily signals in relation to his or her body, and the panic reactions (panic symptoms) that he or she manifests. This type of exposure starts from the theoretical basis that considers that panic attacks are actually learned or conditioned alarms in response to certain physical signals.
5. Live self-exposure
Live self-exposure, the fifth component of psychological therapy for agoraphobia, consists of the patient being exposed to the real situation that generates the fear or anxiety. In other words, the patient should go to public places where "it is difficult to escape", and do so alone.
Moreover, he should not run away from the situation (unless the anxiety he is experiencing is exaggerated). The objective is, on the one hand, to empower the patient in the resolution of his disorder, and on the other hand, to "learn" that he can face such situations without experiencing any panic attack. This type of exposure will also help the patient to understand that the fact of being ashamed of "running away" from a place is not so relevant, and that it can be relativized.
6. Records
Finally, the last component of the psychological therapy for agoraphobia are the registers; in them (self-registers), the patient should write down different aspects depending on what the therapist asks him/her and on the technique used.
Generally, these are daily records that aim to collect relevant information from the patient, in relation to the moments in which he/she experiences anxiety (with their antecedents and consequences), the number of panic attacks he/she experiences, dysfunctional thoughts, degree of discomfort associated with them, alternative thoughts, etc. The records can be of different types, and are a very important follow-up tool.
Characteristics
As for the effectiveness of psychological therapy for agoraphobia, it can be affected and diminished, if the time devoted to the live exposure component is reduced.
On the other hand, an advantage of the cognitive behavioral therapy of which we speak, aimed at treating agoraphobia, is that it tends to produce fewer dropouts and fewer relapses in terms of panic attacks compared to live exposure..
This is because live exposure is a more "aggressive" type of therapy, where the patient is actually exposed to the situation (or situations) he or she fears; in psychological therapy, on the other hand, the operation is different and much less invasive or disturbing for the patient.
(Updated at Apr 12 / 2024)