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     According to Diagnostic and Statistical Manual –IV (DSM-IV), agoraphobia is the fear of being in places or situations from which escape might be difficult (or embarrassing). Agoraphobia is one of several anxiety disorders. It may occur with or without panic disorder, but it is most frequently seen with a panic disorder (Katerndahl, 1996). Agoraphobia can begin even after the very first panic attack. Agoraphobia is both a sever anxiety condition and a phobia, as well as a pattern of avoidant behavior (American Family Physician, 1995). Personality disorders are relatively frequent in patients with panic disorders and agoraphobia (Marchand, Goyer, Dupis, & Mainguy, 1998).
     The National Institute of Mental Health estimates that 5.6% of adults develop agoraphobia at some point in their lives (Ogles, Lambert, Weight, & Payne, 1990). Agoraphobia is more common among women than men and it usually begins when they are in their twenties or thirties. About twice as many women than men report that they experience agoraphobia. The condition of agoraphobia tends to run in families. The severity of agoraphobia is quite variable. Some people with agoraphobia live essentially normal lives as they avoid potentially anxiety-provoking situations. However in severe cases of agoraphobia people are homebound. These people work very hard to avoid any and all situations that might cause them to become anxious.
     Frequently, people report that the onset of their agoraphobia followed a stressful or traumatic event in their lives. Authors have proposed that major life events play a role in the development of panic-related disorders. Certain events involving separation issues
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or interpersonal conflict have been specifically implicated in the etiology of agoraphobia. Most of the evidence in support of an association between life events and panic onset has come from uncontrolled clinical studies of samples of anxiety-disordered patients.
     The current literature on precipitants of panic onset is characterized by numerous limitations, including variability in, and sometimes failure to report, parameters of the time frame within which life events were examined; inadequately defined clinical samples; and non-standardized, unstructured interviews. Even studies that used contrast groups did not control for the possibility that panic-disordered individuals experience more life events in general or during particular phases of adulthood. A close relationship between panic onset and life events cannot be assumed without comparing the period surrounding panic onset with other periods of equal duration in the lives of panic-disordered patients. Finally, prior studies have generally ignored the panic-evoking potential of stress associated with apprehension by not examining anticipated life events that occur after the first panic attack.
     Pollard, Pollard, and Corn conducted a study in 1989, the primary purpose of this study was to provide a more thorough test of the hypothesized temporal relationship between life events and panic onset associated with agoraphobia. In a group of agoraphobic patients, the total number of life events reported and the percentage of subjects that experienced life events during a period around the onset of panic were compared with data from both within-subjects and between-subjects control periods. Anticipated life events that occurred shortly after panic onset were included in this study.
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Subjects included 100 outpatients seeking treatment at the Anxiety Disorders Center, St. Louis University Medical Center who met diagnostic criteria from the Diagnostic and Statistical Manual of Mental Disorders for agoraphobia with panic attacks. There were 72 female and 28 male subjects; their mean age was 33.57 years. Mean years of education were 13.85 and subjects had experienced symptoms of agoraphobia for and average of 8.29 years. The two groups did not differ in education or duration of problem.
     Life events were assessed by the Social Readjustment Rating Scale (SRRS), a self-reporting measure that requests respondents to indicate which items from a list of 43 major life events they have experienced. Subjects were asked to indicate the date or dates on which each life event occurred. A total of 250 agoraphobics completed the SRRS, a demographic data sheet, and a questionnaire requesting the date of the first panic attack. From this original subject pool, and "index" group and a "comparison" group of 50 subjects each were matched by age and sex. Three periods during which life events data would be examined were defined: (a) panic onset period, 12 months preceding and 6 months following onset of the first panic attack experienced by index group subjects (b) within-subjects control period, 18 months in the lives of index group subjects exactly 4 years preceding their panic onset period; and (c) between-subjects control period, 18 months in the lives of comparison group subjects simultaneous with the panic onset period in their index group matches. Agoraphobia 16
Two categories of life events were examined. Experienced items included life events that occurred within the first 12 months of each of the three periods. Foreseeable items included a subset of 20 items involving life events that can be predicted or
anticipated. Foreseeable life events were examined during the last 6 months of each period.
     The three periods were compared in terms of numbers of subjects that reported experienced, foreseeable, or both types of life event and mean numbers of life events reported.
     A total of 36 (72%) index subjects reported at least one life event during the panic onset period, compared with 10 (20%) index subjects during the within-subjects control period and 17 (34%) comparison group subjects during the between-subjects control period. There were significant differences between the mean number of total life events reported during the panic onset period and means for the within-subjects control period and the between-subjects control period. When foreseeable events were examined alone, significant differences were also found between the panic onset period and both the within-subjects control periods were significant as well.
     Results of this study provide convincing evidence that a specific temporal relationship exists between panic onset and major events in the lives of agoraphobics. A significantly higher percentage of subjects reported having experienced at least one major life event during the panic onset period than during either of the two control periods. Significantly more life events were reported during the panic onset period.
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Agoraphobia is both physiological as well as psychological. Those who have Panic Disorder with Agoraphobia (PDAG) are believed to have a physiological glitch in their endocrine system in which the build-up of chemicals finds an outlet through panic attacks (Lundh, Wikstrom, Westerlund, & Ost, 1999).
     Two major characteristics are associated with agoraphobia: 1) People develop anxiety when thinking about being in a situation out of their comfort zone. 2) People avoid those situations which bring them anxiety or panic. It is the fear of the anxiety that
leads to the agoraphobia.
     Agoraphobic fears typically involve characteristic clusters of situations that include being outside the home alone; being in a crowd or standing in a line; being on a bridge; and traveling in a bus, train, or automobile (Carter, Hollon, Carson , & Shelton, 1995).
     There are three main types of treatment for agoraphobia 1) therapy 2) medications 3) combination of therapy and medication. Behavioral and cognitive therapy are the treatments of choice for agoraphobia. If panic accompanies the agoraphobia people are sometimes referred for a brief course of a prescribe medication, such as an antianxiety medication (Michelson, & Marchione, 1991).
     In a study on families of agoraphobics it ws found that relatives hostility and critisism are connected with how a patient progresses in treatment (Chambless, Bryan, Aiken, Steketee, & Hooley 2001). The patient’s relatives’ emotional overinvolvement causes higher rates in treatment dropout (Chambless, & Steketee, 1999). When it comes to spouses Jacobsen, Holzworth, Munroe, and Schmaling state that positive changes in
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agoraphobic behavior are generally correlated with positive changes or stability in marital satisfaction.
Recently, writers have begun to differentiate between psychotherapy efficacy and effectiveness. Efficacy (or research therapy) refers to the effects of psychotherapy in
randomized controlled trials usually conducted in university settings, with the aim of trying to establish a high degree of internal validity. Effectiveness (or clinic therapy) refers to the effects of "natural" clinical psychotherapy conducted in the field using quasi-experimental designs to try to establish a high degree of external validity or generalizability of results to various settings.
     In a study conducted by Hahlweg, Fiegenbaum, Schroeder and Von Witzleben in 2001, the experimenters examined the transportability and the generalizability of high-density exposure therapy (HDE) using unselected patients and a large number of experienced and inexperienced therapists. The goals of this study were to examine the transportability of HDE by comparing the effectiveness and clinical significance of HDE after treatment and at the 1-year follow-up with efficacy studies, and to compare treatment dropouts with treatment completers.
     The participants were 416 patients (67% women), treated in three CDS outpatient clinics. Their mean age was 35.6 years. Eighteen percent completed secondary school, 26% high school, and 27% had a university degree; 65% were employed, 14% were students or in an apprenticeship, and 14% were housewives. Fifty-two percent were married, 25% lived together with a partner, and 23% were single; 46% were childless.
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Typically panic disorder with agoraphobia (PDAG) patients were treated with high-density cognitive-behavioral in vivo exposure (HDE), typically lasting 4 to 10 days, during which patients are expected to confront the feared situations for several hours per day. Psychological assessment (four to six sessions) and a medical checkup, which is
particularly important in the context of HDE because this treatment is stressful and may be contraindicated.
     Patients are exposed to the feared situations, starting with one of the most difficult situations. The therapist is in close contact with the patient during the first days, and it is not unusual for treatment to last for 12 hours per day during the first week. Exposure is extended over prolonged periods of time until the anxiety has decreased to a level necessary to achieve habituation.
     One limitation of the study is that it is entirely based of self-report measures, and another is the lack of treatment integrity data.
     This study provides evidence that the empirically validated situational exposure treatment for PDAG patients can be transported into clinical settings.
     The outcome results for patients completing the intervention 6 weeks after the end of treatment and at the 1-year follow-up provided strong support for the clinical effectiveness of HDE for patients with PDAG. In all clinical variables, highly significant decreases in symptoms resulted at post assessment, which stayed stable up to 1 year later.
     The average percentage of patients with reliable improvement at both assessment points was 80%; however 6% deteriorated after the treatment. At post assessment, on average 55% of patients showed clinically significant changes, as did 59% at the 1-year
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follow-up. It seems justified to conclude that HDE can be transported to natural settings without reducing its effectiveness.
     Patients with a personality disorder improve more slowly than subjects without personality disorders (Marchand et al., 1998).     
People with agoraphobia suffer from a common and unbearable condition involving multiple phobias of activities such as shopping, driving, walking along busy streets, and many others. Although the various phobias sometimes co-occur, they typically are found in highly variable constellations from one agoraphobic person to another. Overcoming agoraphobia, therefore, means learning to think, feel, and behave differently with respect to a diverse and idiosyncratic range of activities.
     Current treatments for agoraphobia are based on clients performing phobic activities in actual community settings. Self-efficacy theory holds that phobic behavior is caused by a sense of inability to execute effective coping behavior. Research directly comparing self-efficacy perceptions to anticipations of danger and anxiety has found self-efficacy to be consistently the overriding predictor of therapeutic behavior change.
     The present experiment conducted by Williams, Kinney, and Falbo in 1989 gave agoraphobic subjects treatment for some of their phobias while leaving their other phobias untreated. The behavioral changes, and the possible cognitive mediators of change, were measured in both the treated phobias and the transfer phobias. They predicted that the treatment benefits would generalize to the transfer phobias, and that perceived self-efficacy would be the most accurate predictor of treatment and transfer effects.
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Participants were 22 white female and 5 white male adults averaging 43 years of age. Subjects’ mean education was 13 years; annual family income was $24,500. Subjects had been agoraphobic for a mean of 14 years, 24 of the 27 subjects previously had received professional treatment for their agoraphobia with little benefit, and all
subjects but one had a history of panic attacks. As is common among agoraphobics, subjects tended to be moderately to severely depressed, scoring a mean of 21 on the Beck Depression Inventory prior to treatment.
     In the first treatment phase, one or two of each subject’s target phobias were selected at random, leaving the remaining target phobia(s) as untreated "transfer" phobias. After the first treatment phase, the 38 treated phobias and 64 transfer phobias were evaluated at mid-treatment; subjects then began the second treatment phase.
     In the second treatment phase, the transfer phobias from the first phase that continued to meet the behavioral selection criterion at the mid-treatment assessment were reassigned at random to be treated or to be left as transfer phobias. The phobias that no longer met the selection criterion at the mid-test were left untreated in the second phase.
     To establish whether any changes in the transfer phobias were true generalization effects or simply reflected the passage of time and repeated assessment, the last 11 subjects to complete the study were assigned at random after the pretest either to the standard procedure described above, or to a delayed-treatment control condition. Control subjects were again tested after 2-3 weeks, which corresponded to the duration their treated counterparts spent in the first treatment phase.
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Subjects were required not to receive other psychological treatment during the study, and to refrain from coping with phobic activities between sessions in the program. Subjects were required to keep constant the dosage of any prescribed medications and to refrain from taking alcohol or discretionary medications.
The identical set of assessment procedures was administered for all target phobias at all assessment occasions, and assessment sessions were always held on different days than were treatment sessions. Assessors were assistants unaware of the phobias’ treatment status of the research hypotheses.
     At each community assessment site, subjects first rated each type of thought separately for each task in a task hierarchy corresponding to the tasks of the behavioral test. In all tests, subjects were instructed to try to complete as many test tasks as they could on their own while the assessor waited just outside the test setting. Performance was scored on the basis of objective indices. All tests sampled tasks ranging from quite ease to quite difficult, with equal intervals of difficulty between tasks. Each test was scored as the percent of tasks completed, with a partial value added for partial task performance. As they completed each task of each behavioral test, subjects rated their present anxiety.
     Treatment was conducted individually in settings different from those used for behavioral testing, but with similar physical dimensions and threat value. Therapists accompanied subjects in all treatment sessions to the designated treatment sites and took an active role in encouraging and guiding subjects to perform progressively more difficult tasks as rapidly and proficiently as possible irrespective of anxiety.
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Treatment produced sizable gains in the treated phobias, and these generalized to the transfer phobias. Prior to treatment, the three groups did not differ significantly on any measure. Generalization of benefit was examined by comparing the changes in the three groups of phobias on each measure from pretest to mid-test. It showed that the
treated phobias improved significantly more than the transfer and control phobias on every measure except subjective anxiety, and that the transfer phobias improved significantly more than the control phobias on approach behavior, anticipated anxiety, ad anticipated panic. It is therefore clear that changes in treated phobias produce substantial change in transfer phobias, but that the treated phobias improve more than the transfer phobias.
     Agoraphobics who received brief treatment for some of their phobias experienced continuing generalized improvements in other phobias that were entirely untreated. The mechanism underlying therapeutic change in agoraphobic behavior must be a factor internal to the individual, but a factor that is finely adjusted to specific functional domains.
     Agoraphobia is maintained by low perceptions of self-efficacy and treatments lessen particular agoraphobic dysfunctions by raising people’s perceptions of self-efficacy for those dysfunctions. The strong link between self-efficacy and functional behavior was not just a reflection of previous behavior. Self-efficacy predicted subsequent coping behavior when pervious behavior was held constant. Subjects evidently were guiding their behavior toward the transfer activities by the sense of self-efficacy they derived from treatment experiences in distinct domains of dysfunction.

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