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
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.
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.
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.
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 , &
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
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
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
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.
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
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
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.,
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
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
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.
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
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.
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
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