Exposure in vivo therapy for agoraphobia

Exposure Therapy for Agoraphobia

A FACE-OFF WITH FEAR

Agoraphobia

Agoraphobia is an anxiety or panic disorder of intense fear of places where escape is perceived as difficult or help unavailable (Medline Plus, 2010; Sanderson, 2010). These places include crowds, bridges, stores, restaurants, movie theaters, areas of travel or simply being alone in the outside world. A person with this disorder avoids these places and situations out of fear of a panic attack. A panic attack is an episode of intense fear or discomfort with specific symptoms, followed by a period of about a month of anxiety about going through the same experience. A change in behavior may also develop. Among common symptoms are rapid heartbeat, sweating, chest pain or discomfort, trembling or shaking, shortness of breath, a feeling of choking, nausea, dizziness, numbing, chills and fear of losing control or dying. Agoraphobia often accompanies a panic disorder or attack. Current annual figures estimate that 1-3.5% of the population will experience a panic disorder (Medline Plus, Sanderson).

Agoraphobia often occurs when a person with a previous panic attack begins to fear situations, which can lead to another panic attack (Medline Plus, 2010). It can develop at any age but is most common at age 25 and more often among women than men. Symptoms of agoraphobia include being housebound for long periods, dependence on others, fear of being alone, feeling of helplessness and perception of the body or the environment is unreal. The person feels that he is seriously ill or dying. He may also go to the emergency room in the belief that he is about to have a heart attack. Diagnosis includes a physical examination and psychological evaluation. Problems involving the heart, hormones, breathing, the nervous system and substance abuse must first be ruled out. Treatment depends on the severity. Current standard therapy is cognitive-behavioral therapy or CBT combined with anti-depressant medication (Sanderson, 2010). It entails up to 20 visits with a mental health professional for a regimen for a change of thought patterns, which cause agoraphobia. Treatment must, however, be started early and effective to achieve satisfactory results. Complications include the risks of self-medication, loss of functioning at work or social situations, and feelings of isolation, loneliness, depression and suicidal thoughts. Exposure is the final component of CBT, which brings the person to confront the object of anxiety, whether external situations or internal sensations. Through repeated exposures, the person develops appropriate coping mechanics in responding to similar situations without anxiety or panic. The therapist exposes the patient to a list of feared situations in a progressive and systematic manner. She guides him in the use of coping skills before the situations (Sanderson).

A meta-analytic review of 42 psychological treatments of panic disorder proved their efficacy in cases of agoraphobia and related conditions (Sanchez-Meca, 2009). The most effective was the combination of exposure -- interoceptive and in vivo -- therapy, relaxation training or breathing retraining techniques (Sanchez-Meca). A randomized controlled comparison was also conducted on the effects of the three types of self-exposure treatment on 80 outpatients over a period of 10 weeks with daily exposure (Ito et al. 2001). These three types were external, interceptive or combined external and interoceptive. Results showed that all three types were significantly and similarly effective at 60% at post-treatment and 70% at follow-up and in short or long-term duration (Ito et al.).

Most people who suffer from agoraphobia can cope by just avoiding the feared object or situation (Greist & Jefferson, 2007). But exposure therapy remains the choice treatment. It can be performed correctly even without a therapist. Drug therapy has been shown not to be very useful, although anti-anxiety drugs may help sufferers in the short-term (Greist & Jefferson).

In Vivo Exposure

This method operates on the three concepts of respondent conditioning, respondent extinction and learning theory (Porter et al., 2006). It has proved effective in many cases of anxiety disorder. It creates situations wherein the patient confronts the feared situation according to the principles of habituation and extinction. According to the principle of habituation, a fear response weakens when elicited repeatedly. According to the principle of extinction, the fear response decreases or weakens when the patient is exposed to the feared situation and does not undergo a fear experience or arousal (Porter et al.).

The therapist first determines and ranks the patient's feared situations according to severity (Porter et al., 2006). Distress is measured by the Subjective Units of Distress

Scale at a range of 0 to 100 from minimal to severe. The person should remain in the situation until his distress level decreases to at least half. Exposure should not terminate when he is at the peak anxiety level or experiencing a panic attack. Terminating exposure at this point will reinforce the phobia. It can also develop aversive arousal that can lead to escape behaviors. These behaviors can lessen the probability of overcoming the feared situation, increase the timetable of therapy or end too early (Porter et al.).

Issues

The five variations are therapist-directed vs. self-directed, massed vs. spaced, graduated vs. intense, endurance vs. controlled escape, and attention vs. distraction (Porter et al., 2006). The therapist-directed type has proved more effective on less motivated or educated patients. The self-directed type, on the other hand, appears more suitable to independent more educated patients. Most therapists begin with the self-directed type before moving to the self-directed type (Porter et al.).