Agoraphobia is an anxiety disorder characterized by anticipatory anxiety due to 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 must 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 about cognitive behavioral therapy for agoraphobia (considered a first choice treatment), 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 . There is also a fear of being in places where it is difficult to get help in case of a panic attack or similar symptoms. In other words, the fear occurs in public places, and not so much in open ones, as is often thought.

Thus, due to this fear, situations involving being in these places are avoided or resisted with great discomfort; in the case 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 photophobia (having “fear of fear”, or fear of one’s own anxiety).

Classification in manuals

As for 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 of the DSM (DSM-III) and in the ICD-10 (International Classification of Diseases), agoraphobia was classified as a separate disorder, and may or may not be accompanied by panic disorder (usually in severe cases).

In DSM-III-R and DSM-IV-TR, but, agoraphobia becomes 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 behavioural 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, the results in research 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.

1. Psychoeducation

Psychoeducation consists of “educating” the patient in his pathology , that is, providing him with the appropriate information so that he can understand his disorder, its etiology, what factors are favouring its maintenance, etc. Thus, in psychological therapy for agoraphobia, this education will deal mainly with anxiety and panic.

The goal is to provide the patient with the necessary information to understand why this happens, and to learn to differentiate some concepts that can sometimes be confusing. This information can help reduce their uncertainty and make them feel more at ease.

2. Breathing techniques

Breathing is an essential factor in anxiety disorders , as learning to control it can greatly help reduce anxious symptoms. In agoraphobia, this is especially important, because the fear is that you will have a panic attack in places where it is difficult to get help. 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 the agoraphobia itself, since agoraphobic patients begin to think that they will suffer a panic attack and that causes them anxious symptoms.

3. Cognitive restructuring

Cognitive restructuring is another key element within psychological therapy for agoraphobia, as it helps to modify the patient’s dysfunctional and unrealistic thoughts, in the face of the belief that he may suffer a panic attack at any time (or at the moment he is exposed to a public place).

That is, the cognitive restructuring will be focused on modifying these thoughts and beliefs , and also on correcting the cognitive distortions of the patient (for example, thinking “if I take the bus and I have a panic attack, I’ll die right there, because nobody will be able to help me”, or “if I go to the party and I have a panic attack, I’ll be very embarrassed, because I’ll also be overwhelmed and won’t be able to get out of there”.

The goal is for the patient to learn to develop more realistic alternative thoughts that will help him/her cope with situations in a more adaptive way, and that will help reduce his/her anxiety or anticipatory discomfort.

4. Interoceptive exposure

Interoceptive exposure consists of exposing the patient to the anxious symptoms caused by a panic attack , but through other mechanisms (that is, artificially produced, simulating them). These symptoms are induced in the patient (in fact, they are usually induced by the patient himself) through different strategies, such as turning in a chair (to obtain the sensation of dizziness), performing 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 body signals in relation to his or her body, and the panic reactions (the symptoms of panic) that he or she manifests. This type of exposure is based on the theory that panic attacks are actually learned alarms or conditioned by certain physical signals.

5. Live self-exposure

Live self-exposure, the fifth component of psychological therapy for agoraphobia, consists of exposing the patient to the real situation that generates the fear or anxiety . That is, that they go to public places where “it is difficult to escape”, and that they do so alone.

Also, you should not run away from the situation (unless the anxiety you experience is exaggerated). The goal is, on the one hand, to empower the patient in resolving their disorder, and on the other, to “learn” that they can cope without experiencing a panic attack. This type of exposure will also help the patient understand that the embarrassment of “running away” from a place is not as relevant, and can be put into perspective.

6. Records

Finally, the last component of psychological therapy for agoraphobia is the registers; in these (self-registers), the patient must note down different aspects depending on what the therapist asks for and the technique used .

Generally, these are daily records that aim to collect relevant information from the patient, in relation to the moments when he or she experiences anxiety (with its history and consequences), the number of panic attacks he or 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 spent on the live exposure component is reduced.

On the other hand, an advantage of the cognitive behavioral therapy we are talking about, oriented to treat agoraphobia, is that 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, by contrast, the functioning is different and much less invasive or disruptive to the patient.

Bibliographic references:

  • American Psychiatric Association (APA) (2014). DSM-5. Diagnostic and statistical manual of mental disorders. Madrid: Panamericana.

  • Horse (2002). Manual for the cognitive-behavioral treatment of psychological disorders. Vol. 1 and 2. Madrid. Siglo XXI.

  • Pérez, M., Fernández, J.R., Fernández, C. and Amigo, I. (2010). Guide to effective psychological treatments I and II:. Madrid: Pirámide.