“My troubles really started last year, when I brought my daughter to the theme park Fun Land,” says Joe, a 36-year-old male client of yours. “I don’t know what it was, but the longer I was there, the more anxious I became. It was especially bad when we were standing in lines. It would get so cramped and crowded, especially in the hallways. And when we were on the rides, I was miserable. I just kept thinking of what would happen if there was a fire, or if I started having a heart attack, or if one of the kids fell off the boat into the water. And the more I thought about it, the more I was freaking out. I just kept thinking of how hard it would be to get help. I didn’t want my daughter to know, because I wanted her to have a good time. But now that I think about it, I’m pretty sure I was having a panic attack. I was sweating, my heart was beating out of my chest. It was like I couldn’t breathe. I couldn’t go on any more rides after that. We ended up going home early. I know she was disappointed, but I couldn’t help it.”

“Have you experienced similar problems in any other situations since then?”, the therapist, ask.

“Well…” Joe begins to fidget with his collar, and you notice that he’s sweating. “To be honest with you, I’m feeling it right now. It was the same way last week, but I didn’t want to say anything, because it’s embarrassing. It seems like whenever I’m in a room without a window or without an easy means of getting outside, I just… I start to get tense and upset. And it’s all I can think about. That need for an escape. I had to leave the movies early last week, because it got so bad. At work, I’m only able to focus when I set my computer up close to the emergency exit. When I’m too far in, I start to freak out. It always happens when I’m in enclosed spaces.”

“Like this office, you mean?” you ask.

“Yeah,” he says slowly. His head drops to his hands, and you can hear him breathing heavily. His hands are shaking. “It’s so weird, because I know logically nothing’s gonna happen. But it could happen. And if it did, what if I couldn’t get out? And then I start to panic, and when I panic, I get embarrassed, because people look at me. It’s just awful.”

“What do you think could happen?”

“Something horrible. And we wouldn’t be able to escape. It’s like the oxygen’s getting sucked out of the room, and I just can’t… I can’t breathe. It feels like I’m having a heart attack.” Suddenly, Joe stands and heads for the door. “I’m so sorry, this is- this is so embarrassing. But I have to go. I can’t be in here.”

Before you can say anything, Joe is long gone.

What Is Agoraphobia?

Agoraphobia is a highly misunderstood, often oversimplified, mental illness that falls under the broader category of Anxiety Disorders within the DSM-V. Many believe that agoraphobia is simply a fear of open spaces or a fear of leaving one’s house. While both of these components can be symptomatic of agoraphobia, the criteria for diagnosis is far more extensive. At the foundation of every agoraphobia diagnosis is the person’s sense of helplessness and fear in response to difficult or embarrassing situations that he or she worries are inescapable (American Psychiatric Association, 2013).

To receive a diagnosis of agoraphobia, the individual must experience fear or anxiety in response to at least two of the following situations:

  • Using public transportation, such as automobiles, buses, trains, ships, and planes;
  • Being in open spaces, such as parking lots, marketplaces, or bridges;
  • Being in enclosed spaces, such as shops or theaters;
  • Standing in line or being in a crowd; or
  • Being outside of the home alone (American Psychiatric Association, 2013).

The person fears or avoids these situations because he believes that escape might be difficult or impossible, in the event of either a panic episode or other incapacitating or embarrassing situations (American Psychiatric Association, 2013). These situations almost always provoke persistent fear or anxiety (the problem lasting at least six months) which is out of proportion to the actual threat posed by the situation (American Psychiatric Association, 2013). The fear causes the person to avoid these situations and creates significant distress in multiple areas of life, such as home and work (American Psychiatric Association, 2013). The problem is not better explained as symptomatic of another medical condition or psychiatric illness (American Psychiatric Association, 2013).

Some who experience agoraphobia also receive a separate diagnosis of panic disorder (Star, 2021). Panic attacks include symptoms such as:

  • Chest pain
  • Chills
  • Diarrhea
  • Dizziness
  • Feelings of choking
  • Feelings of unreality
  • Nausea
  • Numbness
  • Rapid heartbeat
  • Shortness of breath
  • Sweating
  • Trembling (Star, 2021).

About 1.7% of adolescents and adults are diagnosed with agoraphobia each year (American Psychiatric Association, 2013). Females are twice as likely to experience agoraphobia (American Psychiatric Association, 2013). While it is possible to develop agoraphobia in childhood, most find that their symptoms peak in late adolescence or early adulthood (American Psychiatric Association, 2013).

Overcoming Agoraphobia: Treatment

In terms of treating agoraphobia, there are many options available. Some mental health professionals support the use of medication to help with symptoms, such as SSRIs or SNRIs (antidepressants), as well as benzodiazepines, such as Xanax and Ativan (anti-anxiety medications) (“Agoraphobia,” 2017).

Another option for treatment involves a therapeutic intervention called systematic desensitization. Developed in the 1950s to treat phobias, this behavioral therapy strategy exposes individuals to situations that create psychological discomfort, starting with situations that involve the lowest amount of distress, gradually moving up towards situations that cause high levels of distress (McLeod, 2015). The purpose of systematic desensitization is to remove the fear associated with a specific situation and replace it with a relaxation response (McLeod, 2015). Treatment is usually conducted over 4-6 sessions, or as many as 12 sessions for severe phobias (McLeod, 2015). Exposure occurs in two ways: in vitro (the client imagines exposure to the phobic situation) or in vivo (the client is actually exposed to the phobic situation) (McLeod, 2015). Often, clients going through this treatment find it helpful to have a trusted friend or family member accompanying them.

There are three phases of systematic desensitization treatment. The first phase involves teaching clients deep muscle relaxation techniques and breathing exercises, which the client will use to relieve tension when faced with the feared situation (McLeod, 2015). The second phase has the client create a “fear hierarchy,” listing situations surrounding the phobia that create the least anxiety, moving up to situations that create the most anxiety (McLeod, 2015). For example, in Joe’s case, the lowest item on his hierarchy might be “to remain in a room with no windows for two minutes without panicking,” and the highest item might be “to remain in a crowded underground tunnel for one hour without panicking.” The third phase has the client work their way up the hierarchy, starting at the bottom item. The client repeatedly uses the relaxation techniques of phase one to cope with the distress connected with the fear-inducing situation until the situation no longer creates distress (McLeod, 2015). When this happens, the client moves up to the next situation on the hierarchy and so on, until the client has worked through all fear-inducing situations on the hierarchy, replacing fear with relaxation (McLeod, 2015).

The progressive structure of this treatment gives control to the client, allowing him or her to determine which steps must be taken to overcome the fear and at what pace (McLeod, 2015). Putting the power in the client’s hands is one reason why this treatment is so effective for many dealing with phobias, specifically agoraphobia.

Coping with Agoraphobia

While living with this disorder will never be easy, there are many ways for individuals to cope with their symptoms as they find an effective treatment. It is important for those seeking help from a medical professional to stick to their treatment plans (“Agoraphobia,” 2017). This involves taking medications as directed and keeping therapy appointments (“Agoraphobia,” 2017). It is also important to practice self-care, which might include keeping to a healthy diet and sleep schedule, exercising, and avoiding alcohol and recreational drugs (“Agoraphobia,” 2017). In addition to getting psychiatric treatment, many find it helpful to join support groups for people suffering from the same type of disorder (“Agoraphobia,” 2017). Groups enable people going through the same hardship to find comfort and connection, knowing that they are not alone in facing their challenges and that eventual recovery is a reality.

In Conclusion…

Based on his symptoms, Joe most likely suffers from agoraphobia in response to enclosed spaces and lines or crowds. It affects his ability to enjoy time with his family and decreases his work productivity. Though further analysis is needed to determine whether a separate diagnosis of panic disorder is appropriate, Joe clearly suffers from some panic symptoms when faced with situations that trigger his agoraphobia. Moving forward, the therapist would likely use systematic desensitization to help Joe slowly face the discomfort associated with enclosed spaces and lines or crowds. It might be necessary at the beginning of therapy to hold sessions either virtually or in an open space. Moving forward, Joe might try enduring short sessions within the enclosed therapy office, slowly working up his fear hierarchy until he eventually gets through an entire therapy hour without experiencing extreme discomfort or panic symptoms.

Whatever the client and therapist decide, there are many treatment options that would enable clients with agoraphobia to overcome the discomfort and avoidance of triggering situations. With time, commitment, and consistent treatment, agoraphobia, like so many forms of mental illness, can be overcome.

Courtesy: Gwendolyn Brown, M.S..

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