Putting Agoraphobia Behind You
Experts say highly effective treatment options can reach even the homebound.
REFERRING TO THE marketplace in ancient Greece, or “agora,” agoraphobia often involves the fear of public places.
More broadly, though, a person with the anxiety disorder, which disproportionately affects women, may avoid any situation or place in which they previously had a panic attack, not wanting it to happen again. About 1 in 3 people who have panic disorder will develop agoraphobia, according to the Anxiety and Depression Association of America, a nonprofit dedicated to increasing awareness and improving diagnosis and treatment of anxiety, depression and related disorders.
But it’s not only physical situations, such as driving on an expressway, that might elicit fear and which a person might avoid as a result of agoraphobia, says clinical psychologist Karen Cassiday, who is president of the ADAA and managing director of The Anxiety Treatment Center of Greater Chicago. Rather, it’s any situation – internal or in the environment – that a person thinks could trigger a panic attack. It could be a fear of engaging in sexual activity or exercise because you get sweaty and your heart rate might increase and then people can get panic attacks, she says. “I’ve had patients [with agoraphobia] who are afraid to get emotionally aroused – they don’t want to get really happy, they don’t want to get real sad, they don’t want to get angry,” Cassiday says.
Each time a person with agoraphobia quickly escapes a situation to avoid physical symptoms of anxiety, without taking time to calm down in the situation first, it reinforces the fear and makes it worse, she says. “So the agoraphobia usually very quickly mushrooms,” she adds; and what a person fears and avoids can rapidly expand – essentially shrinking their world. “It’s important to be aware of a continuum of distress and impairment when it comes to any kind of mental health issue – [and] specifically anxiety,” says Raphael Rose, a clinical psychologist and associate director of the UCLA Anxiety and Depression Research Center in the school’s department of psychology. “It can, in extreme cases, lead to someone who’s homebound essentially, who doesn’t go out of their house.”
Recovery Is Possible
The good news for those suffering from agoraphobia is that there are effective options to treat it. Unfortunately, experts say, many people with agoraphobia either don’t get treatment or don’t receive the current, proven standard of care. “The thing that makes me sad is when we see people who’ve been in typical talking therapy for 20 years, and no one’s ever suggested to them that, ‘You could get over this,’” Cassiday says.
Laura McMullenJune 2, 2014
She says that by using a version of cognitive behavioral therapy, which incorporates exposure therapy, agoraphobia is quite treatable. “The best treatment for agoraphobia is exposure-based therapy: interoceptive exposure, where you’re deliberately bringing on physical symptoms of anxiety that you’re afraid of,” she says. For Cassiday and her colleagues at The Anxiety Treatment Center, therapy includes going with patients into situations that the patient might otherwise avoid, to talk them through it so that ultimately they can find calm, or a process called habituation. “We drive with patients. I’ve ridden roller coasters with patients. … We’ve gone swimming with people who were afraid to swim – ‘What if I have a panic attack?’” she says. “Also, you deal with the thoughts. So with cognitive therapy, we have the person think all the things they’re scared about and talk to themselves in a different way, which is, ‘This is just uncomfortable.’”
Research shows that with proper therapy, a person can recover in a few months – rather than years, or dealing with agoraphobia indefinitely. “The average is, if you have the right treatment – and this is without medication – you should expect to treat someone to remission in 12 to 16 weeks or less,” Cassiday says.
Besides CBT with exposure therapy, patients may also be prescribed drugs – namely selective serotonin reuptake inhibitors, or SSRIs, that are widely used to treat depression. These can be helpful in reducing anxiety, panic and tension that characterize the disorder – whether given in combination with therapy or alone, says Michael Zvolensky, clinical psychologist and director of the Anxiety and Health Research Lab/Substance Use Clinic at the University of Houston. But long-term, taking drugs is less than ideal because of the side effects, which can range from sexual dysfunction to irritability and sleep problems, and coming off the drugs can cause a “rebound effect” – or worsening symptoms of anxiety, he says.
Before settling on any treatment, experts say, it’s important to first ensure a proper diagnosis. “The first step is to get a thorough evidence-based assessment of your condition by a professional who specializes in anxiety disorders,” Zvolensky says.
Cassiday says it’s important to see a mental health professional who has experience doing exposure-based therapy with panic attacks and agoraphobia, and who is familiar with interoceptive exposure.
Technology Can Bridge the Gap for Those “Trapped” By Agoraphobia
In cases where a person is unable or reluctant to venture out to see a mental health professional, increasingly technology is opening up treatment options to reach those with agoraphobia and other anxiety disorders right where they are – even if homebound. (That’s in addition to home visits some mental health professionals, like Cassiday, make.) Evidence-based care can be delivered through a computer or smartphone, and in that way, make effective treatments available to more people, Rose says. For example, tele-mental health requires only an Internet connection to bring a mental health professional and patient together, even in remote areas, where treatment options may otherwise be limited.
In addition, the ADAA notes certain mental health apps can make therapy more accessible and efficient as well as portable. That includes the free Self-help for Anxiety Management app that the British National Health Service uses.
A boon of technology is, of course, its reach – and initial research on e-mental health for anxiety disorders is promising. “Electronic or digital mental health programs can be as effective as face-to-face … in-person treatment,” Rose says. However, in some cases, adherence can suffer. “There’s a greater likelihood that someone might drop out from a purely self-guided type of treatment online,” he says – and, with any approach, sticking to it is a key for success.
Experts say for any agoraphobia treatment to work it must eventually lead to in-person exposure to feared situations, so that the person can move beyond that fear. “Any online program would, I think, be best for agoraphobia when it is able to help transition the person into actual real life changes. It cannot simply be purely a virtual interaction,” Rose says. “Ultimately the person needs to move toward actual experiments and experience in real-life situations.”
[See: Apps to Mind Your Mental Health.]
Above all, given advances in treatment, experts say it’s important to move forward with the expectation that you can put agoraphobia behind you. “Don’t settle,” Cassiday says. “You need to assume that you can get past it, and the thing that we’ve seen is this is highly treatable.”
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Michael O. Schroeder has been a health editor at U.S. News since 2015. He writes health …