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A systematic desensitisation programme for agoraphobia

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VOL: 97, ISSUE: 33, PAGE NO: 39

John Tredget, BSc, CertEd, RMN, is a community mental health nurse, Pendine Centre, Cardiff

Agoraphobia was first noted in 1871 when it was described as 'the impossibility of walking through certain streets or squares, or the possibility of so doing only with resultant dread or anxiety' (Marks, 1987). The latest psychiatric diagnostic aid calls it: 'anxiety about, or avoidance of, places or situations from which escape might be difficult (or embarrassing) or in which help may not be available in the event of having a panic attack or panic symptoms' (American Psychiatric Association, 2000).

Agoraphobia was first noted in 1871 when it was described as 'the impossibility of walking through certain streets or squares, or the possibility of so doing only with resultant dread or anxiety' (Marks, 1987). The latest psychiatric diagnostic aid calls it: 'anxiety about, or avoidance of, places or situations from which escape might be difficult (or embarrassing) or in which help may not be available in the event of having a panic attack or panic symptoms' (American Psychiatric Association, 2000).

Agoraphobic fears may be precipitated by situations such as being outside the home alone, being in a crowd, standing in a queue, being on a bridge, or travelling by bus, train or car.

The symptoms include:

- Gastrointestinal upset;

- Dry mouth;

- Dizziness;

- Feelings of choking;

- Feelings of impending death;

- Chest pain/discomfort;

- Palpitations;

- Feelings of depersonalisation, where patients feel themselves becoming 'unreal' or 'altered';

- Feelings of derealisation, where the environment is perceived as strange and unreal.

These are also the symptoms of panic disorder and it is typical for those with agoraphobia to also have panic disorders. People with anxiety have a low threshold for the perception of threats and interpret events in a threatening way. For example, they may experience mild palpitations and fear they are having a heart attack.

Agoraphobia is the most common phobic disorder found in adult psychiatric clinics (Marks, 1987). The causes are thought to include an unstable background, unhappy childhood, maternal overprotection, separation anxiety, genetic factors, and stressful life events or life changes (Vines, 1987). It is more common in women than in men.

The onset of agoraphobia can be sudden - within a few hours of a traumatic event - but is more likely to be gradual, over a few weeks, months or even years. Many patients may have been uneasy about going out alone for decades, yet managed to conceal their fears until the anxiety increased or they were unable to cope.

The syndrome typically starts with discrete episodes of anxiety that may be mild at first but increase in intensity over successive episodes. These episodes usually last for a few minutes but may take several hours, after which the patient may avoid the scene of the original panic or anything associated with it for some time for fear of feeling the sensations again (Marks, 1987).

This avoidance may be maintained through a vicious circle of anticipatory anxiety: fear of the fear. The most effective treatment for agoraphobic symptoms is graduated exposure, in real life, to the avoided situations (Brooking et al, 1996).

Desensitisation
Joseph Wolpe is best known for the use and development of systematic desensitisation (Gross, 1996). He argued that as most 'abnormal' behaviour, like 'normal' behaviour, is learned so it can be unlearned and replaced with more adaptive reactions. By facing something that has been avoided because it provokes anxiety - a technique known as exposure - the vicious circle that maintains anxiety is broken (Hawton et al, 1996).

Exposure should be graduated, preferably repeated every day and prolonged (Hawton et al, 1996). On exposure to the situation the patient may try to avoid it or escape from it, seeking reassurance from those around or using rituals or agents such as alcohol, drugs or charms to neutralise the anxiety. To overcome the fear, the patient must be exposed to the situation without escaping or using rituals or agents (Thomas et al, 1997).

Short exposure sessions are not as effective as longer sessions, and allowing the patient to leave the situation while still highly anxious may be damaging. Infrequent exposure to stimuli often results in the patient becoming more sensitised to them (Brooking et al, 1996).

Assessment of the problem is a vital component of behavioural work. It can reveal the severity of the disorder, its impact on the patient and those close to them, and the patient's motivation and ability to change. It also develops the therapeutic relationship and builds trust.

Chambless et al's agoraphobic cognitions questionnaire (Hawton et al, 1996) is useful for measuring cognitive ability, while Chambless et al's (1985) mobility inventory for agoraphobia is used to identify behavioural elements of the problem. These assessments attempt to uncover the extent to which the disorder interferes with patients' lifestyles - how much it prevents them from doing things they would normally enjoy and what situations they try to avoid.

Patient should make a list of all the things they avoid and rank them according to their difficulty, giving the reasons why they make them anxious. They should then undertake each activity on the graded hierarchy of anxieties, starting with the one that causes the least anxiety. The first step might be for the patient to visualise the problem. Anxious people often imagine catastrophic outcomes to normal situations and it can be helpful for them to work through to the conclusion of the imaged event, seeing that no harm will come to them.

Each task should be repeated often and regularly until it causes little or no anxiety. Then the next task is attempted. The patient should work through the hierarchy until he or she is comfortable with each stage. If panic occurs at any stage the patient ought to be exposed to the situation until it subsides. He or she should realise that the panic will subside of its own accord and that there is no need to leave the situation.

Other interventions that can be used alongside systematic desensitisation include distraction, the use of flash cards, challenging conceptions and the use of relaxation techniques.

Distraction involves focusing on external events to prevent the patient from focusing on the symptoms, which intensifies the anxiety. Distraction techniques might include reading the labels on cans and jars in the supermarket while shopping, counting the number of cars that pass while travelling on a bus, or simply jingling keys in the pocket while standing in a queue.

Flash cards are small cards that patients have written on to remind themselves, when they are experiencing panic symptoms, that they can conquer their fears. These cards might remind the patient that 'these feelings will pass' or 'if I stay in the situation it will be OK'.

Another way to break the vicious circle is to question distressing thoughts, such as: 'I'm experiencing chest pain so I must be having a heart attack'. The patient should look for evidence of the presentation and find alternative explanations, such as: 'I'm nervous and I am not having a heart attack'.

Exposure work can be time-consuming and it may be more appropriate for the nurse to train a relative or friend to act as co-therapist. He or she can be taught the basics of exposure therapy and can accompany the patient during exposure sessions when necessary.

There are groups that offer help (see below).

Conclusion
Research shows that 70% of agoraphobic patients who undergo a reasonable trial of exposure treatment improve by 70% or more (Brooking et al, 1996). Nurses who have been appropriately trained in behavioural treatments achieve results that are at least comparable to those of psychiatrists and psychologists (Marks et al, 1987), and such techniques are now routine tools in the practice of mental health nurses.

- To contact the No Panic specialist helpline for people with agoraphobia, tel: 01952 590545.

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