What is it?
Agoraphobia is translated from Greek literally as “fear of the marketplace”. It is a type of anxiety disorder, described as the fear of being stuck in places or situations that would be embarrassing, or difficult to escape from or the fear of being in a place or situation where it would be hard to get help or embarrassing if a panic attack were to occur. People with agoraphobia then face these situations with extreme fear and distress or actively avoid such a situation. For example, a person could fear crowded places such as shopping centers because they fear that it will be hard to escape or very embarrassing if they were to have a panic attack. Therefore, they might choose to avoid shopping centers wherever possible or face them in distress. It can be so severe that people can avoid leaving their house at all.
What does it look like?
Approximately 1.7% of adolescents and adults are affected by this disorder, which has recently been categorised as its own disorder whereas before it was grouped in with panic disorder. The difference is that with panic disorder, people experience recurring panic attacks during which they experience significant distress along with physical sensations that can include dizziness, shortness of breath, heart palpitations and shaking. Agoraphobia on the other hand, often develops in patients who have a history of panic attacks or panic disorder, who then develop a phobia of certain places where a panic attack could occur and avoid these places where they can or face them with fear.
Where does it come from?
We don’t fully understand where agoraphobia comes from, with no direct cause from a biological pathway. But from a psychodynamic perspective, it is understood that agoraphobia could be based on disruption to early psychological development and related back strongly to the development of a person’s ego (their sense of self-identity).
What do we understand about it?
Relational therapy is a therapeutic approach based around the idea that satisfying relationships with others are essential for our own wellbeing. According to relational therapy, trauma to a person’s ego early on in life can contribute to the later development of anxiety and agoraphobia. As infants, we go through a phase called separation-individuation, where we develop a sense of self and that our mother is an entirely different human being to us. This is how we develop healthy attachment, and theorists propose that an attachment deficit resulting from insufficient separation-individuation phase could lead to anxiety in the child and a later onset of agoraphobia. The theory also suggests that traumatic childhood events, such as the death of a family member or friend or abuse can lead to ongoing trauma which can manifest into agoraphobia later on in life.
How can it be treated?
Relational therapy approaches are equally about the patient developing their relationship with themselves as they are about the patient-therapist relationship. Patients are taught how to gain a deeper understanding of themselves and their experiences and symptoms. With agoraphobia, patients will be able to better understand the effects of separation-individuation and how this can correspond to the later anxiety if it is not achieved properly.
Through PFPP, patients develop a deeper understanding of their anxiety and agoraphobia through exploring its origins, their underlying feelings and conflict in symptoms in a supportive space. This is important in dismantling and exposing the underlying roots of agoraphobia, which as mentioned before, can be a result of something that happens during childhood that the patient might not expect to be relevant to the disorder.
Exposure-based CBT is where patients are gradually exposed to stimuli that trigger their anxiety response, working from the least-feared stimuli in towards the most-feared. This is completely tailored to the patient, so that they can move at their own pace to comfortable and successfully overcome feared situations. It also involves retraining the brain to see that feared physical symptoms, such as shortness of breath, aren’t actually as fearful as they believe. Once patients understand that they can control these physical sensations and that they aren’t actually life-threatening, they are less likely to cause panic if they occur and they are able to successfully manage their agoraphobia.