Overcoming Agoraphobia and Extreme Anxiety Disorders

Overcoming Agoraphobia & Extreme Anxiety Disorders

After reading Overcoming Agoraphobia & Extreme Anxiety Disorders, youll be given a better understanding of all things related to the condition, so that you dont have to be afraid anymore. If youve been suffering for any amount of time, dont allow yourself to feel hopeless and alone. This problem is more common than you might think and the first step to overcoming any anxiety issue is by learning all you can about it. Find out what causes panic disorders and discover how you can create a different life for yourself starting today. Here are just a few things youll learn by reading this complete anxiety guide: What anxiety is and why it happensHow anxiety can lead to panic disordersWhat agoraphobia is and how to know if youre at riskHow to recognize symptoms of agoraphobia and how to manage itAn overview of the different types of anxiety disordersWhat you can do to improve this condition once and for allHow to fight the root of anxiety and panic disorders stressWhether or not adrenal fatigue is the cause of your problemsHelpful therapy options that have been proven to be effectiveAlternative remedies for stress, depression and panic disorders

Overcoming Agoraphobia & Extreme Anxiety Disorders Summary


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Author: Tom Lawler

My Overcoming Agoraphobia & Extreme Anxiety Disorders Review

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All of the information that the author discovered has been compiled into a downloadable book so that purchasers of Overcoming Agoraphobia & Extreme can begin putting the methods it teaches to use as soon as possible.

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Panic Disorder And Agoraphobia

Panic disorder is characterized by unexpected panic attacks. These may be followed by panic attacks in response to particular stimuli, and by agoraphobia. Panic disorder with or without agoraphobia is a prevalent and disabling disorder. Panic-depression is a particularly common comorbidity, and contributes to the potentially negative impact of panic disorder 28 . Alcohol and substance abuse and dependence are also frequent comorbidities in panic and other anxiety disorders. Finally, it is possible that early diagnosis and treatment of panic disorder could prevent subsequent agoraphobia, depression and substance use disorders. There is some empirical data to support the assertion that treatment of panic attacks is associated with a lower risk of subsequent depression 35 . Prospective long-term studies are needed to fully understand the course of anxiety disorders such as panic disorder, and to delineate clearly the possible impact of early detection and robust treatment on decreasing...


Agoraphobia refers to fear of being in situations or places from which escape may be difficult or embarrassing or in which help may be unavailable in the event of a panic attack or panic-like symptoms (APA, 2000 Dziegielewski & MacNeil, 1999 Pasnau & Bystritsky, 1990). Agoraphobia may occur with or without the presence of full-blown panic attacks. Panic attacks, or panic-like symptoms usually lead to anticipatory anxiety about experiencing the panic and, consequently, avoidance behavior (Zitrin et al., 1983). Panic disorder with agoraphobia has a lifetime prevalence rate of 3.5 while agoraphobia without a history of panic disorder has a lifetime prevalence rate of 5.3 (Kessler et al., 1994). The severity of the panic symptoms is what differentiates panic disorder with agoraphobia from agoraphobia with history of panic disorder. Individuals with panic disorder with agoraphobia experience full-blown panic attacks, while those with agoraphobia without history of panic disorder have never...

Description Of Treatment

The next section provides a theoretical overview of BGT. Immediately following this overview we present two case illustrations of BGT. The first involves a protocol for panic disorder with agoraphobia, and serves to highlight different types of exposure techniques in BGT. The second BGT protocol has more cognitive components and is designed to treat generalized social phobia. The chapter concludes with a brief discussion of applications and exclusions for BGT, along with a summary of the current empirical knowledge base.

Graded in Vivo Exposure

This is the method most commonly used to reduce fear. It has two components. First, the patient is instructed how to rate the intensity of discomfort using a Subjective Units of Distress Scale (SUDS). This measure of fear and distress ranges from 0 to 100, where 0 none, 50 moderate, and 100 extreme. Second, the therapist and patient devise a hierarchy of real-life fear-evoking stimuli, ranging from stimuli that evoke little or no fear or distress, to extremely frightening or upsetting stimuli. Table 1 shows an example of a hierarchy used in the treatment of agoraphobia. Sample Exposure Hierarchy for Agoraphobia Fear of Traveling Far from Home

Terence M Keane and Meredith Charney

Keane and Kaloupek (1982) treated a Vietnam theater veteran who presented with war-related PTSD, depression, and substance abuse problems. They offered a theoretical model that focused on two-factor learning theory to explain the development and maintenance of PTSD symptoms. Viewing PTSD as consisting of classical conditioning and instrumental avoidance, this model resulted in the use of treatments previously demonstrated as successful in other forms of anxiety disorders such as agoraphobia, panic, and obsessive-compulsive disorder. Implicit in the treatment developed was consideration of the traumatic memories and nightmares as the motivating factors in many of the symptoms of PTSD. Exposure therapy using imagery of the content of nightmares, flashbacks, images, and memories was effective in reducing symptoms of PTSD in a wide range of patient populations (Foa, Keane, & Friedman, 2000).

Virtual Reality in Phobia Therapy

Treatment for fear of spiders and other insects has also been attempted via VR exposure. Victims can expose themselves to increasingly frightening situations in the VE until their anxiety gradually decreases. Realistic virtual exposure can be achieved not only with virtual spiders but also with the tactile enhancement of large fuzzy plastic spiders (Carlin, Hoffman, and Weghorst, 1997). Other phobias treatable with VR therapy include fear of driving, fear of public speaking, and agoraphobia, which is the fear of being helpless in an inescapable situation such as being trapped inside a burning building or being caught in rising floods. Agoraphobia often causes a person to avoid spaces or situations associated with anxiety. Many studies in VR therapy for phobias such as fear of public speaking and agoraphobia have produced remarkable results. More studies are being done, but VR therapy for phobias will likely become a growth industry.

Tian P S Oei and Genevieve Dingle

Brief intensive group cognitive behavior therapy (BIGCBT) is a version of cognitive behavior therapy conducted in full-day sessions over a short time period, for example, 3 consecutive days. This article presents the theoretical underpinnings and applications of BIGCBT, and a review of empirical studies showing the effectiveness of a BIGCBT program for outpatients with panic disorder with or without agoraphobia. A Sample of the Brief Intensive Group CBT Program for Panic Disorder with and without Agoraphobia The BIGCBT is delivered over 3 consecutive days, with an attendance of 8 hrs per day. Psychiatrist Larry Evans and psychologist Bevan Wiltshire initially started the BIGCBT in the early 1980s for the treatment of patients with anxiety disorders, in particular panic disorder with agoraphobia. In 1984, a group of psychologists, Tian Oei, Justin Kenardy, and Derek Weir, joined the group and further developed and evaluated the treatment package.

Jesse H Wright and D Kristen Small

The first computer programs for cognitive-behavior therapy (CBT) were developed in the 1980s by teams of investigators in the United Kingdom (Carr, Ghosh, & Marks, 1988 Ghosh, Marks, & Carr, 1984) and the United States (Selmi, Klein, Greist, & Harris, 1982 Selmi, Klein, Greist, Sorrell, & Erdman, 1990). Using the computer technology of the time, these researchers produced programs that relied on written text, checklists, and multiple-choice questions for communication with the patient. More recently developed computer tools for CBT have incorporated multimedia, virtual reality, hand-held devices, or other methods to rapidly engage the user and stimulate learning (Newman, Kenardy, Herman, & Taylor, 1997 Rothbaum et al., 1995 Rothbaum, Hodges, Ready, Graap, & Alarcon, 2001 Wright & Wright, 1997 Wright et al., 2002). Computer programs have been tested and found to be useful for a variety of Axis I disorders including depression, simple phobia, agoraphobia, and PTSD (Ghosh et al., 1984...

Classical Conditioning

A more popular application of classical conditioning is the exposure therapies. These treatments are used to help people overcome specific phobias and other anxiety disorders in which excessive fear plays a prominent role, such as agoraphobia, social phobia, posttraumatic stress disorder, and obsessive-compulsive disorder. Given that exposure therapies for treating phobias are the most widely used applications of classical conditioning, these treatments and their theoretical bases will be the focus of this chapter.

Exposure in Vivo Therapy versus Cognitive Therapy

In specific phobias, cognitive therapy was generally less effective than in vivo exposure. Several studies found cognitive therapy and exposure in vivo therapy with the addition of response prevention about equally effective in obsessive-compulsives. Similarly, cognitive therapy is as effective as exposure in vivo therapy alone for social phobic complaints. In general, studies find that cognitive therapy alone is of limited value for agoraphobia as compared to exposure in vivo. More recently developed cognitive approaches focusing on catastrophic cognitions are effective with respect to reduction of panic attacks in patients with panic disorder with no or limited avoidance, but less effective than exposure in vivo in severe agoraphobic patients. However, these cognitive restructuring packages contain an exposure component (i.e., behavioral experiments). Finally, exposure in vivo was as effective as cognitive therapy in hypochondriasis. Overall, the literature suggests that cognitive...

Pharmacogenetics and psychopharmacology

The relationships between panic disorder and other types of anxiety disorder have also been the subject of study. Thus some investigators have reported that relatives of those with agoraphobia have a higher risk for the disorder than relatives of patients with panic disorder, leading to the suggestion that agoraphobia should be considered a more severe form of panic disorder which has an independent genetic transmission. Other studies, however, have found that the diagnosis of separation anxiety and agoraphobia in probands increased the risk of both panic disorder and agoraphobia in the relatives of the patients. Such observations support the hypothesis that panic disorder and agoraphobia are two phenotypic expressions of the same condition due to a different degree of genetic penetrance. The analysis of the relationship between panic disorder and major depression has produced conflicting results. The possible link between these disorders has been provided by the frequent occurrence...

Heterocyclic Antidepressants Hcas

Although tricyclic antidepressants (named for their three-ring structure) were first synthesized in the nineteenth century, their antidepressant properties were not recognized until the late 1950s. Since that time, other cyclic antidepressant agents have been formulated thus creating need for the more general term heterocyclic (Table., .282-3). The therapeutic effect of HCAs is believed to be related to secondary downregulation of norepinephrine and serotonin postsynaptic receptors after initial blockade of presynaptic reuptake of norepinephrine and serotonin. HCAs are primarily indicated for major depression but may also be effective for dysthymic disorder, panic disorder, agoraphobia, obsessive compulsive disorder, enuresis, and school phobia. As previously advised, initiation of HCA therapy in the emergency department is not routinely recommended.

Parameters of Exposure in Vivo

The results of the studies on agoraphobia and obsessive-compulsive disorder indicated that the participation of the spouse in the exposure treatment did not enhance the treatment effects. Further, results with respect to the comparative effectiveness of therapist controlled versus self-exposure are inconclusive. However, in six out of eight studies, guided mastery was substantially and significantly more effective than mere exposure. In all these studies the duration of the treatment conditions was equal, and both conditions were therapist-assisted.

Dysfunctional Beliefs

Theories of fear have become increasingly complex in recent years. Classical conditioning and many other factors are thought to be involved. Consistent with the neo-conditioning and emotional processing models, some theorists have proposed that exaggerated beliefs about the probability and severity of danger may play an important role in motivating fear and avoidance. Such dysfunctional beliefs play a prominent role in contemporary theories of agoraphobia and social phobia, and may play a more important role in these disorders compared to specific phobia. People with social phobia tend to be preoccupied with their social presentation and have heightened public self-consciousness. They also tend to be self-critical, to excessively worry about being criticized or rejected by others, and to overestimate the likelihood of aversive social events. This suggests that such dysfunctional beliefs may be important in maintaining generalized social phobia. These beliefs appear to persist because...

Katie M Castille and Maurice F Prout

Anxiety disorders have been identified as the most prevalent mental health problem in the United States. According to the Epidemiologic Catchment Area (ECA) study sponsored by the National Institute of Mental Health, the 1-month prevalence rate for anxiety disorders is 7.3 (Regier et al., 1998). Among anxiety disorders, phobic disorders are the most common, with a prevalence rate of 6.2 . According to the Diagnostic and Statistical Manual of Mental Disorders-IV-Text Revision (DSM-IV-TR American Psychiatric Association APA , 2000), phobias are classified into three categories agoraphobia with or without panic attacks, social phobia, and specific phobia. While panic attacks are most often thought of in regard to panic disorder, with and without agoraphobia, panic attacks can also be experienced in specific phobia and social phobia. One study examining specific phobias found that 47 of individuals with a phobia of heights, 20 of individuals with an animal phobia, 50 of individuals with a...

Cognitive Behavior Group Therapy

The goals of intervention are behavioral, cognitive, and or emotional change. Specifically they aim at the reduction of stress and anxiety responses, depression, eliminating panic responses, reducing bulemic behavior losing weight, the resolution of phobic disorders, ameliorating agoraphobia, effective management of chronic pain, improving general social functioning, abstinence from risky sexual activity, and increasing self-control in the area of drug and alcohol abuse. (A comparable program has been described by Rose in 1998 for use with disturbed children and adolescents.) In the model proposed in this article the clients make use of the conditions of the group to enhance the clients' learning and motivation. Most CBGT models teach specific skills for coping with and resolving unique problem situations. Skills are usually developed for coping effectively with situations that trigger stress, anxiety, pain and or anger through the use of various cognitive...

Outcome Research On Cbgt

Support for CBGT in the treatment of agoraphobia with panic disorder in intensive short-term CBGT (two all-day workshop) was provided by Evans, Holt, and Oei in 1991. They assigned 97 participants with the diagnosis of agoraphobia with panic attacks to either the treatment (n 74) or the control wait-list group (n 23). All subjects in the treatment condition attended the brief intensive CBGT, which consisted of lectures regarding agoraphobia, relaxation training, cognitive rehearsal of panic control messages, in vivo exposure, and group discussion. Waiting list participants were all consecutive re

Prevalence Of Anxiety Disorders

In the past decade, large epidemiological studies have provided information about the prevalence of anxiety disorders in the general population. A landmark epidemiological study in the United States in 1994 found lifetime prevalence rates for all anxiety disorders combined to be 19.2 for men and 30.5 for women. Phobic disorders are the most common diagnosis in broad-based assessments of psychiatric disorders in the community (affecting about 13 of individuals at any point in their lives), whereas PTSD affects 8 of the general population, GAD 5 , and PD and OCD each about 1 . Even apart from the considerable comorbidity between the anxiety disorders, comorbidity rates between anxiety disorders and depressive disorders are high (especially PD with agoraphobia, social phobia, and OCD), ranging from 30 for coexisting in time to 60 lifetime. Comor-bidity rates between GAD or PTSD and other psychiatric disorders are even higher, about 80 for GAD and 90 for PTSD (lifetime).

Summary And Conclusions

Phobias can be distressing and debilitating disorders. Individuals with agoraphobia, specific phobia, and social phobia experience fear in particular situations or around particular objects that often manifests itself in a panic attack or paniclike symptoms. The experience of panic leads to anticipatory anxiety about having future symptoms of panic, resulting in avoidance of the phobic situation. CBT has been found to be effective in treating these phobias through a combination of exposure, cognitive therapy, and psychopharma-cology. Continued research on treatments for phobias will help to find the most cost-effective treatments that can be generalizable across various patients and settings.

Empirical Studies

Empirical outcome studies have proved that exposure in vivo is an effective treatment in reducing phobic complaints in specific phobias, in social phobias, in agoraphobia with or without panic disorder, and in hypochondriasis. Studies have shown that exposure to anxiety-provoking situations also has a positive effect on frequency and intensity of panic attacks in agoraphobics. Obsessive-compulsive disorder patients benefit from exposure in vivo treatment with the addition of response prevention (i.e., the prevention of behaviors that reduce fear).

Efficacy Of Problemsolving Therapy

If effective problem-solving skills serve as an important buffering factor regarding the stress process, training individuals in such skills should lead to a decrease in emotional distress and improvement in psychological functioning. In fact, PST has been shown to be effective regarding a wide range of clinical populations, psychological problems, and the distress associated with chronic medical disorders. These include unipolar depression, geriatric depression, distressed primary care patients, social phobia, agoraphobia, obesity, coronary heart disease, adult cancer patients, schizophrenia, mentally retarded adults with concomitant psychiatric problems, HIV risk behaviors, drug abuse, suicide, childhood aggression, and conduct disorder (see Nezu, D'Zurilla, Zwick, & Nezu, in press, for a review of this literature).

Empirical Support

Since that time, many studies have been done establishing the effectiveness of flooding for the treatment of anxiety symptoms. Flooding has been found effective in treating adults with the following anxiety disorders obsessive-compulsive disorder, simple phobias, social phobia, agoraphobia, posttraumatic stress disorder, and panic disorder. For example, in a 1993 meta-analysis, George Clum, Gretchen Clum, and Rebecca Surls found that flooding was the treatment of choice for panic disorder, showing better results than other psychological techniques (such as systematic desensitiza-tion) or medications. In a 1995 review, Melinda Stanley and Samuel Turner concluded that flooding was the treatment of choice for obsessive-compulsive disorder, resulting in greater reduction of anxiety symptoms, decreased drop-out rates, and decreased relapse rates over time than other psychological techniques or pharmacological treatments. Across all anxiety disorders, flooding has been found to be effective...

Iiiempirical Studies

The long-term effectiveness of BIGCBT was also reported in a 1997 study conducted by Oei and Evans with Michael Llamas. This study investigated the possible impact of concurrent medication use on the long-term outcome of BIGCBT for panic disorder with or without agoraphobia. The researchers found that preexisting medication (antianxiety, antidepressant, or a combination of these) did not significantly enhance or detract from the long-term outcome of the BIGCBT program. The BIGCBT has also been applied to the treatment of patients with comorbid alcohol use disorder and panic disorder with or without agoraphobia. The 2000 report by Bialkowska, supervised by Oei and Evans, documented that concurrent addition of the BIGCBT for panic disorder to the standard hospital treatment for alcohol abuse produced better clinical outcomes than the standard hospital treatment and a placebo treatment. It was found that BIGCBT had an impact on self-reported anxiety but not on alcohol outcome measures.

Further Reading

S., & Evans, L. (1992). Personality and treatment response in agoraphobia with panic attacks. Comprehensive Psychiatry, 33, 310-318. Oei, T. P. S., Llamas, M., & Develly, G., (1999). Cognitive changes and the efficacy of CBT with panic disorders with agoraphobia. Behavioral and Cognitive Psychotherapy, 27, 63-88. Oei, T. P. S., Llamas, M., & Evans, L. (1997). Does concurrent drug intake affect the long-term outcome of group cognitive behavior therapy in panic disorder with or without agoraphobia Behaviour Research and Therapy, 35, 851-857.


Excessive fears, which are a central component of many anxiety disorders, such as specific phobia, social phobia, panic disorder and agoraphobia, obsessive-compulsive disorder, and posttraumatic stress disorder. During exposure therapy, the person is presented with a fear-evoking stimuli in a controlled, prolonged fashion, until the fear diminishes. Treatment is collaborative, with the patient and therapist working together to decide how and when exposure will take place. Exposure duration depends on many factors, including the type of feared stimuli and the severity of the person's fears. Typically, an exposure session lasts 20 to 90 minutes, and sessions are repeated until the fear is eliminated. Sessions may be either therapist-assisted or may be completed by the patient as a form of homework assignment. Joseph K. was a 27-year-old man with a 5-year history of panic disorder and agoraphobia. He experienced recurrent, unexpected panic attacks. These typically occurred whenever he...


SAD is often comorbid with many of the anxiety disorders, including specific phobias, generalized anxiety disorder, agoraphobia, and panic disorder. According to the NCS, 56.7 of people diagnosed with SAD also met criteria for another anxiety disorder (Kessler et al., 1994). SAD is also highly comorbid with depression, with 37.2 of those diagnosed with SAD also meeting criteria for major depressive disorder in the NCS. Finally, SAD often co-occurs with alcoholism, with 34.8 of those diagnosed with SAD meeting criteria for either alcohol abuse or dependence in the NCS study.

Wayne A Bower

Anorexia and described as part of a stepped care approach in the treatment of anorexia nervosa. Across the country, inpatient programs using the Comprehensive Model have been designed and are running. These programs include adaptations of CT to this population. CT has also been used in several large-scale research projects working with the treatment of alcoholism. These studies found that CT had a positive effect on symptom severity, a decrease in conflict, and an overall improvement in well-being. Hoffart (1995) examined the use of inpatient CT on agoraphobia suggesting better endstate functioning compared to guided imagery. An intensive CT inpatient program for hypochondriasis has been reported by Hiller, Leibbrand, Rief, and Fechter (2002). At the end of inpatient treatment, 60 of the sample were seen as responders to the CT interventions and had shown substantial improvement in their symptoms.

Etiology Of Phobias

Harmful (Reiss, Peterson, Gursky, & McNally, 1986). Studies have found that individuals with panic disorder with agoraphobia have high scores on a measure of anxiety sensitivity, indicating their aversion to the experience of anxiety itself (Antony et al., 1997). In addition to a higher level of anxiety sensitivity, there is enhanced attentional selectivity or interoception for physical cues (Barlow, 2001). Individuals with phobias tend to be more aware of body sensations related to arousal. Thus, these individuals have a vulnerability to be able to detect subtle bodily experiences, perceive these experiences as dangerous and aversive, and, as a consequence, are more prone to develop panic attacks or paniclike symptoms. These symptoms are maintained out of a fear of fear in which the experience of panic attacks or paniclike symptoms leads to a fear of experiencing these symptoms again. Because of the increased awareness of bodily sensations, any sensation resembling that of panic is...

Frederick Rotgers

In 1985 this situation changed with the publication of Relapse Prevention Maintenance Strategies in the Treatment of Addictive Behaviors by G. Alan Marlatt & Judith Gordon (Marlatt and Gordon, 1985). Marlatt and Gordon presented the first cognitive-behavioral approach to maintaining behavior change. While the book focused primarily on substance use disorders, the applicability of relapse prevention (RP) strategies to other behavioral problems was readily apparent. Within the next 10 years RP approaches had been developed to sustain change following treatment of a variety of behavioral problems, including a variety of nonaddictive disorders, such as depression and agoraphobia, marital distress, stuttering, and chronic pain (Wilson, 1992). RP also stimulated a substantial body of research into its efficacy and the processes that both contributed to the persistence of addictive behaviors and made it so apparently difficult for treated individuals to maintain those changes.