By Professor Kevin Gournay

Agoraphobia was a term coined by the German neurologist Westphal in 1871. In his original description, Westphal described four patients (all men) who had attacks of anxiety in public places. Interestingly, he described how several of them used alcohol to reduce their fears. The term ‘agoraphobia’ derives from the Greek, the word ‘agora’ meaning the market place. This term, Westphal felt was appropriate because it described how people felt vulnerable in public places and in particular where there was no obvious exit. At the same time, another neurologist, Benedikt, coined another term (Platzschwindel) which translated from the German, means dizziness in public places. Over the years, this syndrome has been called many things, one of the most convoluted terms being the “phobic anxiety depersonalisation syndrome!”

In its fully developed form, agoraphobia probably affects between ½ and 1% of the population, i.e. about 1½ million people in the United Kingdom but, in a less severe form up to 1 in 8 people, i.e. about 7 million, may be troubled by some agoraphobic symptoms. More recently, the American classification system has defined agoraphobia as part of a more general panic disorder and sees panic as being the central feature from which all fears stem. This is a concept which is currently open to some dispute, but there is no doubt that panic attacks form a considerable component of agoraphobic anxiety. With regard to incidence, it is probable that up to 1 in 3 of us may have a panic attack during our lifetime and certainly, at any one time, about 3% of the population may be experiencing panic attacks.

Agoraphobia has its classic onset in early adult life, the peak ages being between 18 and 30. It is very rare for agoraphobia to develop from its beginnings after the age of 30 although, some people appear in outpatients clinics in their 30s and 40s, stating that this is the first episode. However, in many of these people, you can find a history of fear situations during school life and transient episodes of anxiety in public places at other times in their life. If, however, phobic symptoms truly start without any history whatsoever in the 40s or 50s, it is likely that they are part of another syndrome, possibly a depressive illness. Agoraphobia is not a fear of open spaces although, some people with agoraphobia may be afraid in such situations, it is principally a fear of situations in which escape is perceived as difficult and/or help is not perceived as being readily available. Therefore, people may often be able to travel long distances alone or go into crowded public places providing that they know that help is at hand. I have one particular patient of my recollection who was able to travel anywhere on his own throughout the United Kingdom provided he had a mobile telephone with him, so that if he had a panic attack, he felt that he could contact the emergency services (needless to say, he never needed to use it). However, if for some reason he was deprived of his mobile phone, he could not travel beyond a few hundred yards from his house. As most of you know, people with agoraphobia are extremely good at hiding their fears from the outside world and often people mask their symptoms effectively for many years, or even a lifetime.

With regard to sex differences, men are much more likely to hide their fears than women and although we think that there are probably almost as many male agoraphobics as women, the number of men who come to outpatient clinics is a ¼ or less of the number of women who attend. Men are certainly not as good at facing up to the fact that they have a fear and this is probably a very strong socially conditioned response. For example, many men say quite openly that they see the admission of fear as being synonymous with being a wimp or being week in some way.

I have carried out research in the field of agoraphobia since 1979 and this research has looked at both the nature of the syndrome and the outcome of treatment. So, what do we know about this condition?

Cause

The cause of agoraphobia remains a mystery and it is probably more true to say that it is a matter of a number of causes rather than one single cause. Probably, most people with agoraphobia are biologically pre-programmed in the sense that they produce adrenalin more readily than other people do. Secondly, we know that growing up among people who show avoidance traits in their behaviour can lead to avoidance behaviour developing in offspring. We know that separation experiences during childhood can be quite important and a very large number of agoraphobics have been separated from their mother or father.

We also know that agoraphobia may be associated with stressful life events and that people who suffer repeated stresses can often develop phobic symptoms. Sometimes, people develop agoraphobia following frightening experiences and the best examples of this is to be found in people who perhaps have been trapped in a fire, a lift or a motor car involved in an accident. These people often develop agoraphobic symptoms. However, it is interesting to note that there are many people trapped in such situations who do not go on to develop phobic symptoms and, thus, one really has to consider the possibility that there is a predisposition both biological and psychological to this syndrome.

Treatment

Before behaviour therapy, the treatment outlook for people with agoraphobia was not good. Psychoanalytic psychotherapy was often used on people but the outcomes with this approach were very poor. Similarly, the drug treatments which were used many years ago often led to major problems.

The first behavioural attempts to treat agoraphobia were those of systematic desensitisation, i.e. teaching people to relax in association with imagining various phobic situations. However, 25 years ago exposure in real life was developed as a central treatment for agoraphobia and this involved a therapist taking the patient into the phobic situations and keeping them there for long enough so that their symptoms reduced. These exposure exercises often lasted for 2-3 hours at a minimum.

While exposure in real life has remained the mainstay of treatment, therapist aided exposure is much less used today. Professor Isaac Marks at the Institute of Psychiatry, the world’s leading expert in this area, argues that exposure treatments can be as effective using self-help material, computer programmes or therapist instruction and he has a great deal of research evidence to support this proposition. In recent years, cognitive therapy has developed and all over the world, psychologists and psychiatrists are applying cognitive therapy principles to agoraphobia and panic attacks. While there is some evidence that cognitive therapy is useful in the treatment of panic attacks, there is as yet little evidence that cognitive therapy adds much to the outcome of exposure treatments. This controversial area is continuing to be subjected to research enquiry and I am sure that over the years we will see new emerging approaches. However, I am sure that exposure will remain an absolute prerequisite.

The results of exposure on its own are very good and probably 70% of people who complete programmes will achieve 70% or more recovery. However, many people drop out of treatment or fail to complete an adequate trial. Some of my research indicated that some people have difficulty tolerating exposure treatment and for this group of people, cognitive therapy may be helpful as a preparation. However, as most of you know, there is no way round the central truth that, in order to combat a fear, one needs, eventually, to face up to it!!

Self-help groups such as ‘No Panic’ provide a mainstay for the population of people with phobic anxiety in this country, as treatment resources are still desperately short. Unfortunately, although we have many skilled and very competent nurses, doctors and psychologists who have received the proper training in behaviour therapy, there are by no means sufficient numbers to treat the phobic population that exists. As mentioned above, self-help approaches can be very effective and, providing the correct ingredients of treatment are used, i.e. central emphasis on exposure and how it is applied, there is no doubt that the ‘No Panic’ volunteers can achieve outcomes which compare favourably with health professionals.

The main principles of exposure are:

1. Exposure must be prolonged. You must stay in the situation until your fear starts to go. This may take a long time – often several hours.
2. Short periods of exposure without experiencing a reduction in symptoms can be harmful.
3. Exposure should be regular.
4. Try and involve the family as co-therapists.
5. Buy some self-help literature.
6. Avoid the use of alcohol at all costs.
7. If you are taking medication, this must be discussed with someone who has expertise both in behaviour therapy and in the area of pharmacology. I believe the research evidence is that very few people with agoraphobia should be prescribed medication as a first line of treatment and that medication may achieve some short term gains but, in the long term, there is still a question mark over its usefulness.
8. If self-help is not working and you feel that you would benefit from professional treatment go to your GP and request a referral to a suitably qualified therapist. Insist on receiving behavioural therapy for your phobic condition. This is a universally recognised treatment and in my view it is your right to be referred. Under the new funding arrangements in the NHS, your GP should have access to referral to a specialist resource outside your immediate area if, local treatment facilities do not exist.

Professor Kevin Gournay is an Emeritus Professor at the Institute of Psychiatry. He has more than 35 years of experience and is the author of more than 130 articles and books. He is based in Cheshunt Hertfordshire.