Agoraphobia is a disorder where an individual feels getting trapped in a situation like a closed or an open place (e.g., market, or a lift). There is a tendency to avoid such situations and therefore an agoraphobic individual restricts environmental exposure. For example, not going to market places, not driving to far off places from home, trying to remain at home by not attending important social gatherings, or seeking company of some familiar person to remain safer.
There is always an anticipation in the mind of an agoraphobic that he might become anxious, beyond control, and may get trapped. The severity may become so high that a person may get housebound, not leaving home for many days, even weeks or months. The fear is usually very general, that is, it may or may not be confined to few selected places. Unlike specific phobias (like water, heights, snakes, etc), agoraphobia is more global and ranges across different situations. Wherever there are chances of getting into an open or a closed space, the person tends to avoid it.
The management of agoraphobia is successfully done through systematic desensitisation, which is a behaviour therapy, aimed at gradual in vivo exposure of the person to fared stimuli (inside therapy session, imaginally), and leading to cessation of fear responses. This technique has been quite commonly used for several decades. Gradual exposure in real life situations, beginning with less feared stimuli and reaching for more intense anxiety-provoking stimuli, is also employed for good outcomes.
Exposure is based on the principle that once we deal with the anxiety-provoking stimuli, step by step, by being in the situation that evokes it, then we see that anxiety lowers gradually in that situation. Fear is maintained by avoidance of stimuli, therefore, exposure to the stimuli may help us to learn that there is no point of getting fearful, as the object or situation may not be that harmful as is believed. Many people are exposed to the same situation of being in a lift or crowd, but they don’t become scared or panic in that situation. So the situation is not inherently harmful. Because of some initial fearful experiences with such stimuli, the brain learns to evoke anxiety in the same way again and again to generate an avoidance action. This pattern needs to be unlearned to face the situation once again, without fear. Exposure helps in this unlearning.
Many people face problems in attaining the safety of being in an exposure condition, it takes time to feel safer. The experience of encountering the situation that is feared a lot elicits anxiety and feelings of threat. So it is not easy for many individuals to practise exposure easily. There are many cognitive elements like beliefs, appraisals, biases, associated with avoidant behaviours that sustain them. So accepting the treatment becomes difficult. Moreover, a phobic person pays attention to feared stimuli so much that it becomes difficult to shut the mind from looking at them. This gives signals to the brain that threat is present in the environment. So the fear response in body and behaviour is elicited and maintained, unless we do something to interfere with this signalling.
A modern approach that eases the work of the individual in overcoming fears is mindfulness. Mindfulness means attending to your thoughts, feelings and bodily sensations in a way that is non-judgmental and neutral, that makes it easier to manage them.
Researches have shown that mindfulness activates parasympathetic nervous system which calms the body and mind. Mindfulness helps to bring attention to feelings and thoughts, and promotes an orientation of curiosity and openness, leading to acceptance of symptoms during exposure to the stimuli. It enables the person to accept the situation, by not avoiding it, and gradually dealing with the symptoms as they arise, one by one. This helps a phobic person to deal with the situation.
Suppose the phobic person is in a lift, all alone. There is an intense feeling of discomfort and anxiety. The person may feel he would not be able to escape the lift, as he is sure that it may stop or become malfunctional. There are thoughts that no one would hear his cry and he would remain stuck there. Such appraisals of the situation in a lift when alone, may intensify anxiety gradually, with poor self-control.
The mindful exposure would consist of: 1) taking this person inside the lift; 2) making him mindful of the feelings of anxiety and thoughts that go inside the mind; 3) implementing strategies that help in reducing anxiety like breathing; and, 4) regulating movement of lifty using controls inside.
Mindful exposure is effective because: 1) it helps to manage the distress of negative emotions by simply attending to them as they arise and fall; 2) it helps to become curious and open to feelings thereby reducing discomfort and resistance due to them, leading to their acceptance and understanding their patterns; 3) giving time and space to self in order to get the opportunity in regulating the emotions all by oneself; 4) lessening the mental load of working with distressing cognitions and negative feelings during the feared situation; and, 5) developing self-control and self-confidence by knowing how to deal with the symptoms. Symptoms don’t remain alien anymore through mindfulness.
Mindfulness can help give time for the thoughts and feelings to arise and become ready to change them in order to reduce anxiety. Mindfulness prepares the mind to achieve safety and calmness inside one’s own body. This helps to develop self-control and increases regulation of feelings. Mindfulness has been shown to enhance emotional regulation and self-control by rewiring the neural connections in brain. All this is achieved by paying attention to thoughts and feelings.
Tarun Verma is a PhD student at the Department of Applied Psychology, South Campus, University of Delhi. He is conducting doctoral research on effects of alpha feedback training on emotional and neurocognitive functioning of poor children residing in slums of Delhi NCR areas. He is a practising clinical psychologist and is interested in investigating about neuropsychological correlates of mental health with socioeconomic status. He completed his MPhil from Amity University. You can connect with him on Twitter @Tarun_Psych