Agoraphobia is a disorder where an individual feels like they are trapped in a situation such as a closed or an open place (such as a market or a lift). There is a tendency for them to avoid such situations and therefore an agoraphobic individual restricts environmental exposure. For example, they will not go to market places, not drive to far off places from home, try to remain at home by not attending important social gatherings, or seek the company of some familiar person to remain safer.
There is always an anticipation in the mind of an agoraphobic that they might become anxious, beyond control, and may get trapped. The severity may become so high that a person may end up housebound, not leaving home for many days or even weeks or months. The fear is usually very general; that is, it may or may not be confined to a few selected places. Unlike specific phobias (like water, heights, snakes, etc.), agoraphobia is more global and ranges across different situations. Wherever there are is a chance 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. This is a behavioural therapy aimed at gradual in vivo exposure of the person to feared stimuli (within a therapy session, via the imagination) and leads to the cessation of fear responses. This technique has been quite often used for several decades. Gradual exposure in real life situations, beginning with less feared stimuli and aiming for more intense anxiety-provoking stimuli, is also employed with 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 anxiety, then we see that it lowers gradually in that situation. Fear is maintained by the avoidance of stimuli; therefore, exposure to these may help us to learn that there is no point in getting fearful, as the object or situation may not be that harmful as was once believed.
Many people are exposed to the same situation such as being in a lift or crowd, but they don’t become scared or experience panic. So the situation is not inherently harmful. Because of some initial fearful experiences with such stimuli, the brain learns to produce anxiety in the same way, again and again, to generate an avoidance behaviour. This pattern needs to be unlearned in order to face the situation once again without fear. Exposure helps in this unlearning.
Many people face problems in attaining the feeling of safety when in an exposure condition; it takes time to feel safer. The experience of encountering a greatly feared situation elicits anxiety and feelings of threat. Therefore, it is not easy for many individuals to practise exposure easily. There are many cognitive elements like beliefs, appraisals, and biases associated with avoidant behaviours that sustain these. Therefore, accepting the treatment becomes difficult. Moreover, a phobic person pays attention to feared stimuli so much that it becomes difficult for them to stop their mind from focusing on these. This signals to the brain that a threat is present in the environment. Therefore, the fear response in their body and behaviour is elicited and maintained, unless something is done to interfere with this signalling.
A modern approach that helps the individual to overcome their fears is mindfulness. Mindfulness means attending to your thoughts, feelings, and bodily sensations in a way that is non-judgemental and neutral. This makes it easier to manage them.
A number of research studies have shown that mindfulness activates the 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 the acceptance of symptoms during exposure to the feared stimuli. It enables the person to accept the situation, by not avoiding it, and to gradually deal with the symptoms as they arise, one by one. This helps a phobic person to deal with the situation.
Suppose a phobic person is in a lift, all alone. They will experience an intense feeling of discomfort and anxiety. This person may feel they would not be able to escape the lift, as they are sure it may get stuck or break down. They have thoughts that no one would hear their cry and they would remain there unable to get out. Such interpretations of this situation may intensify anxiety gradually in a person with poor self-control.
Mindful exposure would consist of:
- taking this person inside a lift
- making them mindful of the feelings of anxiety and thoughts that go on inside their mind
- implementing strategies that help in reducing anxiety like breathing
- regulating movement of the lift using its controls inside.
Mindful exposure is effective because:
- it helps to manage the distress of negative emotions by simply attending to them as they rise and fall
- it helps to become curious and open to feelings thereby reducing discomfort and resistance to them, leading to their acceptance and understanding of their patterns
- it gives time and space to the self in order to get the opportunity to regulate emotions all by oneself
- it lessens the mental load of working with distressing cognitions and negative feelings during the feared situation
- it develops self-control and self-confidence by knowing how to deal with the symptoms. Symptoms don’t remain alien any more through mindfulness.
Mindfulness can help to give time for thoughts and feelings to arise and help one to 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 the brain. All this is achieved by paying attention to thoughts and feelings.
Tarun Verma is a PhD student at the 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.