View Full Version : Is Agoraphobia a neglected research topic

10-19-2007, 12:42 AM
The term agoraphobia is derived from two Greek words: agom, meaning marketplace or place of assembly, and phobos, meaning terror or flights. Robert
Burton, the British scholar and writer, first described agoraphobia’s symptoms
in his 1621 work, The Anatomy of Melancholy .It wasn’t unti 1871, however,
that C. Westphal coined the term to describe several of his patients who experienced severe anxiety when walking through streets or squares. According to historical accounts, recounted by Isaac M. Marks, Maudsley Hospital, London, in his book Fears and Phobias,7.The French mathematician Blaise Pascal suffered from agoraphobia, as did the Italian writer Alessandro Manzoni. Manzoni, in fact, carried a bottle of concentrated vinegar with him whenever he left home so that he could revive himself if he felt faint.

(1984 research)
Diane L. Chambless,
Department of Psychiatry, American University, Washington, DC, writes that
the primary symptom of agoraphobia is a fear of being away from home, or in any public place from which escape is viewed as difficult. To an agoraphobic, escape can be “blockedâ€￾ by physical constraints such as those imposed by crowds, or by social constraints that call for highly ritualized, regimented behavior. For instance, acting as a bridesmaid or being the “mother of the brideâ€￾ would make many agoraphobias very anxious.
Agoraphobias need to feel that they can escape from any situation readily, because for many, panic attacks can strike anytime. During a panic attack, agoraphobias feel dizzy, nauseous, weak in the limbs, and short of breath.g Throughout these attacks, agoraphobias may worry that their pounding heart or dizziness will cause them irreparable harm. Typical thoughts include, “I am going crazy, â€￾ or “I am having a heart attack (or stroke).
Agoraphobias, therefore, often find that home is the only place where they feel safe, since even if an attack strikes there it will go unobserved, sparing them public embarrassment. Consequently, although their symptoms may wax and wane, some agoraphobias are housebound for years, sometimes for their entire lives. Obviously, this prevents them from working or maintaining a normal life.
here are several theories regarding the etiology of agoraphobia. One prominent view is supported by Weekes, Chambless, and Alan J. Goldstein, Department of Psychiatry, Temple University Medical School, Philadelphia. They
believe that stress precipitates the first panic attack. Events which can trigger an attack include the death of a loved one, a miscarriage, or a divorce. Even happy events such as childbirth or marriage can elicit an attack, since they can also promote stress.
For years, the etiology of agoraphobia was described in terms of psychoanalytic theory, as Wallace H. Vale and Sylvester R. Mlott, Department of Psychiatry, Medical University of South Carolina, Charleston, note in their review of agoraphobia. This rests upon the premise that earlier, usuafly infantile, traumas account for adult neuroses. In his review of psychoanalytic theories, John Bowlby, Tavistock Clinic, London, noted that some adherents of a psychoanalytic viewpoint believed that an agoraphobic’s fear of leaving home indicated a need to return to the security provided by one’s parents. Freud, on the other hand, believed that agoraphobia, like all phobias, was part of an “anxiety neurosisâ€￾ and had a sexual origin. However, such psychoanalytic theories lack empirical support.
Many behavioral scientists now use one of several etiological models to explain the onset of the disease. Some view impulses across nerve synapses. Indeed, certain drugs such as imipramine and phenelzine, which decrease norepinephrine production, also block panic attacks.
Although these drugs have complex effects, in their review of the literature, Dennis S. Charney, Yale University School of Medicine, and colleagues report some scientists believe that their antipanic effects maybe due to their effect on norepinephrine.
As with other psychiatric illnesses, there may be a genetic basis for agoraphobia. Several studies found a higher incidence of phobias among family members than among the general public.
In a study by R.C. Bowen and J. Kohout, Department of Psychiatry, University of Saskatchewan, Saskatoon, Canada, 84 percent of the agoraphobias questioned could identify a close relative who suffered from an emotional disorder.zT Moreover, a study by Gregory Carey, University of Minnesota, Minneapolis, found that agoraphobia was more prevalent among identical twins than among fraternal twins.
For agoraphobia to be effectively treated it must, of course, be accurately diagnosed. But this can take years. Seventy percent of the agoraphobias participating in a study by David V. Sheehan,
Department of Psychiatry, Massachusetts General Hospital, Boston, and colleagues
reported seeing ten or more physicians before a correct diagnosis was made.
Typically, agoraphobias first approach their family physician after experiencing one or more panic attacks. Often, physicians focus on the physiological components such as the patient’s
pounding heart or dizziness. They may then prescribe diazepam (Valium) or another antianxiety agent. In fact, a nationwide survey of agoraphobias by E.H. Uhlenhuth, Department of Psychiatry, University of Chicago, Illinois, and colleagues found that a full 55 percent had used an antianxiety agent.~ Ninetyeight percent of the patients participating
in the Sheehan study said that they had been treated with what were often very high doses of tranquilizers for up to 15 years.zg Whether these agents actually reduce panic attacks is still under debate. While the prevailing opinion has been that these agents are ineffective
against panic attacks.

10-19-2007, 01:03 AM
Up until the early 1960s, psychiatrists
usually treated agoraphobias with psychotherapy.
This is not surprising considering
psychotherapy’s popularity at
the time, and the paucity of other available
treatments. Chambless and Goldstein,
however, believe that psychotherapy
by itself is impotent against agoraphobia.
g By the way, they are the editors
of Agoraphobia: Multiple Perspectives
on Theory and Treatment, a comprehensive
overview of agoraphobia which
was used heavily in preparing this essay.
In the mid- 1960s, some therapists
began treating agoraphobia with systematic
desensitization which, as Matig
Mavissakalian, Western Psychiatric Institute
and Clinic, and University of
Pittsburgh School of Medicine, Pennsylvania,
and David H. Barlow, Department
of Psychology, State University of
New York, Albany, note in their review
of phobias, was then being used to successfully
treat many other phobias.
Systematic desensitization involves exposing
the phobic to the objects or
places feared after relaxation exercises
are mastered. The exposure is graduated.
In several steps, a snake phobic, for
example, would progress from just viewing
a picture of a snake, to actually
handling one. In their review of agoraphobia,
however, Jansson and Ost cite
studies indicating that systematic desensitization
is not effective in treating
agoraphobia, probably because it does
not allow the patient to experience anxiety
in the phobic situation. Although
following systematic desensitization
agoraphobias may think they are cured,
panic attacks usually recur.
The primary behavioral treatment
now used is exposure therapy, of which
there are two types: imaginal exposure
and exposure in vivo. During imaginal
exposure, the therapist describes in detail
situations that the patient previously
stated were fearful. When this is done
gradually, following relaxation exercises,
the therapy closely approximates
systematic densensitization. Imaginal
exposure, however, can also be conducted
rapidly, in which case the therapist
forces the patient to visualize the
fearful situation until reported anxiety
decreases. Rapid exposure is sometimes
called “flooding.â€￾
ln vivo exposure, on the other hand,
involves real-life practice. The agoraphobic
actually enters the dreaded situations.
As with imaginal exposure, in vivo
exposure can be conducted either gradually
or rapidly.
Exposure methods are not only effective,
they work quickly and patients can
learn them easily. A homebound person
treated by exposure maybe able to enter
a local shop on the first session, a suburban
shopping center during the second,
and center city on the third. And, in a
study of agoraphobias treated by exposure,
Paul M.G. Emmelkamp, Academic
Hospital, Department of Clinical
Psychology, Groningen, the Netherlands,
found that once improvements
are made, they last. Relapses are rare.
Emmelkamp also found that four years
after in vivo exposure, patients remained
For financial reasons, therapists often
administer exposure therapy to a group
of patients rather than to individuals.
Group therapy also gives agoraphobias
the chance to meet each other, and thus
learn that their affliction is not unique.
As with Alcoholics Anonymous, they
can share coping methods, and form
close friendships which they so desperately
Not all agoraphobias can be treated
with exposure therapy. In vivo therapy,
in particular, can be very hard on some
patients, especially men. A study by
R. Julian Hafner, Flinders Medical Centre,
Australia, found that of 18 male patients
offered graded exposure in viuo,
44 percent refused or dropped out prematurely.
Only 12 percent of the women
subjects refused or terminated treatment
prematurely. The study also
found, however, that those men who did
follow through with the treatment benefited
from it as much as the women.
Overall, 60 to 70 percent of patients
who undergo exposure therapy improve.
It is likely that as a result of a
therapeutic regimen based on exposure
therapy, a patient will be able to lead a
life relatively free of panic attacks. Occasionally,
however, he or she will probably
still be troubled by some of agoraphobia’s
symptoms. In fact, residual disability
is the norm.
Drug therapy is the other major treatment
that clinicians use. The successful
use of drugs to treat agoraphobia was
first reported in a 1962 paper by Donald
F. Klein, US Public Health Service, and
Max Fink, Hillside Hospital, Glen Oaks,
New York .39 Between October 1958 and
July 1961, Klein and Fink treated 125
agoraphobias with imipramine, a tricyclic
antidepressant. They found that the
drug effectively eliminated the panic attacks
associated with the disorder.
Since that time, Klein, Sheehan, and
others have found that two classes of antidepressants
are effective against the
panic attacks associated with agoraphobia:
the tricyclic antidepressants and
the monoamine-oxidase (MAO) inhibitors.
Imipramine remains the most
commonly used tricyclic, and is usually
prescribed first. If imipramine should
fail, psychiatrists may prescribe phenelzine,
the most commonly used MAO inhibitor.
According to Robert Pohl, Department
of Psychiatry, Wayne State
University, Detroit, Michigan, and colleagues,
imipramine is usually tried first
because it does not place the harsh
restrictions on one’s diet that phenelzine
does.ql Patients taking MAO inhibitors
can experience severe and even lethal
high blood pressure if they eat foods
containing the amino acid tyramine. Examples
of such foods are pickled herring,
aged cheese, chicken liver, and
certain wines.
Antidepressants do not work immediately.
It may take up to six weeks of
treatment before their effectiveness is
apparent . After attacks are relieved,
therapists usually continue treatment for
six months. Although at that point the
patient may be free of panic attacks, it’s
likely that eventually they will recur. Renewed
treatment, however, will once
again halt the attacks.
The existence of IWBIOMEDW research
frent #82-3495, “Clonidine and
imipramine and tricyclic antidepressant
clinical psychotherapeutic drugs for
treating depression, agoraphobia, and
panic attacks, is evidence of the current
interest in using drug therapy to treat
agoraphobia and other affective disorders.
Two core papers are associated
with this front: Treatment of agoraphobia
with group exposure in vivo and
imipramine, by Klein, Charlotte M.
Zitrin, and Margaret G. Woemer, Long
Island Jewish-Hillside Medical Center,
Glen Oaks, New York, and “Treatment
of endogenous anxiety with phobic, hysterical,
and hypochondriacal symptoms,â€￾
by Sheehan, James Ballenger,
University of Virginia School of Medicine,
Charlottesville, and Gary
Jacobsen, Westwood Lodge Hospital,
Westwood, Massachusetts. To date,
over 50 publications have cited one or
both of these papers, which were
published in 1980 in the same issue of
Archives of Genemi Psychiatry. The
first paper gives the results of a doubleblind
study that compared the effectiveness
of group exposure in vivo, combined
with the use of either imipramine
or a placebo. The study found that while
a majority of patients in both groups
showed at least moderate improvement,
imipramine-treated patients fared better
than placebo-treated patients. In the
study reported in the second paper, in
addition to a placebo and imipramine
group, a third group received the MAO
inhibitor phenelzine sulfate. Patients assigned
to the imipramine and phenelzine
groups improved much more than
the patients in the placebo group. In
addition, phenelzine-treated patients
showed more improvement than the
imipramine-treated patients.
Given these results, it’s not surprising
that Klein and several other researchers
enthusiastically recommend the use of
antidepressants for agoraphobia. In addition
to the studies described here, they
cite others that show these drugs often
block panic attacks, and that 70 percent
of the patients treated improve to some
Although these results are encouraging,
there are many critics of drug therapy.
Imipramine, for example, can have
side effects. Even small doses of the drug
can produce insomnia, jitteriness, irritability,
and palpitations, and will exacerbate
panic attacks in one in five agoraphobics.
s Although in such cases other
drugs can be used,ds many agoraphobias
refuse to use these drugs at all.
Chambless and Goldstein have reported
that over 25 percent of their agoraphobic
patients refuse to take imipramine
“because of hypochondriacal concerns,
fears of drug-induced discontrol,
or adverse reactions to previous drugs.
Moreover, they report that most of the
remaining 75 percent of their patients
are afraid or otherwise hesitant to use
the medication. One patient had a fullblown
panic attack on the first two
nights when it was time for her to take
the medication.
In their review of the literature,
Michael J. Telch, Blake H. Tearnan, and
C. Barr Taylor, Stanford University
School of Medicine, California, found
that of those who do go through with
drug therapy, 35 to 40 percent drop
out. This compares to a drop out rate
of about ten percent for drug-free behavioral
treatments. Also, the relapse
rate following discontinuation of drugs is
much higher than for exposure therapy.
They found that between 27 and 50 percent
of patients who improve after drug
therapy relapse after withdrawal.
Current therapeutic regimens often
comprise elements of both drug and behavior
therapy, which seems to reflect a
coming together of the two camps. In
fact, S. Rovner for the Washington Post
described a May 1983 meeting on phobia
treatments held in White Plains, New
York, as “a veritable love feast between
the behaviorists and medical model proponents.
Many behaviorists, however,
still use drugs only for particularly
stubborn cases, or for patients who don’t
wish to take part in behavior therapy.
Goldstein has written that the great majority
of his patients “cease having panic
attacks without the use of medication.
On the other hand, some drug
proponents such as Klein and Michael
R. Liebowitz, Department of Psychiatry,
Cohsmbia University, New York,
will only use behavior therapy by itself
when patients are no longer experiencing
spontaneous panic attacks.
While most psychiatrists treat agoraphobias
with either drug or behavioral
therapy or a combination of both, some
recommend a self-help program of treatment.
Such programs have appeal because
they greatly reduce the need for a
therapist’s costly time. One of the bestknown
proponents of self-help therapy
for agoraphobias is Weekes. Between
1966 and 1974, Weekes treated 2,000
agoraphobias through “remote direction.
This is basically exposure therapy.
But instead of personally accompanying
patients when they leave home,
Weekes encourages them by telephone
to conduct the exposure sessions on
their own. Then, throughout the therapy
program, patients periodically call in to
report on their progress. Weekes’s patients
can also receive instruction
through her three books, a record
album, cassettes, and a quarterly magazine.

Recently, Arthur E. Holden, Center
for Stress and Anxiety Disorders, State
University of New York, Albany, and
colleagues have criticized self-help strategies
for agoraphobia. They found that
subjects in a self-help program consisting
of in vivo therapy did not perform
the practice required by the manual
given them. They also criticized
Weekes’s claims that her strategies were
inffective since she used questionnaires
to assess effectiveness and her improvement
criteria were not made clear.
Through drug and behavior therapy,
therapists can now control the most severe
symptoms of the disease. But few
scientists currently feel the disorder can
be cured. Agoraphobias can be brought
to the point where they are “in control, â€￾
but remnants of the disorder commonly
If scientists are to improve on this success
rate, they must find new drugs that
do not present imipramine’s side effects.
One promising drug which is receiving
increasing attention in the literature is
alprazolam (marketed by Upjohn Company
under the trade name Xanax). According
to Guy Chouinard, Department
of Psychiatry, McGill University, Montreal,
Canada, and colleagues, alprazo-
am seems to be effective against panic
attacks. s Moreover, alprazolam does
not seem to cause the side effects associated
with antidepressants although, like
other benzodiazepines, it may induce
But therapists may also have to view
agoraphobia in a larger context. Previously,
most therapists did not consider
the effect family members might have. A
number of researchers have found that
family members can help agoraphobias.
But in other cases, the spouse can severely
impede progress.
Frank Milton, Kenley Ward Kingston
Hospital, Kingston-on-Thames, Surrey,
England, and Hafner, then at St.
George’s Hospital Medical School, London,
studied 15 agoraphobias. They
found that in nine cases, when symptoms
improved, marriages deteriorated,
In a study of 25 patients, Chambless
and Goldstein found that only
those that divorced their spouses remained
improved. However, a former
agoraphobic, Ruth Mass, Miami, Florida,
has formed several self-help groups
for agoraphobias. Out of 50 members,
only one out of six married patients divorced
after treatment.
Part of the problem may be that
agoraphobias often choose mates that
they know will care for them as a parent
would. Subsequently, a symbiotic relationship
can form where the spouse
needs the agoraphobic as much as the
agoraphobic needs the spouse. In one
case, the husband of an agoraphobic developed
a paranoid psychosis one month
after the successful treatment of his
wife. He recovered shortly after his wife
resumed her agoraphobic ways.
Other family members can also hamper
the agoraphobic’s progress by over protection.
They may insist on accompanying
the agoraphobic on forays outside
the “c***le of safety,â€￾ thus keeping
the patient from coming to terms with
the disorder. To prevent such problems,
Hafner recommends that members of an
agoraphobic’s immediate family also
undergo treatment. This therapy should
include education as to the nature of
agoraphobia, advice on dealing with the
effect the disorder has on family life, and
help in coping with the changes that will
occur after the agoraphobic’s symptoms

10-19-2007, 01:04 AM
Neuroscientists are finding that biological factors, such as greater blood flow and metabolism in the right side of the brain than in the left hemisphere, may also be involved in phobias. Identical twins reared apart sometimes develop the same phobias; one pair independently becoming claustrophobic, for example (Eckert, Heston, & Bouchard, 1981).

I guess my point is that its now 2007 and they are still using treatments from the 60's and 70's. One would think by now someone would have figured out a better method, not another med.
Man Im reading and viewing (online psyc seminars) to much psyc stuff. LOL

10-19-2007, 07:01 AM

took me 5 times to read all this :blink: :lol:

very intersting and i say if they aint cracked it since 1671 you may in 2007

at the rate yer going on Line :lol:

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yas know's in all serious i thank you fer all the info yer great :)
neglegtad or just blind to it?well 1 day hope fully they will figure it out.

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10-19-2007, 12:39 PM
First of great to se you back on the forum , i will read through your post tomorrow as i have either a sinus infection or im about to croak cos my bloody eyesights all blurry :rolleyes: :rolleyes:

I hope your doing well and still look like bon jovi lol :lol: :lol:
love Dino


10-19-2007, 01:23 PM

I am gonna take this to my DR, he want's me Back on an MAO (Moclobemide)
ive tryed nardil ive tryed amitrpilin added way more SSRIS every one of them :blink: .

and still want's me on xanax and clonazapam, makes me wounder as it's so clear to see since 60 to 70 it's back at the old meds and i just don't understand.
i don't fear taking the med's as i did younger, just hate going back forth on
all the med's, ill hope for a better out come from my dr once he read's this :)
and thxs for alway's just being around, and the info.
and as Dino pointed out GREAT to see you on the fourm.

Get yer but back in chat to MR ahaha , o yas know's i adore you. ;)

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10-20-2007, 05:48 AM
Nice post, i only managed to skim it as iv read so much today my eyes are blurry and strained now. Id actually like to see more research done on it integrating the body as a whole system. Id like to see more about the effects of metabolism- as mentioned and liver function and digestion and nerve nourishment also unresolved emotional issues and colon and gut health. I do alot of alternative research and see many many links with this. Alot of orthodox psychologists and doctors are realising the links between physical and psychological/emotional disorders and overall health, particularly of gut and digestive health and i think there is so much to be learned there. Id much rather see reasearch into this and correcting and balancing the body to restore its own systems rather than research into more drug therapy. But yes i think its so unfortunate that all of us who suffer this are left with such inadeqate treatment and understanding on it from a medical point of view.

10-21-2007, 04:32 PM
I am sure there is an enzyme link link somewhere but who knows where to look. Why I say this is because eventhough we might be all the same in a medical sence (organs) everyones bodily functions are diferent in one extent or another. One way I look at it where does the body throw the stress enzymes. Some people it goes to the intestional track where as others it might goto the brain (headaches) or muscles.

10-21-2007, 05:09 PM

thats quite a post you did there. fair dues!I was extremely agoraphobic until quite recently.I came across a highly trained Thought Field Therapist (TFT) from Wales that specialises in panic/agoraphobia.I dont know if you have come across TFT?its fantastic when done properly.

10-21-2007, 05:53 PM
Yes Bet, im doing EFT which is pretty much a drummed down more version of TFT, I think its brilliant, its amazing what memories you store that still act as hooks and blockages. It actually comes from ancient philosophies thousands of years old, ive given up on conventional medicine as they dont seem to know **** about how the body works on a whole, they may be good for patching you up in dire c***umstances but in terms of maintaining good health they are hopeless. Youve only got to look at what they serve as food in the hospital to know they are truly missing the point!!! I see on the news the other night the local hospital doing a sausage sizzle and serving cake with all its multi coloured frosting and sugar and junk, makes me throw my hands up in the air in a huff lmao.

About that enzymes link... there are several good books, 'gut and psychology syndrome' 'body ecology diet' 'liver cleansing diet' etc, each individuals symptoms might vary a little but they all pretty much follow a set pattern, some may develop leaky gut, some ibs, etc but at the end of the day its all very similar.