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Diagnosis & Treatment of Phobias with Cognitive Restructuring Interventions
Diagnosis & Treatment of Phobias with Cognitive Restructuring Interventions

Section 8
Cognitive Models for Panic Disorder with Agoraphobia

CEU Question 8 | CEU Test | Table of Contents | Phobias
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On the last track we finished our discussion regarding approaches to cognitive restructuring.  The focus on this track was on decatastrophizing.  First we discussed the technique of decatastrophizing and then we examined coping plans and a method for combining both decatastrophizing and coping plans called the point/counterpoint technique.

On this track we will discuss agoraphobia.  We will discuss the five principles of agoraphobia, indicative attitudes of agoraphobics, and how dependency leads to agoraphobia. 

#1  Five Principles of Agoraphobia
First, let’s discuss five principles of agoraphobia.  I find that clients entering an agoraphobic situation generally operate on these five principles. 
a. One of the first principles of agoraphobics is that they believe that an overwhelming disturbance can happen at any time. 
b. Second, they believe that there is nothing that can be done to ward off or mitigate that occurrence. 
c. Third, agoraphobics operate under the principle that if they have access to a helpful expert, such as a therapist, they can avert or redirect the dire consequences. 
d. A fourth principle under which agoraphobics operate is that any particular sensation may be a sign of the phobia. 
e. And finally, a fifth principle is that if the phobia is not stopped, it can lead to death. 

How might an understanding of these five principles of agoraphobia make treatment more productive?  Do any of these five principles apply to your client?

#2  Indicative Attitudes of Agoraphobics
Next, let’s look at some indicative attitudes of agoraphobics.  If you are treating a phobic client, this information may help you decide whether your client is suffering from a generalized social phobia or from agoraphobia.  You may find that agoraphobic tendencies are manifested by extreme scores on the following attitudes.  I find that agoraphobics generally believe that it is important to be free to get up and go whenever they want. 

You may hear an agoraphobic client say something similar to, "I feel confined when I have to sit through a long meeting!"  Or you may hear, "I get fidgety when sitting around talking and would prefer to get up and do something."  Also, agoraphobics prefer to make their own plans and will explain this as way to prevent being controlled by others.  Finally agoraphobics will express discomfort when they perceive people trying to direct their behaviors and activities.
There appear to be varying combinations of attitudes and traits that make clients vulnerable to agoraphobia.  Among these are an emphasis on self determination and a related hypersensitivity to control or interference.  Also, the agoraphobic may display a tendency to react to threat with weakness and a desire to flee.  Third, you may see in the agoraphobic a pattern of interpreting somatic symptoms as a sign of an immediate physical or psychological disruption.  Finally, have you found that the agoraphobic may have a strategy of depending on a caregiver for reassurance and medical assistance?

#3  How Dependency Leads to Agoraphobia
In addition to five principles of agoraphobia and indicative attitudes of agoraphobics, let’s discuss how dependency leads to agoraphobia.  The following case illustrates the lifelong pattern of separation fears and dependency that can develop into agoraphobia. 

Pam, age 26,
had always had problems being away from home. Pam stated, "I had trouble going to school when I was a kid.  And summer camp was always a horrible experience for me!"  Pam was always propped up by her mother who was very managerial, but at the same time indulgent and concerned about Pam’s welfare.  Pam’s mother had a high degree of hypochondriasis herself and intended to interpret any sign of disorder in Pam as a possible disease. 

Pam’s mother was prescribed a number of different medications.  Pam stated, "Whenever she thought I had a symptom of some weird disease, she’d give me some sort of pill that she had.  It got to the point where I started to think whatever she was giving me worked!" 

Thus Pam entered adult life with the belief that she was a frail individual and needed to be close to medical help at all times.  She also believed that she could only manage successfully if she had a strong person to lean on.  Pam managed to get along fine until her husband was called into the service.  At that point she got a job for the first time but experienced an enormous amount of fear and anxiety over her performance.  With the increase of anxiety, she experienced her first panic attack.  Pam stated, "From then on it just got harder to go to the office.  Finally, I just stopped leaving the house altogether." 

Think of your Pam.  Has dependency put your client into a position to develop agoraphobia?  What type of treatment plan do you currently have in place? 

On this track we discussed agoraphobia.  We will discuss the five principles of agoraphobia, indicative attitudes of agoraphobics, and how dependency leads to agoraphobia. 

On the next track we will discuss Interventions for Agoraphobia.  Interventions for agoraphobia include cognitive strategies, methods to choose acceptance, and action strategies. 

What Are Panic Disorder And Agoraphobia?

- What are Panic Disorder and Agoraphobia, Mental Health and Research, Education, and Clinical Center, Long Beach VA Healthcare System. Unit 6/116A. Long Beach, California.

Peer-Reviewed Journal Article Reference:
Chambless, D. L., Allred, K. M., Chen, F. F., McCarthy, K. S., Milrod, B., & Barber, J. P. (2017). Perceived criticism predicts outcome of psychotherapy for panic disorder: Replication and extension. Journal of Consulting and Clinical Psychology, 85(1), 37–44.

Chambless, D. L., Milrod, B., Porter, E., Gallop, R., McCarthy, K. S., Graf, E., Rudden, M., Sharpless, B. A., & Barber, J. P. (2017). Prediction and moderation of improvement in cognitive-behavioral and psychodynamic psychotherapy for panic disorder. Journal of Consulting and Clinical Psychology, 85(8), 803–813.

Hoffart, A. (2016). Cognitive models for panic disorder with agoraphobia: A study of disaggregated within-person effects. Journal of Consulting and Clinical Psychology, 84(9), 839–844.

Online Continuing Education QUESTION 8
What are the five principles of agoraphobia? To select and enter your answer go to CEU Test.

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