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THE TREATMENT OF AGORAPHOBIA.
Beginning in the 1960s a variety of behavioral treatments for agoraphobia were investigated including systematic desensitization, and imaginal flooding, in addition to prolonged in vivo exposure.
Of these, in vivo exposure is clearly superior. Systematic desensitization, developed by Wolpe
(1958), involves having the patient construct a hierarchy of fear-inducing situations that are then recalled during deep muscle relaxation.
The rationale for the procedure is that deep muscle relaxation is incompatible with anxiety and will inhibit anxious arousal in the feared situation.
In imaginal flooding, the therapist describes in vivid detail a fear-evoking situation, thereby exposing the
patient to increased anxiety.
In vivo exposure, of course, involves actual contact with a situation feared by the patient.
In each of the behavioral procedures, the individual is exposed to fearprovoking situations; what distinguishes them is the mode of presentation.
Systematic desensitization and imaginal exposure involve exposure in imagination, while in vivo exposure calls for direct contact with the fear-evoking situation.
Studies that investigated the relative efficacy of the imaginal procedures have indicated an advantage for imaginal flooding over desensitization in some cases (Boulougouris, Marks, & Marset, 1971), and in
others an equivalence between the two (Crowe et al., 1972; Mathews et al., 1974). However, when imaginal procedures were contrasted with in vivo exposure, a consistent advantage was demonstrated for the latter (Emmelkamp & Wessels, 1975; Mathews et al., 1976; Stern & Marks, 1973; Watson, Mullett, &
Pillay, 1973).
Numerous parameters of in vivo exposure have been investigated. Group exposure appears to be as effective as individual treatment; social cohesion seems to enhance the immediate effects of group exposure, but evidence supporting its ability to promote better long-term results
is inconsistent; self-directed exposure, which is characterized by less intensive therapist involvement, has produced excellent results, as has self-directed home-based spouse-assisted treatment; additional studies have suggested that including spouses in treatment may provide some particular advantage among patients in problematic marriages, and that communication training between couples may enhance the effects of exposure therapy.
Despite consistent demonstrations of the effectiveness of in vivo exposure for agoraphobia, it has important limitations.
While many who undergo such treatment achieve significant decrements in symp- tomotalogy, others fail to make gains considered clinically significant.
Barlow et al. (1984) have estimated that 30 percent of those who undergo in vivo exposure therapy for agoraphobia become treatment failures. In one long-term follow-up study involving 56 agoraphobics who improved following treatment, 61 percent of whom underwent in vivo exposure therapy, only 18 percent reported themselves symptom-free four years later.
One must also consider dropouts from treatment.
Mavissakalian and Barlow (1981) have noted dropouts rates between 8 and 40 percent, with a median of 22 percent Recent efforts to obtain better outcome results with agoraphobics have been geared toward enhancing exposure therapy by incorporating additional treatment strategies, particularly pharmacotherapy, but also cognitive therapy.
