Many people were, and still are, being given a graded exposure program as treatment for their agoraphobia. Along with medication this may be the only other form of treatment people have received. Graded exposure does not cover the many strategies used in CBT and is simply exposure to situations and/ or places we avoid.

The question many people with panic disorder/agoraphobia ask is, ‘exposure to what’? Many graded exposure programs treat the avoidance behaviour in panic disorder as though it was the situation or place which triggered the attack. Much to their confusion, people who have panic disorders without any form of avoidance behaviour have been, or are given, a graded exposure program.

The rationale behind graded exposure programs is that when people put themselves into avoided situations/or places and stay in that situation or place, then the anxiety and/or panic attack will peak and slowly ebb away. In other words the person will habituate to the anxiety and panic attack in that situation or place. As many people say, even though the panic attack does subside, if they are not directly frightened of the situation/or place why would the anxiety ‘ebb away’ when it has never done so before.

Trying to correct avoidance behaviour without working on the cause means limited success, which can be destroyed by the next panic attack.

Most of these programs insist people stay in the situation or place until the anxiety and panic attack subsides and this is also one of the main complaints from people with panic disorder. It seems illogical to stay in a city mall (or any other place) for hours on end in an effort to reduce anxiety. Many are chronically anxious day-in, day-out, and are also experiencing ongoing panic attacks. As people say, if they were going to habituate to the anxiety and the panic attacks they would have already done so, irrespective of where they were.

To compound the issue and the confusion, many panic disorder clients are asked to list their secondary fears and a graded exposure program is built around them. In some cases the list of fears included specific fears which pre-dated the attacks and have no bearing on the disorder, yet they are incorporated or become the main feature of the exposure program. This little known but crucial fact has also been noted by researchers. One such study showed, ‘half the simple (specific) phobias in panic disorder had childhood onset and half had onset associated with the onset of panic disorder’ (Argyle et al. 1990).

The new categories of panic attacks demonstrate quite clearly the spontaneous panic attack is triggered by internal cues not external ones. In panic disorder, treatment needs to be aimed at these internal cues.


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