Report of a Clinical Case in Agoraphobia: The Challenge to Fly

This is a report of a clinical case in which the patient wishes to modify dysfunctional avoidance behavior, in order to be able to confront his fears of elevators, high places and planes. The presence of activator tasks between sessions as motivation for the final objective was of significant importance. Cognitive behavior therapy was used as base methodology. It was concluded that it is an effective and tangible treatment for the agoraphobic, providing assistance and bringing success and applicability in this case [1].


Introduction
This study has the objective of reporting a clinical case of cognitive behavior therapy, which is short term structured therapy, focused on the resolution of problems. According to Cognitive Behavior Therapy, the therapist teaches the client to respond to negative emotional states in an adaptive way. Clients frequently describe their bodily state corresponding to internal processes: "it is horrible to feel like this", or to suppression of behavior: "I literally paralyze myself".
It is the responsibility of the therapist to demonstrate the action of aversive events in the client's life and lead them to discriminate how such events acquire aversive functions. According to IDC-10 (WHO, 1993), the term agoraphobia refers to the fear of leaving the house, fear of public places, fear of crowds or the fear of travelling alone on trains, cars, buses or planes [2]. The lack of a way out or available help is a key aspect of the disorder. It is the most incapacitating of the phobic disorders, causing some patients to remain completely confined at home. In the absence of effective treatment, agoraphobia frequently becomes chronic.
According to Fyer & Coplan [3], the prevalence of agoraphobia in the general population during life is 2.5 to 6.5%. In clinical populations, agoraphobia is almost never seen without a concurrent history of panic attacks or panic disorder.

Formulation of the case
Brief case description: The patient is a 62 year old accountant who owns and runs a small accounting business. He likes having things under control and well defined. He reports a desire to travel by plane, which he has never managed to do due to fear. He is married to a patient wife who always provides assistance. They have two children that no longer live with them, as they live with their respective partners. Due to his age and having an easier schedule, he feels more necessity to break this barrier and be able to travel and know places he would no longer go to by car. It is important to emphasize that the supposed fear that he reports goes beyond the barrier of planes, also including fears such as elevators and high places [4].

Initial experiences:
The patient suffered a difficult childhood, with his parents working hard to pay for his studies, without the financial conditions to buy much beyond what was necessary to feed him and his brothers. When he was a child he had the desire to have a good job, a more comfortable home and to provide his future children with things that he was not able to receive from his parents.

Central beliefs
"I won't be able to stay there with the door closed." "I need to know how to get out."

Intermediate beliefs
"I won't feel well." "I won't have control." "I need to know how everything will be."

Strategies of the patient
He never takes the elevator alone or when it is very full, in which case he takes the stairs. When travelling by car he takes a route that avoids high places. In regard to airplanes he has no strategies and no excuses not to take a flight.

Behavior maintainer
As he always has to be in control of everything; the business, the family, himself; his maintainer is control; being aware of and understanding everything that is happening.

Event
The landmark event in relation to this case occurred in his adolescence at a football match at the Maracanã stadium, where, to maintain the groups of fans in order, the exits werelocked. He felt imprisoned, without a way out, becoming desperate and feeling awful. He remembers that since that day he has always worried about finding the exit, and about knowing that he could come and go. Recently he didn't feel well inside his car on the Rio-Niterói Bridge, experiencing various symptoms such as tachycardia and tensed muscles, which is when he realized that he really needed help [5].

Symptoms
Dry mouth, tachycardia, tingling, hot flushes, tensing of the muscles.

Automatic thoughts
"I have to take care of everything." "I mustn't be foolish."

Emotions
Sadness, fear, anguish and anxiety.

Behavior
Paralysis faced with what is desired; searches for a way to have more time so as not to resolve the situation (avoidance).

Consequence
Delay in seeking and accepting help Paralysis faced with what is desired; searches for a way to have more time so as not to resolve the situation (avoidance).

List of problems reported by the patient
I need to use the elevator without fear, as the office is on the tenth floor.
I really want to travel with my family without thinking that we are going to fall from high places, leaving them in a panic.
I would like to know a little of the world, as I have worked so much and have the financial resources to travel.

Strategies
As he does not know how to deal with these situations, he has resorted to psychotherapy on the recommendation of a close personal friend. Despite still disbelieving, he resolved to accept the recommendation and try this alternative to remove his discomfort. In the first session together we questioned alternatives, his thoughts and beliefs on how we might develop the treatment.

Text on the Case
The patient arrives with the complaint of not being able to take the elevator, problems driving through high places and having the desire but never having been able to travel by plane. He had already considered seeking psychological help, but had put it off as he thought it wasn't necessary and didn't think it would be of great value. After having a panic attack in the car while crossing the Rio-Niterói Bridge, tensing up his muscles and experiencing tachycardia and excessive sweating, remaining paralyzed and taking a long time to return to a relaxed state, he realized that he would need help. It was discussed in depth how much the patient desired to improve, what would change, what the gains would be, how affective he believed it would be and how dedicated he would be. Strategic planning for the treatment was then started, commencing with psycho education on what constitutes fear, phobia and panic attack, what cognitive behavior therapy is, and desensitization. It is worth emphasizing that he has a strong memory that all this began when he was at a football match in the Maracanã stadium and felt imprisoned and suffocated at not being able to exit the stadium. His profession is in the area of accountancy, working in a managerial role in an accountancy office. He often reports the anxiety in his thoughts: "I need to know I can get out". His principal symptoms are dry mouth, tachycardia, tingling sensation, hot flushes and tensing of the muscles. The exercises were the strong point of the case, given that they created a new perception on what he thought, reconstructing his belief in impossibility. The first step to be overcome was the elevator, which was upsetting him greatly as he had to take an elevator every day. Subsequently, we moved on to doing exercises for high places, before coming to underground trains, which were not the focus, but he hadn't used them for some years and they were good training for the airplane in terms of lack of control of the door and the opportunity to remain Global Journal of Intellectual & Developmental Disabilities seated and relaxed, gradually increasing the number of stations that the train passed.

Activities performed in the clinical case
All the activities carried out in the case, which were essential for the efficacy of the treatment, are listed below, and divided by cognitive technique and behavioral technique [6].

Results
With the use of desensitization and performance of the various activities described in the tables 1 & 2 above, a great improvement was perceived. The patient reported no longer having problems taking the elevator and that his discomfort with high places had been greatly reduced. Table 1 Cognitive Techniques

Confrontation card
My thoughts are worse than my reality. Objective: To create a positivity switch when faced with negative thoughts and fear.

Diaphragmatic breathing
Count 10 breaths every night before sleeping. Breathe in to the count of 2 / Breathe out to the count of 4. Objective: Relaxation, reducing anxiety and improving the quality of sleep.

Informative texts
Themes: Fear, anxiety, confrontation, quality of life, cognitive behavior therapy, phobia.

Motivational stories
The Story of the Elephant (on dysfunctional beliefs) The Story of the Gold Buddha (Self esteem, strong points) The Story of the Pearl (Adaptation, transformation)

Writing a letter to yourself
This exercise gives the patient the opportunity to write a letter is as if writing to himself, also providing the opportunity to read and listen to himself.

Giving Scores
The patient writes down all the signs and symptoms that he has felt or feels in a situation generating discomfort, focusing on situations related to the principal complaint. E.G: Sweating: 7/tachycardia: 8 Objective: To understand the intensity of the symptom.

Control and Unmanageability
On a sheet of paper there is a figure with various arrows around its body, with the theme of control. For each of these arrows the patient chooses things in life that are under his control. On another sheet of paper with the same figure, the arrows are to be completed with the theme of unmanageability, to describe things that are beyond the patient's control. Objective: To perceive that not everything can be controlled, and what we can do to relax when faced with something which cannot be controlled.

Choose something that you have already overcome
The patient is stimulated to remember something that has already been achieved in the past to serve as an example to himself. Besides being personal, the justification for having this as an example is that the best example is for the patient to perceive that he has already confronted an issue and will be capable of overcoming something again. (obs: It doesn't need to be anything big.) Objective: To generate self confidence.

Fear Questionnaire
Questions about what frightens the patient, fears from childhood and current fears.

Write a confrontation script giving scores
The patient writes what he usually does, step by step, as if he has just done it and gives a score for the level of anxiety each step would normally generate. Eg: Enter the building (5)/Call the elevator (7)/Enter the elevator (9)

Visualization Exercise
The patient imagines himself confronting his fears, visualizing himself in a situation which he wishes to confront. Eg: Fear of flying. "I am getting in the car to go to the airport, parking the car at the airport, going to check in, entering the departure lounge, ..."

Exercising Worry
Text on the difference between productive and unproductive worries. The patient then describes his productive and unproductive worries. Objective: Change the patient's perception when faced with worry, focusing on the involvement and strain of unnecessary thoughts and situations.

Advantages and Disadvantages
After dividing a sheet of paper in half, the patient writes the advantages of confrontation on one side and the disadvantages on the other. Objective: To fixate on the advantages so as to motivate and engage in the action.

Table 2
Behavioral Techniques

Body Relaxation
Sitting or lying in a comfortable position, the patient closes his eyes and imagines each part of the body from the feet to the head, fixating on each part, allowing it to become heavier and relaxed.

Training on the underground
The patient tries passing through as many stations as he can manage, slowly increasing the number of stations. Objective: To train for flight by not being able to open the door and not having control over the train.

Training on a viaduct
The patient is encouraged to pass over a viaduct several times each week. Objective: To gradually eliminate the discomfort that exists in being exposed to fear.

Trip to the airport
This exercise is aimed at giving the patient experience of the environment, knowing he is not going to travel by plane, but understanding how the place is and the choices to be made, working on the exercise of imagining how it would be to travel (sitting in the airport, the patient imagining himself entering the departure lounge, passing through the x-ray at security, entering the plane). Objective: To break the ice in regard to the patient's biggest challenge.

Physical exams
A request for the patient to see a doctor may not be seen as an exercise, but confronting the fear of having a problem and managing to overcome it is good training. This is an important detail for therapists, as it makes the patient more relaxed to know that nothing physical will cause them problems, or in the case that the patient does have some kind of problem, they will see how this new question can be reformulated.
In the second session after triage, Beck's Anxiety Inventory was applied, with a result equivalent to 60 points (demonstrating an extremely concerning level of anxiety). After twenty sessions the inventory was applied again, with a significant improvement, the result having been 15 points (demonstrating a low level of anxiety) [7].
The patient made his first short flight (Rio-São Paulo), together with his wife and in the company of the therapist, which involved a great deal of work and motivation. The therapy sessions were increased to twice weekly one month before the flight, in order to increase the patient's determination and confidence. On the day of the flight many techniques were used such as relaxation, positive thinking and occupying idle time. The trip was a great success with the patient remaining calm and relaxed until landing, full of joy and pride at having overcome something he had desired for over 50 years. A new target of repeating the flight without the therapist was established in order to continue this action of confrontation and desensitization.
Consequently, it can be concluded that the more opportunities the patient has to be in contact with that which he desires to confront, the lower his discomfort becomes, as a result this generates the security to repeat the action.
It can be observed that this demonstrates that reinforcing the confrontation behavior brings the security and confidence required to achieve the desired results, with the assistance of the techniques and the application of Beck's inventory [8].

Conclusion
It was concluded that the technique of systematic desensitization is effective, in both the applied activities and Beck's Anxiety Inventory, which reinforces that cognitive behavior therapy brings these techniques as a construct that assists in perception, motivation, attention and engagement of the patient in the treatment. It also reinforces the possibility of formulation of the case as a solid structure for therapeutic strategies and defined goals within an agreement framework with the patient. The case study presented here illustrates the typical behavior of a person who avoids situations which evoke unpleasant bodily sensations. The procedures used were effective in teaching the patient to reduce and manage such sensations.
The patient learned to discriminate his negative emotional states, as well as the detailed process of his own reaction when in these states. He also learned to reduce the associated physiological responses and commemorated each step that was accomplished, taking more and more control of his problems.