Agoraphobia; Imprisoned By Fear

One of the most debilitating mental illnesses is agoraphobia.  Agora from Greek means “marketplace”, which is somewhat misleading as it more a phobia of being in any place, where people are congregated and other places as well!

This is not the same as social phobia, which is entirely different.

All agoraphobics have extremely high levels of anxiety, and panic that controls their life, but not all panic disorder patients have agoraphobia.

When panic attacks happen to them in these places, they become sensitized.  By that I mean they start to associate that particular place as being fearful and causing panic.

They will then start to avoid every place where they experienced extreme anxiety or panic.  The two key words essential in diagnosing are avoidance due to fear of having a panic attack.

Panic attacks are overwhelming feelings of terror that include physical manifestations of anxiety.

• Trembling or shaking
• racing pulse
• palpitations or chest pain
• shortness of breath
• tightness in the chest
• hot and cold chills
• hyperventilation
• dizziness and light-headedness
• feelings of going to faint
• feelings of choking
• tingling or numbness
• nausea
• sweats
• jelly legs(feelings that your legs are going to give out)
• early morning awakings with anxiety/panic
• feelings of losing control
• feelings of going crazy
• the feeling of being unreal or detached

Avoidance usually includes supermarkets, restaurants, classrooms, department stores, concerts, movie theaters and shopping malls.

Basically, it is just about everywhere that there are crowds of people indoors or out.  The avoidance often extends to other surprising places and driving.

Most of my agoraphobic patients were not able to drive very far from their home, if they could drive at all.

Those that could drive, usually had a short routine route they could manage, but would consistently avoid bridges, and overpasses.

They usually had to have someone with them in order to drive at all.  Many were panicky about standing in line in stores, even if they could go inside.

Elevators, escalators, and varying modes of transportation such as buses, trains, and planes are also avoided.

Even if you can get them to go anyplace, they are constantly searching for an exit, and prefer to be against a wall, and near the door if seated in a restaurant.

Fears of not being able to escape if they have a panic attack are foremost in their minds.

As the illness progresses,  due to experiencing more anxiety and panic attacks, the world of the agoraphobic grows smaller.

Some of the more disabled become unable to even leave their home.  Walking to the mailbox is a fearful chore, or even going outside in their yard.

They literally become prisoners within their home.  Not surprisingly, these patients become very depressed and the risk of suicide mounts if left untreated.

Even with the confines of their homes, they can develop avoidance to certain rooms, and may only feel safe in bed.

Because of their fears, they can become unable to work or go to school. These limitations interfere with parenting chores as they are unable to take children to school or activities.

This crippling illness puts tremendous stress on familial relationships.  All agoraphobic patients I have treated have had severe dependencies on a spouse or family member.

Most will feel anxious being alone, and only feel truly safe in the presence of whomever they have this dependency.

As with most anxiety disorders, there is more prevalence in women.  The average onset is in late teens to mid-twenties.

Higher levels of anxiety and or panic are usually exacerbated premenstrualy.    Agoraphobia and panic disorders have a tendency to run in families, as most other anxiety disorders.

Strangely, the vast majority of my agoraphobic patients were extroverted with zero social anxiety, that is; if you could only get them out.

You must remember they do not avoid because of people, just fear of places where they had panic.  All of my agoraphobic patients were very warm individuals who actually loved being with others.

I remember one who had a very difficult time getting to the casino, which I had assigned as homework, but once there became the room flirt and even picked up a date!

Treatment is difficult in the beginning until you are able to turn down the fire of anxiety and panic.

Using medications in the benzodiazepine family initially, and antidepressants with anti-anxiety/panic properties,  such as Paroxetine(Paxil), or Escitalopram(Lexapro).

It is imperative to eliminate all caffeine, from coffee and sodas, as any stimulant can increase anxiety. Herbal teas such as hops, valerian root, and passion flower helped some.

Using meditation and relaxation tapes I find helpful too.  These can help in preventing or reducing anticipatory anxiety, which is quite prevalent in these patients.                                                                                                                              Once the anxiety is under control, systematic desensitization is very helpful.  Basically, it is asking patients to take baby steps toward restoring whatever activity or places avoided.

An example would be to slowly increase by increments walking or driving distance from their house each time.

To practice going to places that they had avoided in the past, which generally requires doing so with someone else.

They have to feel safe again to regain activities loss due to fear.  It is slow and tedious work not only for the patient but the therapist too.

It requires a lot of courage of the patient’s part and willingness to risk having a panic attack.

At times I have accompanied patients to give them a boost of security and confidence.   I find this effective, especially at the beginning of treatment.

If they can accomplish the feared behavior with someone they trust, then they are encouraged to do it again by themselves.

  Cognitive behavior therapy involves mostly learning NOT to resist fear or panic, and how to deal with any panic that does occur.

The more someone tries to resist any feeling state, the more the feeling builds up.  Beter to accept it as part of the disease process and know that it will pass.

Though panic attacks are very frightening, they have a peak then will diminish in intensity.

Although their fear may be perceived as insane, these patients are not remotely psychotic, and cannot go “crazy”.

Almost all describe the feeling of being overwhelmed with a tremendous sense of doom with a need to escape.

Just knowing that these symptoms stem from a panic disorder, provides some relief in itself for most of them.

I have had some patients break out in tears after explaining what they have since many were convinced that they were “going insane”.

No one has ever died from panic, though these type of patients often show up in the ER thinking they are having a heart attack.

Some are also body scanners, and often run to doctors with every little ache or pain.

They have a tendency to catastrophe everything and are often preoccupied with dying.

Treatment is long and frustrating and can entail setbacks.  Most patients can regain the majority of activities once avoided, but it must be reinforced continuously.

I find them very courageous to live their lives, despite their anxiety and fears.  Their triumphs in therapy are monumental and well deserving of praise!