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Agoraphobia,
or the fear of experiencing fear, and panic attacks.
Normally,
that cognitive change arises from the first panic attack, or some episode of
intense fear in those people who suffer agoraphobia even without having suffered
a panic attack. This leads those who suffer agoraphobia to avoid all types of
places or situations which can cause them the sensations they fear, due to the
fear of losing control and suffering a panic attack, or to die imminently when
experiencing them, or to lose control and go crazy or to commit
some kind of mad act. That
terrifying experience, the panic attack, remains printed in the memory of those
who suffer it, beginning a whole process of cognitive changes aimed to avoid a
similar experience from happening again. The individual moves on to a general
state of alert in which his attention is always vigilant to the possible
appearance of some symptom that could reveal the risk of that attack being
reproduced. This happens because while experiencing a panic attack the
individual feels in all of his being, in an intense manner, that the danger of
death or insanity is imminent. That sensation, manifested by the set of
sensations one experiences, is accompanied by a strong conviction about the
fatality of the event. So, the affected person will try thereafter to avoid all
types of places and situations in which he considers to be at risk of suffering
those sensations he fears. These sensations are characteristic to a state of
high anxiety, such as palpitations, sweating, sensation of lack of air, nausea
and sensation of anguish, sensation of dizziness, neck pain, sensation of
tingling or numbness of legs and arms, pain in the chest, ringing in the ears,
etc. Not everybody who suffers panic attacks experiences all these sensations,
instead, these vary in number and type amongst different people, and in some
cases others are added which are different. Due to the complexity of
illustrating this disorder adequately I will use the story of a supposed
experience as an example. Maria, a
20 year old who liked to have fun with her friends and enjoy life, was
"sensation down" emotionally speaking. A series of events in her life
at the time made her more nervous and uneasy than was usual for her. One
day one of her friends told her about a fatality a relative of this friend of
hers had suffered: The aunt of this friend, who was young and apparently
enjoying good health, had suffered a heart attack and the doctors could not do
anything to save her. According to some accounts, she suddenly felt discomfort
in her chest, turned pale and passed out, never to be awaken. She was
very shocked by that story, because she knew the deceased and, certainly, she
seemed to be full of vitality. She suddenly understood that she also could die
in a similar way, and that put her on alert, although she was not very conscious
of the repercussion that fear could have on her. One
Saturday she went out to have fun with her friends, as was usual. They had some
drinks (I do not know if they took something more than alcohol, because she
never told me) and they began to dance. Suddenly, in the heat of the night,
amongst a lot of people and noise, she felt a pain in her chest that really
alarmed her. She remembered her friend’s aunt and her fatal outcome. She
thought immediately that what she had taken was causing a fatal effect in her
body, and kept herself very alert before any such symptom or the indication of
it could be manifested. She felt the beating of her heart strongly, which had
increased its rate rapidly, at the same time as her stomach shrank and she began
to feel sick. She believed her suspicions were confirmed, and her heart began to
beat even faster, reaffirming those suspicions as she looked for a way out of
that place as quickly as possible. While she was leaving the premises it seemed
that she was choking, her face became pale and distorted, and a sort of
electrical shock went through her being. Her friends, alerted by the situation,
asked her what had happened to her, while they went with her to get some fresh
air. She told
them that she felt very ill, that she felt she was going to pass out and had a
lack of oxygen, that she thought she was suffering a heart attack, and requested
them to take her to a hospital. They got
in a car and went to the nearest hospital. Maria’s uneasiness spread
nervousness amongst her companions. She kept breathing rapidly and deeply the
air that came in through the car window, as she thought that perhaps they would
not arrive in time. It had not been more than ten minutes since her heart began
to beat strongly and she felt short of air; nevertheless, it seemed an eternity.
They arrived at the hospital, and the intensity of
her symptoms, which had lessened remarkably during the last few minutes,
resurged again. She explained to the doctor who took care of her what she had
taken and the experience she had, after which they carried out all types of
check ups, while her symptoms diminished remarkably, and the doctors saw that
she did not have any cardiac condition or of any other condition they should
worry about. They
gave her an ansiolitic via the drip they had installed in her shortly
before and explained to her that it was anxiety, a panic attack, stress. She was
advised to rest and visit her Doctor. She left
the hospital warn out; she seemed to be more exhausted than calm. She was taken
home and slept for hours. The next day she continued to be exhausted, it seemed
as if she had been beaten, although without blows. She reflected about what
could have caused her something so terrible . She thought the worst had been
about to happen to her. She
decided never to take again what she had taken, whatever it was, so that such a
dramatic situation would never be repeated again; and she remained rigid, alert
before any symptom, just in case... Some
Saturdays later, on the same premises, she began to feel badly again. She had
not taken anything strange, only a soft drink and some crisps; and,
nevertheless, her heart returned to beat at a frenetic rate, and again she was
lacking air and felt as though she was dying, at the same time as she
experienced a sort of shock throughout all her body that would have scared even
the bravest. She quickly called one of her friends so that he could take her to
hospital. On the way the same story from the previous time seemed to be
repeating itself, and, even more once in the hospital. Again
they told her it was anxiety, and on this occasion they advised to her to visit
a psychiatrist, or a psychologist. During
the days following that second attack she remained extremely scared and vigilant
so that her symptoms would not return to appear again. Her Doctor had prescribed
her some tranquilizers, and she was waiting for the appointment with the
psychiatrist, which would be a month later. She hardly left her house during the
first week after this latest episode, but, shortly afterwards, she returned to
go out almost with total normality. I
say almost, because since then, and for a long time, she did not visit the
premises where her attacks had taken place, because of the fear that these would
be repeated. Weeks
later, when going up the stairs to her house, she felt her heart beating,
beating strongly, at the same time as she thought she was at risk of suffering
that kind of attack again. Luckily, it was only a scare; but from that moment
she went up and down to her floor using the elevator, trying to avoid this way,
the repetition of a similar episode. Until the time she went to the appointment
with the psychiatrist, she had already decided, half consciously and half
subconsciously, not to do any type of exercise that could alter her heart rate;
dancing, which she used to like so much, going up or down the stairs, practicing
sport or even walking too fast were practices she had excluded from her life. At the
beginning, the medication the doctor prescribed her was working relatively well;
but despite this she was still unable to return to carry out those activities
she had decided to avoid in case she suffered one of those attacks. It was not
long afterwards when, one day while she was queuing at the supermarket, she
began to feel badly again; it seemed like she was going to suffer one of those
attacks without being able to escape from that situation; it is hard to imagine
the things she thought in that moment. "What would the others think about
her if they realized she was having an attack?" "They would think she
was crazy". Eventually it was her turn to pay and to take her shopping; but
that was a terrible experience for her, although not as intense as the previous
ones. In fact, she did not even go to the hospital, because she knew it was
anxiety. Instead, she took one of her tablets, an ansiolitic, which recently she
used to carry with her in case she suffered an attack, as her doctor advised her
to do. That
made the situation even more complicated, because after that experience it
seemed that there were no safe places outside of her house. Since
then public places in general were a source of anguish for her. She only left
home accompanied by a relative she trusted who could take her out of danger if
an attack was triggered. In respect to everything else, all types of fears were
nesting in her head attracted by her constant preoccupation; as well as at the
beginning it was just the beating of her heart that produced panic in her, now
there were several more sensations that terrified her, the sensation of
dizziness or lack of oxygen, and those sensations she could not tolerate were
multiplied. Thus,
any sensation, like cold or heat, hunger or satisfaction, pain or relaxation
produced uneasiness in her, and she fought, unsuccessfully, so that they were
not manifested in her. Depression
was almost a constant in her life, and the obsessions were totally present. ...
Luckily, she learnt to overcome that situation. This is
a totally fictional story; but it reflects the reality for many people, men or
women, who have suffered or suffer agoraphobia. A solution Independently
of receiving aid from the adequate professional or professionals, the solution
to agoraphobia comes through the comprehension, in those who suffer it, of the
origin of their disorder. Those who enter the web woven by panic attacks with
the conviction that their problem, in this respect, is merely physical, are
many. They believe they suffer some condition, whether cardiac, or related to
their hearing or their neck muscles, or any other to which they attribute their
anxiety problem, as the only cause of their tremendous suffering. There are many
cases in which the affected person also suffers a physically related problem,
which has directed their fear towards certain sensations related to that, having
in this way two totally different problems; the physically related, and another
which is psychological that has nothing to do with the former, apart from us
being scared by the sensations derived from this. Each person must be well
advised, by doctors and psychologists, and learn to differentiate their physical
problem from the psychological, in order to be able to give each one the
suitable treatment. In the
case of those who suffer agoraphobia with panic attacks, the first thing they
must do is to learn that their panic attacks are fed by the irrational fear that
they will die imminently as a consequence of experiencing the sensations they
fear (these are the sensations characteristic to intense fear). Thus, verifying
and learning that nobody dies just by experiencing these sensations, they would
stop fearing such a fatality as result of these types of episodes. By doing this
they would stop suffering panic attacks. In my opinion, the difference between
experiencing panic or experiencing a panic attack is that when we experience
panic we feel an intense fear, caused by a certain situation we consider
tremendously dangerous for our lives, and it causes in us the typical sensations
of panic; the panic attack is experienced when the cause of panic is that we
consider our sensations to be fatally dangerous, characteristic to that state of
general high anxiety. The DSM IV (The Diagnostic and Statistical Manual of
Mental Disorders, Fourth Edition (DSM-IV) is a guide to the diagnosis of mental
disorders) this gives a definition of the panic attack, by means of which we can
understand this as a
limited period of intense fear or discomfort, in which four (or more) of the
following symptoms developed abruptly and reached a peak within 10 minutes: -palpitations,
pounding heart, or accelerated heart rate. -sweating. -sensations
of shortness of breath or smothering. -trembling or shaking. -chest pain or discomfort. -feeling of choking. -feeling dizzy, unsteady,
light-headed, or faint. -nausea or abdominal
distress. -derealization (feelings
of unreality) or depersonalization (being detached from oneself). -fear of losing control
or going crazy. -fear of dying. -paresthesias (numbing
or tingling sensations). -chills or hot flushes. All
these sensations are harmless by themselves; that is to say, all of them are
totally normal and natural sensations, consequence of our anxiety during those
episodes, and will not do any damage to us by themselves. We
are not in danger because we feel a sensation of asphyxia, but we will be in
danger if we really lack air, which is a very different question; since those
who suffer panic attacks think they have an air shortage, and for that reason
they breathe fast, hyperventilating, which creates in them even more anxiety. We
will not die by the mere fact of experiencing the throb or the beat of our
heart. Our heart rate varies very frequently throughout the day; if we walk, if
we remain seated, if our work requires exercise, if we are digesting food or if
we are alarmed by any cause even if we are not aware of it, our heart beating
changes its rate, and this is completely natural. A qualified doctor should tell
us if we have or do not have a heart condition, as well as about how appropriate
or inappropriate it is to avoid certain situations, instead of guiding ourselves
only by our own natural instincts. The same
happens to those who experience a sensation of dizziness and feel fear for that
reason. They think that sensation will make them pass out and never wake up, or
something similar; nevertheless, the sensation of dizziness can be caused by
diverse reasons. For example, when we become obsessed for whatever reason and we
put our mind under an intense reasoning workout, anxious to solve our obsession
and our anguish, we enter a state of relative daze, in which we experience,
sometimes, a sensation of dizziness. Also if we have a problem relating to the
vestibule of the inner ear, or when we hyperventilate and more oxygen than we
need gets to our brain, or when we have tension in our neck, preventing the
normal blood flow, we experience a sensation of dizziness; but it does not imply
necessarily that we will pass out and never wake up whenever we experience those
sensations. We will have to take into account the true repercussion of our
bodily related problem, because on many occasions we limit and cause distress in
our lives unnecessarily, influenced by the fear this produces in us. Equally, we
will have to make sure we do not confuse a bodily related problem with a panic
attack, which also occurs on some occasions. Learning
to observe our sensations we will learn that we do not have any reason to fear
them, we will learn to tolerate them and to prevent them from awakening in us
fears that generate an exaggerated and unnecessary anxiety. Since, learning to
observe our sensations, as we have seen in previous chapters, implies learning
to observe the thoughts by which they are accompanied, the beliefs or cognitions
that in many cases cause the rise of our sensations, as well as the way in which
we perceive them. So, in
this second phase we will have to work towards learning to tolerate our
sensations and learning to change our irrational thoughts, those which in
general generate our panic and anxiety thoughts, to others that are more
rational. This work implies that we should expose ourselves to those sensations
and thoughts, in a gradual and progressive way, with the greatest possible
observance, which will mean an enormous effort for those who are affected by
this disorder. This way
they will be able to control their panic attacks, although they will continue
having high levels of anxiety and even threats of quite unpleasant attacks. In
order to continue advancing in their treatment it will be sufficient to keep
listening, paying attention to their sensations and thoughts, in addition to
nature in general, and to comprehend that whatever bond we have to life, no
matter how much we try to avoid death with all our strength and means, we will not
change the reality, which is that this can happen at any time. We will have to
accept that reality, not with resignation, but with certainty; with the decision
to live every moment, good or bad to the full, and with the attitude of to keep
on learning from this life and ourselves, with the purpose of passing through it
being as happy as we possibly can. By
experiencing so much anxiety throughout their life, and now also now because of
their treatment, they will have to learn from the emotion of loss and how to
treat it; but it will not be very difficult for them, if they have gained skills
with regards to the sensations and thoughts through their task destined to
eradicate their agoraphobia. They will also have to learn about their
obsessions, because their fears will nest there, especially after removing them
from their avoidance behaviour; but now it will no longer be a very complicated
task, after having learnt to handle their panic attacks in this way. As a whole,
the work will be long and hard, but very gratifying. So, the
story of our dear Maria is continued like this: ...
After spending living years in such a terrible situation, in which hopelessness
made her devise terrible things, she sometimes even thought about ending her
life in order to leave behind so much suffering, she felt willing to look for
what was the true origin of her disorder. She decided to transform all her
anger, even in the midst of the confusion, into the energy necessary to face her
fears. She also decided to use all her kindness and love towards her goal. She
looked for information about the possible solutions there could be for her
disorder; she was very careful, because she had heard enough already about what
had happened to her, and a lot of what was said was, to say the least, useless. She
tried to look for trustworthy information; data regarding epidemiologic studies
in respect to panic disorder, with or without agoraphobia, that could help her
to differentiate the type of treatment suitable for her. Once she saw the
different therapies available to solve her problem, she chose one called
cognitive-behavioural, since this was one that offered better results by far
with respect to the others. She learnt lots about what the therapy consisted of,
the way this works in a person, the steps to follow, etc., because she knew that
the mere fact of visiting a psychologist did not mean she was going to get help,
given the amount of different types of therapies these professionals work with,
and the huge disagreements with the types of therapies and the psychologists who
give them. Therefore, since going to a psychologist did not
guarantee her that she was going to receive the suitable treatment, she acquired
knowledge from a good book, at the same time she also visited a psychologist. She dedicated several months solely to her recovery.
Firstly she dedicated herself to comprehend that, indeed, what caused her
attacks was her fear to die just by experiencing certain sensations she feared a
lot. Already from the beginning it was not easy, because she had spent many
years convinced that feeling those extreme sensations was really dangerous for
her; it was necessary to add her first disappointment
to this, because she believed that by just understanding that there was no
reason to fear her sensations she would stop doing so, this was very far from
reality. She understood it reasonably, but, all her being continued believing
that her sensations were dangerous. She had to expose herself to them,
practicing physical exercise that produced those sensations she was scared of,
while she learnt to change the irrational thoughts, the ones that made her
perceive her sensations as dangerous, for others more rational and practical. Soon she discovered that the key to
optimizing her efforts in learning and comprehending quickly was the attention
(or observation), remaining very attentive to her thoughts, as well as to her
sensations, in order to comprehend better how those and others emerged; that is
to say, in order to see for herself how every time she felt fear when faced with
a sensation, this happened because in her mind appeared a thought that alerted
her, incorrectly, to the serious risk she was at when experiencing it. In that way, she was soon able to
observe clearly how her anxiety increased when she perceived a sensation and,
simultaneously, in her mind appeared a thought that warned her about things such
as:... “Oh no, my heart is going to beat strongly!” “Be careful, I must get myself to safety”. She also observed
that following the thread of that type of thought she always found the same fear
to die as a consequence of it. That was a great help, because in those really
difficult moments she made an effort to say to herself time after time: “It is
not true that what I fear so much is going to occur just because I experience
those sensations, and I will keep observing them, without avoiding them, so that
all my being comprehends that I do not have any reason to fear them ”. In this
way, thanks to practicing that difficult task time after time, and meditating
and reflecting at home about all that happens to her, learning to relax and to
“let go”, little by little, of her terrible fears; progressively she
accomplished all those activities that she was no longer carrying out due to her
excessive fears, exposing herself gradually to them, beginning with those that
came out to be more easily attainable and continuing with others that were more
difficult for her, but soon she able to accomplish them as well. She applied everything she had learnt to
the different areas of her personality, since already before being agoraphobic
she was very demanding with herself and with life in general, and that had
created in her more and more, increasing every time, emotional problems. In
addition, over the last few years and due to her agoraphobia, and now with the
huge effort she has carried out, the emotion of loss (the sensation of
exhaustion) had become stronger in her, and the same happened to many of her
obsessions. However, she did not have a great difficulty in overcoming this, at
least in comparison with the effort involved in overcoming her agoraphobia; and
with the skills she learnt during her recuperation, she could conquer her
problems of anxiety and, in addition, learning to love and enjoy the beautiful
things of life as she had never done before. She comprehended what she had
learnt went far beyond the overcoming of her huge and limiting fears. She had
learnt to know and comprehend herself and to act consequently and consciously. A small
summary of pieces of advice for agoraphobia: 1. Take good advice in order to
understand what the problem is. 2. Try to understand that we feel
according to what we think. If we think something is dangerous we will
experience fear, aside from how dangerous it really is; if we do not think
something is dangerous for us we will not experience fear, even if it is so. For example: Imagine that you get on
ride in a fair, like a roller coaster. It is statistically proven that a ride on
it will not be dangerous, because the number of casualties or other types of
accidents that happens there demonstrates so. However, we will experience
anxiety and fear when riding it, given our perception of the same. Now let's imagine that we travel as
passengers in a good car on a good highway with a pleasant temperature, and we
listen to some relaxing music while doing As a consequence, it is very important
that you understand that you have an incorrect perception of your sensations and
thoughts, responsible for your panic attacks. 3. Practice the exercises of meditation
shown in previous chapters, with the aim of exercising the perception and
attention to sensations and thoughts. This will be a great help towards learning
to tolerate your sensations and changing the beliefs (cognitions) that create
your attacks. 4. With the help of a book, and if this
is possible, the advice from a good professional, set out to provoke the
sensations you are scared of, with the aim of learning to tolerate them. Almost
all the sensations people with panic disorder fear can be experienced with the
practice of physical exercise, like jogging, aerobics, etc. Because with them we
can make our heart rate increase, induce sweating, produce a sensation of a lack
of oxygen, abdominal pain, sensations of dizziness (any exercise that requires
movement will do, besides, it is useful as vestibular re-education). An
extremely important sensation of a panic attack is the one experienced when
hyperventilating. In order to provoke that sensation it will be enough with
breathing quick and deeply during a minute. You will experience the sensations
characteristic to hyper-ventilation, these are well known to the majority of
those who have experienced panic attacks. Normally they produce paresthesias (numbness or tingling sensations) and other
sensations fairly unpleasant for the individuals affected.
Warning: If
you decide to carry out any one of these practices, please consult your doctor,
because he can let you know if there is any reason for you not to do them. 5. After having practiced with your
sensations and thoughts, start gradually confronting the situations you avoid,
which should be a part of your daily life. 6. Bear in mind that the learning will
not be an even road, in your recuperation there will be moments when you might
think that you have moved backwards instead of forwards. That is normal, do not
lose heart over it: it has happened to everyone that has gotten over the
problem. Nevertheless, carry on and you will be able to overcome your obstacles,
learning to know yourself and to tolerate your sensations and thoughts. |
