AGORAPHOBIA

Anxiety is a human trait and most individuals will have experience of it. Anxiety helps with vigilance, learning and general performance but in excess, it starts to work against us as extreme self-focus and apprehension reduces this attention and performance. Basically, people have then turned inward, defending themselves from their anxiety and usually from life in general. This means that instead of embracing activities as a challenge where things are anticipated with pleasure and the person is open to new experience, many activities come to be seen as a potential threat and are looked at with suspicion and fearful anticipation; and life begins to close down.

Anxiety at the minor symptom level is familiar to virtually all of us and from Anxiety Care's experience, this often seems to weigh against an acute sufferer seeking help. Embarrassment and shame at an 'over reaction', perhaps aggravated by the particular blending of emotions (such as anger, shame, guilt or sadness mixing with a dominating fear) that make up their 'personal anxiety' keeps the problem hidden and prevents this person from understanding that their response doesn't mean they are weak, soft or immature. It is often not understood that anxiety can follow a continuum from mild to acute that leaves some people with 'liveable' responses but others deeply disabled.

Agoraphobia

According to research, there are no particular personality differences between agoraphobics and members of the general population. 'Fear of fear' (fear of a panic attack) seems to be a component of the problem but there are many other factors that lead to the avoidance central to the disorder and not all agoraphobics experience panic attacks. People with agoraphobia typically suffer from a 'cluster' of phobias. Generally they will find it very difficult or impossible to carry out certain activities. These could be going into crowded or public places, lifts, public transport or simply anywhere away from home where 'escape' or immediate access to help is not possible. They will probably also fear standing in queues, going on bridges or sitting in any place where they feel 'trapped', such as at a hairdresser's or dentists. A companion for outings is often sought and rapidly becomes essential. There can also be additional fears, predominantly 'social' ones such as a fear of blushing, trembling, talking eating or writing in front of people and of being stared at. (These latter fears can also be part of social phobia or separate specific phobias and don't necessarily mean that someone suffering in this way is agoraphobic.) There may also be obsessional and depressive symptoms. If the person becoming agoraphobic was significantly depressed before onset, which is more common when the problem appears later in life, this could be the disorder that is treated first.

The common belief that agoraphobics fear 'open spaces' is, in general, untrue. So is the belief that a person must be totally incapable of doing any of the things mentioned above - or be totally consistent in their ability to do these things - before they can be designated agoraphobic. Many agoraphobics are able to undertake certain activities under specific circumstances or when the need is great. This falls into the category that anyone should be able to understand when we make super-human efforts at times. For example, the documented case of a woman who lifted a car off her child. Anyone would understand that this was an incredible action fuelled by extreme need. However, the agoraphobic might be in much the same situation when heavily pressed to attend a family gathering or when faced with something that he or she desperately wants to do. This is about 'balance': the weight of need equalling the weight of ability and/or desire. Because an onlooker cannot understand the particular balance involved, does not mean that the agoraphobic can be written off as: 's/he can do it if s/he wants to!' The contempt in this and the allied suspicion that the disability is not genuine stops a lot of agoraphobics from trying new things when they feel 'strong' and feeds in to a, possible, personal self-doubt and self-contempt. This is never useful and actively works against an agoraphobic's recovery.

Onset of agoraphobia is usually between the ages of 18 and 35 and affects between 1.5% and 3.5% of the general population. Onset can be sudden or gradual, over weeks, months or even years; or it can come and go for a considerable length of time before becoming a permanent problem. Severity of symptoms can also vary enormously, with many people hiding their problem, or just about coping, for many years. In some people, agoraphobia may 'come and go' and there may be periods of years in between episodes where there are virtually no symptoms. When someone develops Panic Disorder (see the article on this site), agoraphobia often occurs too within the first year. When there is severe panic with the agoraphobia, this may actually maintain the disability even when other possible reasons for anxiety have dwindled, and the person maintains a high fear of having more panic symptoms. This would aggravate any anxiety condition.

Onset is often preceded by a large number of adverse life events in the year or so before the condition is recognised (see: 'transitions' on this site), but there is little evidence that a sudden trauma can cause it. Once present for about a year, the condition may persist for decades unless it is treated.

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The Symptoms of Panic

Not all agoraphobics panic. In fact, many will experience little everyday anxiety if they are able to avoid the situations they fear. Below are the symptoms of panic found in Panic Disorder. Someone with less than four of these would be defined as having agoraphobia without panic disorder. The agoraphobic without panic disorder would still be afraid of the symptoms that were seen as 'his' or 'hers', particularly if it is thought they might lead to extreme embarrassment or danger like losing bladder control or being left lying in the road. However the fear would revolve around individual symptoms not fear of a full-blown panic attack. If more than four of these symptoms have been experienced at any one time, it is likely that the sufferer will be diagnosed as having Panic Disorder with Agoraphobia. For the diagnosis of Panic Disorder alone, a person will have had at least two spontaneous, 'out of the blue' panic attacks where there are no fear-generating situations.

The panic symptoms are:

• Shortness of breath or feeling smothered
• Heart palpitations
• dizziness and/or faintness
• sweating
• feeling 'unreal' or 'not there'
• numbness and tingling
• hot or cold flashes
• chest discomfort or pain
• fear of going mad and losing control
• fear that s/he is about to die
• choking
• feeling nauseous
• trembling and/or shaking

Treatments

There are a wide range of treatments available for anxiety disorders, from psychotherapy to simple exposure work. The usual responses available on the NHS are behavioural therapy and rational-emotive and cognitive-behavioural therapy. Behaviourists tend to believe that our behaviour is learnt and that we are a product of our environment. The behavioural approach usually involves practicing more appropriate behaviour and reinforcing this by repetition and, possibly, imitation. A good behavioural therapist will work out, with the client, a plan for treatment and the goals to be reached by it. This will almost certainly involve a series of practical steps as described below, for becoming used to the anxiety generating situations (desensitising). It might also include relaxation, anxiety self-management and practice with changing habitual thought patterns (cognitive restructuring). Some therapists might include a course of medication if symptoms are perceived by the client to be too overwhelming to counter. However, many behaviourists subscribe to the view that the anxiety must be faced 'head on' without chemicals between it and the sufferer. So whether or not medication is involved will depend on the therapist. From Anxiety Care's experience, sufferers need to be in a state of mind where such practical work is viewed as viable if it is to succeed. With long NHS waiting lists, the huge number of sufferers and the lack of therapists, it is often pot-luck when such therapy is offered. If this behavioural therapy is then available over a limited period and only at a specific time and date,it would be also understandable if the therapy centre involved accepted only those clients who appeared most likely to benefit from it. And these might not be the clients most in need.

Rational-emotive and cognitive-behavioural therapies tend to work with the client's thought patterns and the assumption that we are all able to think rationally but may have become side-tracked into irrational pathways. The therapist will help the client, much as a teacher would a student, to look at their thinking and belief systems and to attempt to eliminate self-defeating beliefs and attitudes. While it will probably be accepted that these beliefs were mostly generated in childhood, the therapy will be based on current difficulties and achieving a balance between what the client believes should be and what is, in reality, the reasonable option. The client may also be encouraged to delve into, and express, personal feelings. This is not analysis.

Many people coming to Anxiety Care believe that there is some fundamental 'thing' in their childhood that caused their disorder and that once this is found, their problems will be over. Anxiety Care's position is that virtually everyone could make a case for being emotionally ill, or plain 'barking mad' on this basis, if they wanted to, as it is not possible to go through childhood without some kind of damage. Endlessly picking over this damage, great and small, might be interesting but is unlikely to lead to recovery unless the current life is still heavily linked in to this damage through a belief system. The idea that, once this causing factor is found, cure is accomplished, just isn't true and is more to do with a wish to be better rather than to go through the, often painful, process of getting better.

Bearing in mind the huge need and the limited therapy time available, most people with agoraphobia are going to have to organise their own structured recovery programme. (See 'Self-treatment for Phobias' on this site). The practical steps would start with what could just about be managed with some difficulty and work up to what is desired, with as many steps in between as necessary. These steps can be very small and practice needs to be undertaken for an hour or so a day, everyday, so that the new behaviour can be reinforced in the mind.

Here are some steps that might help someone with agoraphobia who can make it out into the street, but finds that the next step - walking to the local shops - is too large to manage in one go. This big step, 'go to the shops alone', has been broken down into a number of smaller ones:

Some Hints for Self-Exposure Work

• When treating your phobia it is important to work out exactly what the problem really is. If it is lifts, does their size, or their structure (metal walls, open bars etc.), or how high they go make a difference? If it is stairs, is it their width, something about the handrail, or the way the stairs are built (for example, open or closed steps, whether you can see through them etc.)? In the case of bridges, is it to do with the parapet? With tall buildings, the windows? If you don't work out the real focus of your fears, you could be wasting time trying to overcome the wrong problem. It is especially important to do this for agoraphobia, so that you are clear exactly how many different fears are involved in your condition.
  
  
• The first step in the programme can be very simple - perhaps staying in a situation that can just be managed now, but for a little longer than before.
  
  
• The steps can be as large or as small as necessary, and big steps can be broken down into smaller ones. However, it is important to make sure that each step challenges the anxiety a little more than the last.
  
  
• Don't be overwhelmed by the size of the task. As a rule, the steps become steadily easier as you work through them.
  
  
• Don't expect to be completely free from anxiety before you leave each step and go onto the next - it will go completely in its own time as you progress.
  
  
• Do the exercises as often as you can. You are trying to build up positive memories to replace all the bad ones of being beaten by the phobia, and too long a gap between efforts makes this more difficult.
  
  
• An hour or so at a time and repeating this every day is best. Waiting until you feel 'strong' or until you cannot avoid it any longer is not a positive approach.
  
  
• Do enough at each step to raise your anxiety. You are trying to get used to a level of physical symptoms that you can manage, and where you are in control.
  
  
• If it is possible to find someone to work with, who can talk to you calmly and positively while you are doing the steps (not over-sympathising or endlessly asking how bad you are feeling) this can help.
  
  
• If you have a panic attack during your exposure work, try to remember that the physical symptoms of panic will not do you any harm, and will always ease off eventually, whether you run away from the situation or not. Many people believe that a vague but terrible 'something' is going to happen to them during a panic, and that they just manage to save themselves in the nick of time by avoiding or escaping from the phobic situation. This is not true.
  
  
• Relaxation techniques can be helpful in tackling the next step, and it is easy to practice relaxation in the privacy of your own home. If the steps you have chosen prove impossible, of if you are depressed or have other severe anxiety problems, then professional help from a clinical psychologist or psychiatrist may be needed. You can reach such professionals through your GP; and in any case we recommend that you contact your GP and talk to him or her about your disorder.

Exposure Work and the Agoraphobic Cluster

Phobias tend to strike 'across the board', and grow to cover many different situations in quick succession. However, the fear of these different situations may need to be tackled one at a time. So, a person with a fear of many different public places should not feel despondent if they sort out their fear of the supermarket only to find that the hairdressers or the church still cause a problem. It does not necessarily mean they will have to plod through the same series of steps all over again with these other situations. They will usually be able to start at a higher step level, and will have the confidence of at least one practical success behind them.

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Coping with Panic Attacks

Panic is the most extreme kind of anxiety reaction, and often becomes the experience that people with agoraphobias fear most. It is the point where they become absolutely convinced that something truly awful is about to happen to them - and will happen, unless they can get away from it quickly. Typically, they feel that they are about to lose control and do something horrible or humiliating (such as defecating, urinating, screaming, running amok or having some kind of 'fit'), or that they are going to go insane; or that they are going to have a heart attack, stroke or brain haemorrhage.

Anxiety Care has looked most carefully into what happens during a panic attack,and we can say with absolute confidence that:

• we have never come across a single case of someone dying as a result of a panic attack.
• we have never come across a case of anyone 'going mad' as a result of a panic attack.

Panic is an internal event. It may feel as if your mind and body are breaking up, but the fact is that other people seldom notice, especially in busy places. They are far too busy with their own affairs: if they see someone running out of a shop, their first thought will not be "There goes one of those stupid phobics". If they notice at all, they will assume you are late for something; after five minutes they will have forgotten.

Genuine 'loss of control' is also very rare. Even in the very small number of examples that we have come across, where the person claimed to have lost all control, it wasn't really true. One person described how she "rushed screaming out of the house" (but only after she had closed the doors and windows). Another said she "kicked insanely at the car window to get out" - but she had taken her shoes off first so as not to hurt herself or damage the car. As for the fear of going berserk and attacking children or mowing down passers-by, there are simply no records of a person in panic ever having done such a thing.

Everyone who has had a panic attack (and this may include up to half the population) realises that they have survived it unscathed. They may be shaken and drained by the emotional stress of the experience, but panic attacks do not cause permanent harm. What is more, panic attacks quickly subside, and this is equally true if the person affected resists the urge to escape and stays in the situation where the panic happened. But because escaping and the reduction of the bodies responses happen at the same time, we 'learn', incorrectly, that escaping is what causes them to do so. This is the process that turns the anxiety into a phobia. In order to stop ourselves being permanently on the run from fear itself, we need to 'unlearn' this false logic. That means developing the strength NOT to run away when a panic occurs.

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Advice for Family and Friends

1. The most important thing is just to be there, and to be caring. Keep calm yourself and don't start a cross-examination or over-react. Someone who honestly feels they are about to die, or at the least pass out, does not want to be interrogated with questions like "What on earth happened to you?", and "What caused this?" Above all don't 'flap'. If you do, it will only make things worse.
   
   
2. Too much concern can also make feelings of extreme fear even worse. Don't say things like "Oh you poor thing!", "Oh dear, this is terrible", or offer to call an ambulance. Families of agoraphobic people may unconsciously help keep the problem alive by offering too much support.
   
   
3. Don't denigrate with comments like "Stop being so childish", or "Grow up and snap out of it." A panic attack is no joke, and if the person affected could just `snap out of it', they would have done so long ago.
   
   
4. Hyperventilation can be a problem. Hyperventilation means over breathing; and over breathing means rapid, shallow breaths, rather than slow, natural ones. We all breathe in oxygen and breathe out carbon dioxide, but when over breathing, we breathe out too much carbon dioxide, leaving the blood chemistry temporarily unbalanced. The net result is a sort of reduction in 'pressure' which causes a constriction of some blood vessels and a slight increase in the blood's alkaline level. This is not a dangerous situation. The body soon compensates and retrieves the balance, but the physical symptoms a person may experience while this is being done can be extremely alarming.
   
   One such symptom can be a painful contraction of muscles across the chest which frequently results in the erroneous belief that a heart attack is imminent. Other symptoms include tingling in hands and feet, abnormally rapid heart beat, dizziness, disturbance in vision, tight throat, general 'wobbliness' and pain in the abdomen. With all that, it is not difficult to understand why somebody who hyperventilates is usually in a semi-permanent state of alarm about their body.
   
   There are a number of methods which can be used to reduce the effects of hyperventilating fairly quickly. One often recommended is to place a paper bag over the nose and mouth and to breath into it, thus inhaling extra carbon dioxide which quickly retrieves the blood chemistry balance. However, if somebody feels that they are gasping for air, further restricting its passage into the lungs is unlikely to be welcomed. There are also the additional problems of making shaky hands find the bag, inevitably folded small somewhere, and of withstanding the startled looks of people walking past as the exercise is undertaken. (Of course, thinking about this might take the person's mind off the attack and so be an aid to recovery).
   
   Other methods suggested have been: using cupped hands instead of a bag. Slowing breathing down as with "In.. one.. two.. three.. Out.. one.. two.. three". (Ensuring that 'slower' doesn't mean 'much deeper' or the good work can be undone), Trying to avoid 'gulping air' if there is a strong feeling of breathlessness. (Swallowing a couple of times helps here or holding the gulp for a few seconds if it cannot be avoided, and then letting the air out slowly). Running, and doing knee squats. Both of the latter physical responses seem to be good ways to retrieve the sagging carbon dioxide 'pressure' and may be readily undertaken by those who experience a driving need for action/escape at such times.
   
   Running away, if the hyperventilating is part of panic in reaction to anxiety problems, is one of the prime things people are urged not to do. However, if it reduces the attack and the sufferer is aware that returning to the phobic situation as quickly as possible afterwards is essential, then it can be an option.
   
   
5. The panicking person will want to 'escape' from the situation they are in. If you, as a helper can, try to persuade him or her not to. Running away may seem to bring relief, but it will make the situation much harder to bear next time and will reinforce the belief that the situation was dangerous and that escape is the best way to deal with it. Both of these responses lead to chronic habit. Try to negotiate a small delay: "You can hang on for one more minute ... just count to 60 and then we'll go". But don't bully, agoraphobic people have to make their own choices.