Most people feel that they are in control of themselves. They take being in control for granted. They feel just as much in control when they are flying on an airplane or when they are driving a car, when they are seated on an aisle seat, or when they are seated in the middle of a row. Sometimes, some of them may speak of losing their tempers, but they realize they are still in control. If they choose to punch the wall, when they are angry, they know, really, that they punched the wall purposely. Certainly, other people will regard that as a purposeful act. Phobics, however, often speak of the possibility of “losing control.” They do not think they have lost control in the past; but they feel they almost lost control on many occasions. The panic attack is experienced by most phobics as a sense of losing control. Loss of control may represent to them any of a variety of fears: vomiting, fainting, acting crazy, and so on. Loss of control may represent something dangerous to themselves or to other people, for example, by driving an automobile into a crowd or off a bridge. They often say that they feel uncomfortable flying in an airplane because they are not in control of the airplane. Other people can be passengers and still feel “in control.”
The situations that may cause a phobic person to fear losing control are legion: sitting quietly in a classroom or a restaurant, or in church, or in a movie theater, standing in front of an open window or on a subway platform, public speaking or being a spectator while someone else is speaking. Situations where they are relatively passive, like waiting on line, are especially likely to elicit the sense of being on the verge of losing control. But, sometimes, the same fear of losing control manifests itself in different phobic patients in almost opposite ways:
One person cannot drive a car, but can be a passenger. He is afraid that if he is the one driving, he may lose control and cause an accident. Another person has to be the driver. Otherwise, she does not feel in control!
One woman cannot take a shower, unless other people are in the apartment. She is afraid that if she faints or loses control of herself in some other way, someone will be there to take her to a hospital. Her cousin, who is also phobic, cannot take a shower unless she is alone in her apartment. She is afraid that if she loses control of herself, she may run through the apartment naked and embarrass herself.
Some drivers go especially slowly, so if they lose control of themselves, they can move to the shoulder safely. Other drivers who are similarly afraid drive very quickly in order to get off the highway as soon as possible.
The essential element in the treatment of agoraphobia and panic disorder is to convince the patient that he/she never loses control in such a way. It is a striking fact that in the 40 years of the Anxiety and Phobia Center, which has treated thousands of such patients, all of whom have had very many panic attacks, no one has yet had an automobile accident while having a panic attack! Someday, I suppose, it will happen by chance alone, but not yet.
In order to convince patients that panic attacks do not cause loss of control, we ask them to do those things, intentionally that otherwise cause them distress when they find themselves in those situations inadvertently. In other words, we ask them to drive slowly purposely, if their natural inclination is to drive fast and to drive fast if their natural inclination is to go slowly. Oddly, this increases their sense of being in control. Of course, getting somebody to do something they have been especially afraid of, often for years, is not easy. It takes time, and, usually, is accomplished in small steps. © Fredric Neuman 2012
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