Fighting Fear

Confronting phobias and other fears

An Overview of Agoraphobia and its Treatment

Two things must be learned to achieve success in treatment

I developed an interest in phobias, and in agoraphobia in particular, in 1954, as the result of developing the condition myself. One day without any evident reason I became panicky. I had the feeling I was going to go crazy or scream or in some way lose control of myself. It was a dramatic and inexplicable feeling. It was obvious, I thought, that something terrible was the matter with me.  After leafing through the pages of my college psychology textbook (I was in college at the time), I tentatively decided I was suffering from an anxiety reaction, a neurotic depression, probably, a panic state also, and a variety of other illnesses—possibly including schizophrenia. In the opinion of my roommate, I was also a hypochondriac.

But my readiness to see myself as ill in all sorts of ways was not solely an expression of my suddenly heightened concern about myself. There is indeed an overlap among some of these conditions and also a tendency by different clinicians to call the same illness by different names. I would have chosen to settle the matter by seeing a psychiatrist—hoping along the way to get cured—but I was concerned that being on record as emotionally ill would hurt my chances of being accepted into medical school. That would not be so, the physician at the student health service told me when I asked, unless I was suffering from a “character disorder.” But I naturally assumed that I had a character disorder, whatever that was, along with everything else.

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So I lived with the condition for the next few years—with considerable difficulty, as everyone does—and along the way stumbled over the principles of treatment that allowed me finally to get well. These methods have been independently advanced and reformulated by a number of different investigators. By now they constitute the standard, conventional treatment of phobic and panic states. As usual, everyone has a name for his own particular method, but most commonly this sort of treatment—exemplified in the eight-week clinic at White Plains Hospital—is called cognitive-behavioral treatment or, more specifically, exposure therapy.

Most serious phobias are variants of agoraphobia. Those so affected are afraid of becoming panicky in situations from which they cannot immediately extricate themselves. They are afraid of being trapped while their panicky feelings spiral suddenly out of control. Their fears are usually more specific. They are afraid that once they lose control, they will do something dangerous, such as drive off a bridge or into a crowd, or do something embarrassing, such as screaming, falling to the ground, throwing up or soiling themselves. They may also be afraid of a physical calamity such as a heart attack.

The specific circumstances in which they feel trapped differ from one person to another. If they are afraid of being stuck in an elevator, they are likely to be called claustrophobic. If they feel trapped in an arena or driving across a bridge, or in formal social situations, their disorder usually goes by the name of agoraphobia, but the condition is the same.

I felt troubled especially in classrooms or in quiet places such as the school library. These were places where I could imagine how awful it would be if I suddenly lost control and screamed out some vulgarity. No such thing ever happened, but the fear was very real.

A person who is suffering from agoraphobia is likely to have been subjected over the course of his or her illness to an extraordinary variety of diagnostic procedures—everything from brain scans and hair analyses to cardiac catheterization, including especially glucose tolerance tests and other determinations of endocrine function—all to no benefit. Very likely that person has been told he, or she, was suffering from any of a great variety of physical or mental disorders—everything I could imagine as a naive college student, and more. Very many phobics have been diagnosed as having hypoglycemia —almost always in error. On the other hand, they may have been told also they had nothing at all the matter with them. Whatever the diagnosis, most of these patients have been treated previously. Even those thought to have nothing the matter with them were likely to have been offered some kind of treatment, usually drugs, often one of the minor tranquilizers, but also diets of various sorts, hypnosis, techniques of muscle relaxation, meditation, and so on. Occasionally someone may have been hospitalized, sometimes for considerable periods of time.

Success has been reported with these different modalities of treatment and others, including psychoanalysis, but the failure rate is very high. Therefore, most patients, having been treated at different times by different doctors for different disorders, and having failed to improve, become discouraged and disbelieving of anyone who offers to embroil them in still one more method of treatment. It is just this cynicism and hopelessness that makes treatment difficult. The proper treatment of phobias is not easy at best, and entering into it halfheartedly makes success unlikely. In short, getting well depends as much on morale as on anything else. The patient has to keep trying long enough to succeed.

As for my own illness, it receded slowly after considerable effort, then went away entirely. I became a doctor and then a psychiatrist. My interest in these disorders remained, however, and I found that I was seeing more than my share of such patients. About thirty years ago I was invited to join the staff of the White Plains Hospital Phobia Clinic, which I currently direct. Over three thousand patients have been treated at this clinic, and through questionnaires, newsletters, and contact with other physicians around the country who specialize in the treatment of phobias, we have knowledge of additional thousands of such patients. The great majority of these patients report themselves—and indeed seem to be—markedly improved by proper treatment.

I give this account of myself and the experience of the phobia clinic for two reasons: to indicate plainly that there is reason to be optimistic about treatment. Among those greatly improved or cured are some who have been seriously phobic for twenty or thirty years sometimes to the point of being housebound. And to indicate that it is possible for someone working solely by himself or with a helper to get well. There is reason to be optimistic even for those who have failed repeatedly in previous treatments. 

In order to get well only two things must be learned:

1. The phobic person can learn to confront those situations of which he, or she, is afraid and come to understand that escape is possible from every place. (These circumstances include some places, such as a stuck elevator or mid-flight in an airplane, which seem at first blush to be exceptions to this rule.)

2. More important, the feeling of panic itself can be mastered. If it cannot be prevented from coming, there are means by which it can be driven away. And, in any case, it never causes the loss of control that I used to fear, and that all the others who are still symptomatic, fear.

There are other conditions with which agoraphobia and panic disorder can be confused. An agitated depression is frequently confused with a phobia because it can cause panicky feelings. This illness responds well usually to antidepressant medication and not to behavior therapy. It is important, therefore, in the treatment of phobic disorders—as in the treatment of any medical condition—to be certain it is indeed that condition from which the patient is suffering. For that reason, each patient deserves an evaluation by a properly trained psychiatrist or psychologist.

 

(Excerpted from "Rising Above Fear")

Follow Dr. Neuman's blog at fredricneumanmd.com/blog/ or ask advice at fredricneumanmd.com/blog/ask-dr-neuman advice-column/

Fredric Neuman, M.D. is the Director of the Anxiety and Phobia Center at White Plains Hospital.

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