A few years ago I worked with a young woman named Lily who had developed symptoms of agoraphobia. This is defined as the fear of being in places or situations from which escape might be difficult or embarrassing, or where help might not be available in the event of a panic attack. Usually a history of panic attacks precedes agoraphobia. Panic attacks, for those who have never had them, are intensely unpleasant experiences. They begin with the sudden onset of intense fear, with no obvious external danger. There is usually shortness of breath, dizziness, choking, accelerated heart rate, tunnel vision, shaking, sweating, flushes, and the firm conviction that one is either about to die, go crazy, or do something uncontrolled.
As you might guess, anyone who has experienced these symptoms lives in dread of their recurrence. Sometimes they become associated with a specific situation, like airplanes or elevators, and a simple phobia develops. As long as the victim avoids the phobic situation he or she fears no recurrence. John Madden, the football announcer, is a famous airplane-phobic who has adapted by traveling from game to game in a specially equipped bus. Agoraphobics are not so lucky because there is no single situation for them to avoid. The helplessness that these symptoms cause often leads to depression.
In Lily’s case, her symptoms severely restricted her life. An attractive young woman trained in a highly technical skill, she was only able to drive from her parents’ home to her job and back again. Her job itself was far below her abilities, and she had no social life at all except for a couple of girlfriends. Going to a mall for a shopping trip took months of planning and worrying. She was miserable living in her parents’ home. Her father was an alcoholic who had abused her as a child, and her mother was unpredictably supportive of Lily’s problem or shaming her to get out and do better.
No one agrees on the causes of agoraphobia and panic attacks, and there are disagreements as well on the best treatment. Some clinicians take a psychodynamic view, which emphasizes the fear of separation from home and potentially rescuing parental figures. Anxiety, from this point of view, is thought to reflect a fear of an outburst of forbidden impulses, usually sexual or aggressive. Behavioral therapists view agoraphobia as a learned response; like Pavlov’s dog salivating when the bell that means food is rung, the patient begins to feel the physical precursors of a panic attack in certain situations. Much attention is then given by the patient to controlling these warning signs.
These problems are favorite subjects in the field of psychotherapy research, partly because the symptoms are so easily measurable and reproduced, and partly because there are several different treatment approaches which can be readily compared. People can get better in a number of ways; one usually reliable treatment is systematic desensitization. You teach the patient how to attain a relaxed state, perhaps through meditation or biofeedback, then gradually expose him or her to situations more and more like the feared situation. Cognitive restructuring, or challenging the patient’s way of thinking, can also be effective. Medication, often a mild antidepressant, can help either by itself or in combination with psychotherapy.
Lily got gradually better with a lot of acceptance and encouragement from me. Alhough she didn’t see the connection at first, I thought it was very important that, when she was 15 her parents had had her put in a psychiatric hospital against her will. From how she described her behavior at the time, she had not been psychotic or dangerous, only angry and disobedient. Nevertheless, as a result of the experience she began to think of herself as a crazy and unstable person. I encouraged her to think of herself as a normal person living in a crazy and unstable family.
Her first Adult Children of Alcoholics meeting was a turning point for her. She came in the next week beaming, not only because she had braved a scary social situation, but because she found a whole group of people just like herself. From then on she began to think of herself as capable. Before long she was living in an apartment in the city with a much more rewarding job and a social life, still very active in her groups.
Last year I got a postcard from Lily, which she’d proudly written from the top of the Mayan ruins at Chichen Itza.