Thursday, March 30, 2006

How to Offer a Healing Relationship to Someone with Agoraphobia: Unconditional Acceptance

If you want to be a support person for someone with agoraphobia, your first job will be to establish a therapeutic relationship with the person who is suffering. It can be tricky to offer a safe, supportive relationship with a friend or loved one with agoraphobia, even if you had a good relationship with them before.

It is important to build a therapeutic relationship before you start trying to help someone with agoraphobia. Thats because a safe, supportive relationship is the vehicle through which real help can be offered.

Offering unconditional acceptance to someone who is suffering from agoraphobia is critical to building a healing relationship with them. Those of us who have had agoraphobia know that we are often self-critical and have a hard time accepting ourselves. Its even harder to accept yourself when you have agoraphobia and can't function normally. That is why it is so important to have people who accept us no matter what we do or go through. Experiencing the acceptance of others helps us to accept ourselves.

Offering unconditional acceptance means being non-judgmental and non-critical. It means not thinking of agoraphobia and the behaviors that go with it in terms of good and bad or right and wrong. It means not putting the person down or voicing disapproval when they do things you don't understand. It means letting the person know that you love them, care about them, and will not abandon them whether or not they recover from agoraphobia.

Offering unconditional acceptance means not only accepting the person with agoraphobia but accepting the condition of agoraphobia as well - at least for the time being. It means not trying to fix them all the time, refraining from constantly offering advice or suggestions, and not needing to always correct their irrational thinking. It means being able to relax and have fun with them - and talk to them about subjects other than what they need to be doing to get well. It means being willing to let the agoraphobic act agoraphobic - not that you don't want to help them get well - just that there is no pressure from you to hurry in doing so. nobody wants to feel like a project 0r like they are letting someone down if they arent getting better fast enough.

People with agoraphobia need people around them who accept them just as they are. Just like someone suffering from a physical illness or injury - it takes time to heal. If you are able to show your loved one with agoraphobia that you care without conditions and will stand by them through the ups and downs - you will have taken a big, first step towards building a relationship with them that will contribute to their recovery from agoraphobia.

Tuesday, March 28, 2006

Agoraphobia: Unhealthy Family Reactions

Once a person has tried to help a family member or spouse with agoraphobia by offering logic and reason and sees that it doesn't help, he or she will usually get frustrated and do one of the following:

1) Give up and emotionally detach from the person with agoraphobia
2) Become and enabler
3) Provide healthy support

The first two options are polar extremes - taking zero responsibility for helping and taking all of the responsibility. Both are unhealthy responses to agoraphobia.

Those who give up and emotionally detach from their family member or spouse with agoraphobia may start to say things like, "Well I guess I'll just let this be your problem since you won't let me help you" (putting the blame on the person with agoraphobia for not being receptive to help) or simply "I've tried everything I can, there's nothing I can do to help." Either way, they start detaching emotionally.

The people who emotionally detach from a family member with agoraphobia are not usually trying to be mean. In most cases, they just can't handle caring and feeling powerless to help or fix the problem.

Those who become enablers start trying harder to help when their first efforts fail. They may start doing everything for the family member or spouse like going shopping for them, communicating with others for them, driving them, entertaining them, fixing their meals, or in short, making their whole life about helping the family member or spouse with agoraphobia.

At first the enabler may seem kind and caring but in the long run they do the loved one with agoraphobia more harm than good. They, in effect, shield their loved one from having to face up to their fears or take any initiative toward recovery. A good enabler can make it too convenient for the agoraphobic not to work toward getting well. In some cases the person with agoraphobia enjoys the all the added love and attention they are getting from their spouse or family member so much that it actually gives them a reason not to get well.

Both giving up and detaching and becoming an enabler are unhealthy responses a spouse or family member can have to someone with agoraphobia. The most helpful response is to provide healthy support.

Providing healthy support means offering consistent encouragement and care without assuming responsibility for the disorder, or making it too convenient for the person with agoraphobia to stay sick and not his or her fears. (I realize agoraphobia is never convenient - but you know what I mean).

I will talk more about how to be a healthy support person for someone with agoraphobia in a later post.

Saturday, March 25, 2006

Agoraphobia: Don't Expect Your Family To Get It

When I say don't expect your family to get it, I don't mean that agoraphobia is not contagious. What I mean is that most families do not understand agoraphobia, at least not right away.

In my case, I was the son of a psychologist, and he didn't understand what was going on with me for over a year.

When someone gets agoraphobia, the first stages of common family reactions are as follows:

1) Denial

When you first get agoraphobia, most parents, husbands, wives, or children will not understand what is happening even if you tell them. They are most likley to shake their heads in disbelief as to why you can't do the normal things you used to do.

They may think you are making the symptoms up.
They may accuse you of being lazy, unmotivated, or purposely trying to avoid some responsibility.
They may try to use logic or reason to try to help you.
They may try to talk you out of your feelings
They may say things like "there's nothing really wrong with you" or "there's nothing to be afraid of."

2) Frustration

When their logic and reason don't help you, family members are likely to get extremely frustrated. Most people will want to fix you, and if they can't fix you they may start blaming you for not trying hard enough to get better or be normal.

I remember my dad got mad at me once and said, "Come on, any fool can breathe." That was right during a massive hyperventilation spell. I knew he just wanted to see me get better, but comments like this can really hurt.

Eventually, family members see that all of their logic and simple solutions will not solve your problem. They will have to quit denying the problem or trying to fix it. They will be forced to admit you have agoraphobia, a psychological disorder. They will have to admit they can't help you so easily. They may even have to admit that they have contributed to the development of your problem.

When family members get to the level of frustration that forces them to admit reality - they will have a big choice to make.

They can respond to your disorder in a healthy, helpful way.

Or they can respond to your disorder in an unhealthy, unhelpful way.

I will talk more about family responses to agoraphobia in the next post.

Friday, March 24, 2006

Agoraphobia Treatment: How Can You Tell It Is Working And How Long Should It Take?

How do you know if your therapy for agoraphobia is working?

Your therapy is working as long as you keep seeing forward progress no matter how slow. Another good sign is if you still feel encouraged and still have your sights set on the goal of recovery. Its also a sign that therapy is working if you are feeling connected with your therapist in a therapeutic way and you feel the two of you are working together as a team to reach your recovery goal. In sum, as long as there is some momentum and forward progress, no matter how little, the therapy is working.

How long should you try a type of therapy before you decide its not working?

You should see some major progress in 12-16 weeks. If in this amount of time, you still feel frustrated and at a standstill, its time to change treatment plans or therapists, or so says the Anxiety Disorder Association of America.

Thursday, March 23, 2006

A support group for agoraphobia meeting downtown?

When my mom first showed me an ad for an agoraphobia support group in the newspaper, I thought it was a total joke. The group met downtown and I couldn’t see how anyone with the type of panic disorder and agoraphobia I had getting downtown. Go figure.

I attended the group a few times and it just affirmed how bad my case was compared to others. To get to the group’s meeting place downtown I had to knock myself out with Valium and lie on the floor of a van facedown while my dad drove me. Once there, sitting in a metal folding chair facing a circle of people was a lot harder than lying on the shrink’s couch. I could only stay in my seat about five minutes without feeling on the verge of a collapse from hyperventilation. I had to leave a lot to catch my breath outside in the van.

What I heard spoken in group was not inspiring at all. After several visits, I lost my motivation to go back. Most of the group members had been suffering from anxiety disorders for longer than I had been alive.

They had formed a cozy little sub-culture around their pathology with inside jokes and the whole bit. It seemed that illness had become an identity for some. It was their ticket into the sub-culture where they found a sense of belonging.

Though my symptoms were far worse than anyone’s, I wasn’t about to join the club. I didn’t want to make a life out of my anxiety disorder. I just wanted to get well. It didn’t seem healthy to spend too much time with people who seemed content with being sick.

Also, comparing myself with others discouraged me. Especially with people who claimed to have panic disorders or agoraphobia but sat through the whole group on a hard folding chair without having to leave. Maybe they were taking lots of drugs or something, but I didn’t stick with the group long enough to find out.

How to find a support group for agoraphobia

Here are some places to look for information about agoraphobia support groups in your area:

1) In the your local telephone book under a section called "Community Services." It may be in the white or yellow pages. Once you find the community service section look under the category of "Mental Health."

2) If you cannot find any support groups in this section look in the yellow pages under "psychiatrists," "psychologists," "marriage and family counselors," "social workers," or "mental health clinics." If any therapists or clinics say they specialize in anxiety disorders or agoraphobia, call and ask if they know of any local support groups for agoraphobia.

3) Sometimes support groups put ads in the newspaper in the classified ads section. That's where I found the one I went to nwhen I had agoraphobia.

4) Finally, if you cannot find a local support group, The Anxiety Disorders Association of America helps people organizing local support groups through their network of people who specialize in working with anxiety disorders. You can check their website or contact them by phone or mail at:

Anxiety Disorders Association of America
6000 Executive Boulevard, Suite 513
Rockville, MD 20852
(301) 231-9350

How to choose a good support group for agoraphobia

Support groups can be helpful in recovering from agoraphobia. Going to a support group can help you to know that you are not alone in your suffering and give you a chance to build relationships with people who are going through the same thing and will understand what you are going through. At support groups, agoraphobia sufferers can share their successes with one another and give each other encouragement.

There are basically two types of support groups:

1) Professionally led
2) Peer led

If you are thinking about finding a support group, here is what you should expect from each type of support group:

A professionally led group should offer professional training in cognitive and bahavioral recovery methods, the latest information on agoraphobia related to recovery, referrals for medication as needed, opportunities for support/counseling for the sufferer and for close friends or family.

A peer led group should offer insight from people's personal experiences in recovery, self-help recovery methods, a supportive atmosphere of care and confidentiality, and information on agoraphobia, treatments, and medications.

Peer led support groups should also promote the use of research proven recovery methods (cognitive and behavioral) and encourage sufferers to be disciplined in the practice of facing their fears using these methods. Peer led support groups can also be a good source of accountability for setting goals and actively striving to meet them.

Finally, peer led support groups should be free of charge. Only pay for a support group if it is led by a professional.

How to know when to seek help for agoraphobia

When I had agoraphobia I went for a long time without treatment. That's because I was busy going to doctors and couldn't admit I had a psychological problem.

Once you recongize you are having agoraphobia symptoms, the question is "How do you know when it's time to seek outside help?"

Here's a general rule of thumb:

If your symptoms are interfering with the regular flow of your daily life it's time to get help. This is when the symptoms are hindering you at work, school, social events, or in your relationships with family or friends.

When you decide you need help, the next question is "what type of help?"

Here's another rule of thumb:

The type or level of help you need should depend on the degree of avoidance behavior. If you are just anxious and have no or mid avoidance behaviors then you probably don't need to see a professional psychologist. In this case, giving yourself a good education on agoraphobia through reading or consulting others who nay have experience with agoraphobia is a good idea. In getting a good education on agoraphobia you will probably be able to learn and use anxiety management techniques to keep the symptoms at bay and function in your normal life.

However, if you are showing signs of severe avoidance behavior that is disrupting your life (like missing work or school) you probably need to find a good individual therapist to guide you or get involved in group therapy.

Tuesday, March 21, 2006

What Causes The Personality Behind Agoraphobia?

The agoraphobia personality I described in the last post isn't just genetic. A number of factors might conspire to create it. If you have agoraphobia, check out the list below and see if you can relate:

1) A parent who models anxiety. Role modeling by a paret can have a powerful influence on a child. If a parent models the anxious personality traits, the child is likely to devlop them as well.

2) Critical parent. If a child has an overly critical parent that places unrealistic expectations on them, this can lead to the child developing a perfectionistic personality.

3) Overprotective parent. An overprotective parent shields their child from life's hardships, acting as if their child couldn't handle life on their own. Overprotection on the part of the parent teaches the child that taking risks in life is too dangerous and that risks should be avoided. It also teaches the child that he or she is fragile and not equipped to face challenges independently. As a result, children of overprotective parents are likely to fear taking risks ad feel anxiety and unsure of themselves in the face of a challenge.

4) Approval based on peformance. Parents who only show approval for their child when he or she does something that pleases them. This type of parent does not make a distinction between what the child does and the child's worth as a person. Children with parents like this may also grow up failing to make that distinction, and feel they must always perform well to be a valuable person. This leads to the anxiety that comes from always having to strive to achieve something to maintain a sense of personal worth. Perfectionistic parents who only give approval based on performance are even worse. Not only do their children learn that they have to perform well to be loved, they must perform perfectly. When a child feels like his or her worth is riding on being perfect, this can lead to a lot of performance anxiety and fear of losing the love and approval of significant others.

5) Rigid family rules. Children who grow up in families with overly strict rules tend to become black-and-white thinkers. As adults, they may end up creating their own set of rigid rules about the way things "should" be, and feel anxiety when these standards are not met.

6) Rigid belief systems. Children who grow up in families that hold rigid belief systems also tend to become black-and-white thinkers becuase parents with rigid beliefs usually model this type of thinking.

7) Surpression of feelings. When children grow up in families where they are taught that it is not ok to express feelings (example: being told not to cry or not to feel a certain way) , they are prone to holding their feelings in as adults. Parents may teach a child that it is not ok to express feelings in several ways: 1) telling the child directly not to feel a certain way, 2) ignoring the child's feelings, 3) reacting with violence or anger when the child expresses feelings. All of these cases lead to adults with bottled up emotions that could cause anxiety or panic.

8) Alcoholism, physical abuse, or emotional abuse. Children from homes with alcoholism or abuse tend to feel anxiety from the insecurity of having an unstable emotional environment. They grow up to become ustable emotionally as adults and are more prone to having an anxiety disorder.

9) Sepration from parents. Children who are separated from their parents for long periods of time without knowing why develop anxiety over separation and loss. This may happen if a parent is sick or in the hospital for a long time, goes on a long business trip, ignores their child for lon periods, gets divorced, or dies.

10) Having to play the parent role too early. When children who are forced into the parent role too early due to a parent being sick, busy, or absent they may develop a a rigid set of rules for themselves in order to survive. This may be the only way they can cope with having adult responsibilties before they are developmentally prepared to handle them. In adulthod, this can lead to many of the agoraphobia personality traits; black-and-white thinking, a high need for control, perfectionism, and unrealistic expectations.

I'm not saying that these factors cause agoraphobia in all cases, but the more of these factors a person experiences in life, the more likely they are to develop the personality traits of agoraphobia.

The Personality of Agoraphobia

Tonight I would like to write about a set of personality traits that are common among people with agoraphobia. These personality traits are not likely to cause agoraphobia alone, but usually conspire with other factors in a person's life to cause the disorder. Still, people with agoraphobia or who are highly anxious will typically have many of these anxiety-producing personality traits:

1) Oversensitvity to emotional stimuli. It takes less stimuli for a person with agoraphobia to respond with feelings of sadness, anger, hurt, rejection, or loneliness, than it does the average person. On the other hand, it also takes less stimuli to make them feel excited, joyful, elated, passionate, or affectionate. People with agoraphobia not only feel emotions more readily, but they also feel emotions throughout their entire bodies (hence, the capacity for panic attacks). The are more likley to have physical responses to emotion than other people. In addition to being overly sensitive to their own needs, they are also highly sensitive to the needs of others.

2) Highly creative and imaginative. People with agoraphobia usually have vivid imaginations and lots of creativity. This can be a blessing or a curse. Imagination and creativity are both great virtues, but with an anxiety disorder like agoraphobia the ability to create powerful visual images of dreadful possibilities can really work against you. People with agoraphobia can come up with an infinite number of negative possibilities to worry about in a given situation. They can also imagine a catastrophic event like having a panic attack in a feared setting so vividly that they can start to hyperventilate because the imaginary experience feels so real.

3) Rigid Thinking. People with agoraphobia tend to perceive everything in extremes or absolutes. Things are black or white, right or wrong, good or bad, fair or unfair. They also have a strong tendency to think in terms of what "should" or "must" be. When they experience events, people or life circumstances to be different from how they think they "should" be, they are easily upset or get anxious.

4) High need for approval. People with agoraphobia are often people pleasers. Because they have a low sense of self-worth, they rely on the approval of others to feel valuable or significant. Because they need the validation of others so much, they are sensitive to criticism and have an extreme fear of rejection. They also have trouble saying no and avoid conflict or confrontation for fear of losing the approval of others. This extreme need for approval can combine with their high levels of sensitivity, causing them to feel responsible for other people's problems and feelings.

5) Perfectionism. People with agoraphobia have a tendency to set unrealistic expectations for themselves and then fear not living up to them. Because they are people pleasers, they also worry about meeting the expectations they perceive others have set for them. Since they consider anything less than perfect a failure and they have an extreme fear of failure, the constant striving for perfection causes people with agoraphobia a lot of worry and stress.

6) Need for control. People with agoraphobia have a high need for events to be predictable and to be able to exert large amounts of control over their environment or circumstances. In many cases, they even feel the need to control the feelings and behaviors of others. They live in fear of losing control and after the onset of agoraphobia, feel a lot of anxiety over hiding their condition to appear to be in control to others.

7) Inhibition of feelings. People with agoraphobia feel a lot of anxiety over trying to hide or supress negative feelings. This may be because they fear losing the approval of others, fear losing control, or feel like they "shouldn't" be feeling a certain feeling. Whatever the case, holding in feelings over a long period of time cause them to build up inside the person. Then when the person gets under stress, they are likely to feel all of their bottled up feelings all at once which causes panic or anxiety.

8) Neglecting physical needs. People with agoraphobia often show the tendency to ignore their bodies needs for rest or proper care. This may be because they are constantly striving towards unrealistic expectations. They are usually only aware that they are tired and need to rest when they become completely exhausted.

Tomorrow I will talk about where these personality traits behind agoraphobia come from.

Friday, March 17, 2006

Why Do Most People with Agoraphobia Take a Year or More to Figure Out What's Wrong and and Even Longer to Start Recovery

Agoraphobia is the fear of having a major panic attack in public or open spaces.

Understanding agoraphobia is the first step toward recovery. However, the average person with agoraphobia takes at least one full year to get diagnosed and even longer to learn enough about agoraphobia to start recovering.

Here are four reasons why:

1) Most people don't know what is wrong with them at first. The symptoms of agoraphobia, especially during panic attacks, feel like those of a physical illness. For example, when you are hyperventilating it is easy to suspect something is wrong with your lungs. When your heart is racing it is easy to think something is wrong with your heart. When you are sick at your stomach day after day it is easy to think something is wrong with your digestive system. Plus, one symptom of agoraphobia is to "scan" your body for physical symptoms and worry about every little twinge as if it may be a major life-threatening illness.

2) Many doctors don’t know how to diagnose agoraphobia. People with agoraphobia commonly visit a succession of doctors trying to find a diagnosis. Most doctors will listen to physical complaints and run tests. They will report that the tests are negative, but often fail to suggest the presence of agoraphobia due to a lack of training. Doctors who can tell that your symptoms are caused by a panic attack may still not be able to tell what type of anxiety disorder you have or provide information about it.

3) Most people go through a period of denial. If finally faced with a diagnosis of a psychological disorder like agoraphobia, the human reaction is to throw up defenses and deny it. Most of us don’t think of ourselves as the type of person who would have a "mental problem" or "psychological disorder." Psychological problems carry a stigma in society that physical illnesses and injuries do not.

The average person tends to consider a psychological disorder as personal weakness or lack of will power. People are more likely to treat a psychological disorder like agoraphobia as your fault than they would in the case of a physical illness or injury. If you were diagnosed with cancer, no one would stand over your bed during chemotherapy and question your will power, work ethic, or desire to go to work or school. But try having agoraphobia. People will do exactly that. Since no one wants to be viewed that way, it is hard for most people to admit to anyone they have agoraphobia.

4) Most people are reluctant to seek treatment for a psychological disorder because of the stigma. Even people who are able to admit to themselves that they have a psychological disorder might still have trouble admitting it to anyone else. It’s hard enough to try to explain irrational fear and panic attacks to your friends and family, and even harder to seek out professional help.

A word to the wise - the best course of action to take if you start experiencing panic attacks or the symptoms of agoraphobia is:

- See a doctor to rule out medical problems.
- Consult a mental health professional to get a diagnosis and/or begin treatment.
- Learn everything you can about your disorder.

Knowledge is the first step to recovery and the sooner you get started on your recovery from agoraphobia the faster it will be.

On the flip side, the longer it takes you to get diagnosed and admit that you have a disorder - the more agoraphobia has a chance to take root, and the more difficult your recovery may be.

If you suspect that you or someone you know might have agoraphobia, don’t take a year to start learning everything you can about it. Start today. You can learn more by reading or asking questions at:

Thursday, March 16, 2006

Is Agoraphobia the Same as Panic Disorder?

Since people with agoraphobia usually suffer from panic attacks, people often ask me if agoraphobia is the same as panic disorder.

The answer is no, but....

Agoraphobia and panic disorder usually come hand-in-hand. Over 95% of people diagnosed with agoraphobia actually have panic disorder with agoraphobia.

Panic disorder (with or without agoraphobia) is defined by:
- frequent panic attacks
- persistent worry about having panic attacks
- worry about the implications or consequences of the panic attacks (like losing control, having a heart attack, or going crazy).
- Significant changes in behavior related to the panic attacks.

Looking at the features of panic disorder, you can probably see why people with panic disorder commonly develop agoraphobia also. Worrying about panic attacks and their consequences can easily lead to fear of being out in public or open spaces and cause one to retreat to “safe” and familiar places.

Less than 5% of people with agoraphobia have what is called “agoraphobia without history of panic disorder.” People in this category fear public and open spaces because of panic-like symptoms but don’t meet the full criteria for panic disorder (according to the DSM-IV). In other words, they may fear going out in public because they are afraid they may get dizzy, faint, or fall helpless to the ground – but do not experience full on panic attacks.

Wednesday, March 15, 2006

Insight Therapy for Agoraphobia

If you have agoraphobia, insight therapy can either help you make a major breakthrough or turn out to be an expensive trap. Insight therapy has not been proven by research to be as effective as the cognitve-behavioral approach, but some therapists do practice it. If you are going to try insight therapy, it's good to know something about it.

Insight therapy comes from Freudian Psychoanalysis which was popular in the early 20th century. In this type of therapy, the patient talks at length about his or her thought and feelings, and the therapist analyzes them. The goal of insight therapy is to figure out the deeper reason behind why you are suffering from a particular psychological disorder. In the case of agoraphobia, the goal would be to figure out what about your life is behind all the fear.

Before you go to a therapist, it might be worth it to try to figure out what is behind your fear on your own. Ultimately, the answer will come out of you, with or without the therapist. Therapists are trained to help you figure it out if you can't do it on your own.

Here are three questions to ask yourself to gain insight into your fear:

1) What life circumstances coincide with your fear?

To answer this question it might be helpful to journal. Recall the times in your life when you have felt the most fear and anxiety, and struggled the most with agoraphobia. Write down what was going on in your life during each of these times and then look for themes.

Many people with agoraphobia discover that their symptoms are the worst during times when they
- felt stuck in a bad situation they couldn't get out of
- felt like they really needed to or should do something but felt helpless or powerless to do it
- felt like they were being negatively affected by circumstances beyond their control
- felt like they were never good enough for themselves or for someone else they could not please

2) What emotions went along with these circumstances?

The answer to this question could be one of a myriad of negative emotions. You may have felt angry, frustrated, sorrowful, sad, ashamed, anxious, nervous, guilty, weak, helpless, overwhelmed or simply out of control.

3) What type of fear did your circumstances or emotions lead to?

Some possibilities would be:

- fear of failure
- fear of insignificance, or lack of purpose
- fear of losing control
- fear of loss
- fear of identity or role loss
- fear of losing approval
- fear of abandonment or isolation

The idea behing insight therapy is that once you can answer these questions you can start to do something about getting free from agoraphobia. You can exert power to change your circumstances once you know what is leading to the fear. Cognitive-behavioral therapy offers a faster road to recovery from the symptoms of agoraphobia, while insight therapy offers the possibility of slowly removing the psychological roots of the fear so it won't come back.

Put another way, cognitive-behavioral therapy may help you get well, and insight therapy can help you stay well.

Here is an example of how insight therapy can be used on your own to recover from agoraphobia:

A young boy grows up with parents who put immense pressure upon him to perform in school, but he is more interested in sports. Though he makes b's in the classroom, he excels in sports. The b's are not good enough for his parents and he is scolded and punished for doing so "poorly" in school every time he brings home a report card. When he begins high school, he starts falling behind in classes because sports are taking so much of his time. After receiving poor grades on his first tests, he starts having panic attacks every time he goes to class. he becomes afraid to go to school because of the panic attacks and its not long before he is housebound with agoraphobia.

Although he "recovers" and finishes high school, he experiences panic attacks and hyperventilation two more times in his life. One time is when he is in a job with boss he can not please no matter what he does. The other time is during a relationship with and engagement to a woman whom he can never please either.

After journaling about the times in his life when he experienced panic atttacks, he comes to the realization that they all had one thing in common - they occured when he was caught in a relationship of some form with someone significant he felt unable to please. This made him feel helpless and nervous and led to fears of failure and loss (loss of approval, a job, and a fiancee).

After choosing to work for and be in relationships with people whom he could please, his anxiety lessened and he quit having panic attacks.

Of course, this example is overly simplified, but it illustrates how insight therapy can work.

Sometimes it is not so easy to get insight. In some cases your feelings may be unknown to you or lurking at a subconscious level. That's when it might be helpful to consult a therapist, but if you do you should proceed carefully and follow a few guidelines:

1) Tell the therapist what your goal is - that you are recovering from agoraphobia and that you need help discovering the life circumstances and feelings that are behind your fear.

2) Make sure the therapist is willing to share direct and honest conclusions with you.

3) Agree on how many sessions the therapy is expected to last. Make sure the therapy can be done in no more than 5-6 one-hour sessions. An experienced therapist should be able to provide the insight you need within that length of time.

Following these guidelines will keep you out of an expensive trap with a therapist who takes forever leading you to your own conclusions. If you pay for professional help, you are paying for the therapist's insights and you don't want to get caught in a never-ending therapy program where you are expected to keep coming to therapy until you make your own.

Also, it's easy to get too comfortable with therapy or attached to the therapist if it goes on too long. Especially if you are isolated, lonely, and need someone to talk to. Remember that if you have agoraphobia, your goal is to get well, not to settle into a comfort zone and get content with just talking about your illness with a friendly, caring person.

Your life is too valuable to spend suffering from agoraphobia.

Monday, March 13, 2006

Coping with Agoraphobia: Enjoying The Present Moment

One time when I had agoraphobia my therapist asked me what I was worried about. I told her I was really anxious over the idea of trying to go back to school at the end of the summer and being trapped sitting in crowded classrooms.

My therapist brought up a good point, that it was still summer vacation. She reminded me that since school was not starting the next day or anything, to practice enjoying the present. Enjoying the present moment, as she called it, would distract me from worrying about the future and thinking catastrophically.

Enjoying the present moment is a good way to cope with daily life when you have agoraphobia. This is not necessarily a recovery technique, but a way to cope with anxiety about the future while you are recovering.

If you have agoraphobia then you probably feel some level of anxiety most of the time, even if you are in your safe place and are not having a panic attack. That's because most of us with agoraphobia experience some degree of anxiety about the future all the time. Learning to focus on the present moment is an effective way to cut down on free-floating, anticipatory anxiety that comes with agoraphobia.

To focus on enjoying the present moment, it is important to use all of your senses and treat whatever you are doing, or whatever is around you like it is the most important thing in the world.

For example, you can enjoy the present moment when you are eating:

- slow down and take a look at your food before taking a bite.
- become aware of how the food is aranged on your plate.
- take notice of the colors, textures, and shapes of the food
- put a small bite on your fork or spoon and take time to smell its aroma before putting it in your mouth.
- put your food on your lips first, and then on the tip of your tongue to taste it.
- when you put it all the way in your mouth, wait a moment to bite down.
- chew the food every slowly and thoroughly, noticing small changes in tastes and textures with every bite.
- move the food to different parts of your tongue, noticing subtle differences in tastes.
- when you swallow, concentrate on how the food feels going down your throat.
- repeat these suggestions, savoring every bite, and take at least 20 minutes to finish the meal.

You can also enjoy the present moment when you are taking a walk outside, although this may be a little more difficult at some stages of agoraphobia. But if you can feel safe taking a walk through your neighborhood:

- stand still and breathe deeply and quietly five times before starting your walk.
- for the first few minutes, notice every sensation in your leg muscles as you walk, focusing on your things, calves, and then your ankles.
- then, for the next few minutes, notice how the bottom of your feet feel as they touch the ground. Notice how the heel makes contact with the ground first, then the foot rools, and then you push off with the ball of your foot and toes.
- focus on the rythym of your walking, feeling the pace of your legs and swinging your arms. Continue to do this for a minute or two.
- now focus on the rythym of your breathing, focusing on how the air flows into your nose and to your lungs, Exhale each breath through your mouth.
- now move your attention betweem your feet, legs, walking rythym and breathing, focusing on each for a few minutes at a time.
- if troubling thoughts come into your mind, simply take notice of them. Watch them as you would watch clouds float by overhead and let them float right out of your mind.
- practice meditation for about five minutes during each walk, focusing on something pleasant. If your mind starts to stray from your object of meditation, gently bring it back.

The more you learn to focus on what you are doing in the present moment, the less you will focus on being anxious about the futre. Its that simple. Living in the moment is a great technique to use to get through the day if you have agoraphobia.

Sunday, March 12, 2006

Agoraphobia Strategy: Getting Your Imagination To Work For You Part 2

Besides dreaming up a secret place when I had agoraphobia, I used my imagination to create positive visualizations of myself being anxiety-free in real life.

I pictured myself sitting calmly in a classroom at school surrounded by other students. I saw myself coming up to bat in a baseball game and getting a game-winning hit. In the same way, I pictured myself shopping in the mall, sitting in church, or having fun with friends.

In each of these visualizations, I was careful to create added sensory details with my mind. I would not only see each image, but also hear it, smell it, and touch it.

For example, when I pictured myself sitting in the classroom, I saw the faces of the students around me and words written on the chalkboard. I heard the sound of my teacher’s voice as she gave the lecture. I felt the texture of the surface of the desk I sat in, and of the pages in my notebook. I felt the pen in my hand as I took notes. I spent time picturing each scene and let my mind fill in every detail I could think of.

Most importantly, I pictured myself sitting there in my desk calmly breathing, slowly and deeply, totally free of any worry or panic. In this way, I was able to experience the success of recovery and leading a normal, anxiety-free life before I actually recovered. The more I was able to see it in my mind, over and over, the more these images of success became a reality.

How to Pair Visualization with Relaxation Exercises

One of the more effective things I did was to pair visualization with my breathing and muscle relaxation techniques. Over time, this developed a mental association between positive mental imagery and a deep sense of calm in my body.

I started each relaxation session with deep breathing first. Then tensed and relaxed each muscle group until my body felt limp. Once my breathing was slow and deep and the tension in my muscles was released, I visualized myself at my secret place. This added a visual component to my relaxation response. Then whenever I started to feel anxious in public and said my cue word to trigger relaxation (see chapter seven), I could close my eyes and add a visual dimension. I did this by picturing my secret place which I had also learned to associate with a deep sense of calm.

Another way I used mental imagery was to visualize successes in real life while doing my relaxation routine. For example, I pictured myself being calm in public while doing deep breathing or muscle relaxation exercises. Then when I found myself in a setting that usually caused anxiety, like school, I associated that setting with deep relaxation after having pictured it so many times in my head when I was relaxing at home.

Practicing positive visualization, places I used to associate with panic became associated with deep experiences of peace and relaxation. Even though I only imagined these experiences of calmness and success, my mind started building positive associations related to places and situations I once feared. These new positive associations were as powerful as if I had experienced each imagined success in reality.

How to Put Together a Successful Visualization Program

Here’s a summary of how you can harness the powers of your imagination and make them work for you in your recovery from agoraphobia:

1) Develop a secret place and write out a script that you can record or have someone read to you. Then if you can’t find a place you feel safe and relaxed in real life, you will have one in your mind. You can always close your eyes and let your mind take you far away.

2) Practice positive visualization at least twice a day. Practice at least once in the morning and once in the evening before bed.

3) Combine positive visualizations of being calm in feared settings with deep breathing and muscle relaxation exercises. This way, positive visualization becomes part of your overall relaxation response and you can learn to visually associate relaxation with places you once feared.

I know from experience that if you can picture a new reality in your mind, you can eventually experience that reality in real life. Even if it feels like reversing the flow of a mighty river at first, by reversing the current of your creative powers to get them flowing in a positive direction, your imagination will become an asset for you in your recovery from agoraphobia.

Agoraphobia Strategy: Getting Your Imagination To Work For You

Most people with agoraphobia have a great imagination. People with agoraphobia are able to imagine the most terrible possibilities in any circumstance and their catastrophic imaginings are vivid enough to produce fear and panic.

One key to recovering for agoraphobia is getting your imagination to work hard for you instead of against you. The cognitive strategy that has been developed to do this is commonly called "positive visualization."

I turned a major corner in my recovery from agoraphobia when I could visualize situations that evoked pleasant emotions as clearly as I could visualize situations that evoked fear. Through practicing positive visualization at least twice per day, I put my creative powers to work for me.

I used the power of my imagination to help me in two ways. First, I used it to create a place of tranquility in my mind. I could always retreat to this place when I started to feel anxious or visualize something negative. Second, I used it to picture myself being calm while sitting in class among other students, going to the shopping mall, playing in school sports, or attending church again. These visualizations let me practice feeling calm in anxiety-producing situations without going anywhere.

Using my imagination in my favor, I was able to experience and feel as if I had recovered from the anxiety disorder in my mind before I actually did. Once I was able to feel and see recovery in my mind’s eye, my reality was soon transformed.

How can you create a private retreat in your mind?
Harry Truman once said, "I have a foxhole in my mind." This meant he had created an imaginary place where he could go to escape the pressures of the outside world. I read about this when I had my anxiety disorder and thought it was a great idea. I figured if this worked for the 33rd President of the United States, then it might work for me.

I used my imagination to create a secret place in my mind where only I would go. I carefully imagined what it might look like, and what sounds and smells I might experience there. Once I imagined this secret place in minute detail, I wrote out a script that described it. I recorded this script on tape so that I could either listen to it myself read it or have my mom read it to me. My script went something like this:

"Lie back, close your eyes and imagine you are entering a place of ultimate relaxation that no one knows about but you. You are walking along a dirt path in a forest beside a stream of cool running water. The water is clear and you can see the forms of rocks below the stream’s currents. Tall trees are all around you providing shade from the sunlight that peeks through their branches. You can hear birds chirping and see butterflies fluttering through the air.

After you walk for a while you stop to lie down in some grass by the stream. As you lie back in the grass you close your eyes and focus on the sound of water gently flowing by. The gurgling of the stream and the chirping of the birds brings you a deep sense of peace as you relax alone, surrounded by nature. You can also smell the fragrant aroma of the pine trees wafting trhough the air.

You don’t have to do anything or be anything here. No one will ask you to do anything or expect anything of you. In fact, no one will ever find you here. You are completely free to lie down and relax for as long as you want to stay here. You feel your body go limp as you lie on your back in the grass without a care in the world."

My script was actually longer than this but you get the idea. I shared this much to encourage you to write your own.

Your imaginary retreat doesn’t have to be in nature. It can be a palace on a cliff overlooking the ocean. It can be a monastery in the middle of the desert. It can be a warm, sunny day at the beach. It can be anything or any place you want it to be.

The important thing is that you create a place in your mind that you can visit any time just by closing your eyes. Then when you are in an anxiety-producing situation, you can close your eyes and take a trip to your personal place of tranquility.

Here are some things to remember when creating a secret, imaginary place in your mind:

1) Have fun with the process and enjoy yourself. Treat it like planning a real vacation.

2) Let your imagination run wild. Use your creativity to come up with a place that would feel the most iviting and relaxing to you.

3) Include details that involve all the senses if you can. Include, touch, taste, smell, sounds and sights.

4) Add as much description as possible to make it real. Use a thesaurus to come up with adjectives if you need to.

5) Make your script long enough to give your body time to get into a deep state of relaxation. You might want to create a script that takes at least 15 or twenty minutes if read slowly.

6) Record your script in a soft voice with relaxing music in the background. You might even ask a familiar person who has a voice that relaxes you to read it for you.

7) Include statements that suggest relaxation like "Your body feels calm and relaxed from head to toe" or "Here in this place, you have nothing to worry about, no one you have to please, and no obligations to fulfill."

Positive visualization works because our subconscious mind doesn’t always distinguish between the real and the imagined. Our thoughts and what we see in our minds has great influence on our emotional state, even if it is pure fantasy. Creating an inner life gives your mind a break from thinking about all of the stresses that may be bombarding you.

If you have agoraphobia, then you probably have a powerful imagination that will make it easy to imagine a secret place. Creating a private retreat in your mind will be the first step toward harnessing the power of your imagination and making it work for you in your recovery from agoraphobia.

Agoraphobia Strategy: The Principle of Non-Resistance

Here is a strategy to use your mind to overcome the panic attacks that are part of agoraphobia:

Practice non-resistance by trying to have a panic attack.

Go ahead. Try to hyperventilate. Try to get dizzy and faint. try to sweat and get your stomach tied up in knots. Try to make your mind spin out of control.

Guess what? If you actually try to bring on a panic attack you probably won't be able to. Trying to bring on a panic attack is probably the best way to avoid having one.

So why does this work?

Think about it - panic attacks rely on tension and anxiety to fuel them. In the case of agoraphobia, a lot of the reason people with agoraphobia have so many panic attacks is because they fear having them so much. In other words, panic attacks rely on tension between you and the panic to occur.

Here is how to ensure that you will have a panic attack:

1) Worry about having a panic attack.
2) Avoid all situations where a panic attack might happen.
3) Set the goal for yourself of never, ever having another panic attack no matter what.
4) Try to ignore any tension in your body that feels remotely like panic.
5) Try really hard to brace yourself against and actively fight off a panic attack through sheer will and determination if you start to feel one coming on.

If you do these things you are sure to increase the number of panic attacks you have because you are increasing the tension between you and the panic.

To stop having panic attacks, its better not to resist them. If you start feeling panic just go with it. Accept what is happening, face up to the symptoms, and just let some time pass. Whatever you do, don't put up a fight against it. When you give up the fight against panic, paradoxically, it will lose its power over you.

I was watching a movie the other day where a man with a gun tries to kidnap a girl and hold her for ransom. He threatens to shoot her if she does not come along with him. Ironically, she was about to commit suicide when he found her, so she does not care if the kidnapper shoots her. She even asks him to go ahead and shoot her to save her the work of jumping off the roof of the building. Because the girl actually wants to die and is inviting him to shoot her, the kidnapper cannot scare the girl into following him by threatening to shoot her. In effect, he has no power over her.

That's how it is with panic. If you stop resisting panic attacks and try to force a panic attack on yourself instead, the panic will loose its power over you. I know it sounds strange and you may be very skeptical, but try it. More times than not, when you try to bring on a panic attack, you find it absolutely impossible to have a panic attack.

When panic loses its power over you, you are one giant step closer to overcoming agoraphobia.

More Agoraphobia Thought Stopping: Focusing

If you have agoraphobia, a technique most recovery books call "focusing" is another way to stop irrational thoughts before they turn into anxiety or panic.

Most good athletes perfect this technique to block out possible distractions and anxiety in situations where the pressure is on. A baseball pitcher may see only the catcher's mitt. A basketball player may see only the rim as he shoots. A kicker in football may see only the goalposts. None of these athletes, when focusing, will hear the noises of the crowd, or see banners waving that are meant to distract them, or even pay attention to their own internal doubts and insecurities about their performance. They are lost in the moment and focused on what matters.

If you have agoraphobia practice focusing to shut out irrational thinking that leads to anxiety and panic. As soon as you catch yourself thinking an irrational thought, willfully focus your thoughts on something else as if it were of utmost importance. You can focus on anything, and the more senses you can engage the better.

A good example of focusing is in Albert Camus' The Stranger, where the main character does not hear a judge speaking his death sentence because he is caught up in enjoying the colors on his lawyer's tie.

You can choose anything to focus on:
1) Try to remember what you did last weekend.
2) Sing the lyrics of a favorite song.
3) Try to estimate the temperature in the room.
4) Guess what material a chair or piece of furniture is made out of.
5) Count the number of ceiling tiles.
6) Put your hand on your wrist and take your pulse.
7) Feel the thickness of two books and try to decide which one has more pages.

The more you can learn to focus on things from your immediate environment and focus as if your life depended on it the better. The main thing is that you distract yourself from whatever irrational thought has come into your mind and to keep it from staying around long enough to cause anxiety, panic, or another symptom of agoraphobia.

Agoraphobia Thought Stopping

For people with agoraphobia who are trying to defeat the irrational thinking that causes unneeded anxiety, one alternative to thought replacing (see earlier post) is thought stopping.

Thought stopping was one of the first types of cognitive therapy. The technique of thought stopping is just what it sounds like. Once you learn to identify your irrational thinking, you can say the word, "stop" out loud or to yourself every time you catch yourself thinking an irrational thought. You can even add a visualization like picturing a big red stop sign, a bright red traffic light, or flashing red lights at a railroad crossing right before a train comes.

Saying "stop" and visualizing something will distract you just long enough to take your focus away from the irrational thought. If you don't think this works then try it. You will be surprised at how this simple exercise can cut off irrational thinking right after it starts, and before it turns into anxiety, or full-on panic.

Agoraphobia Thought Replacement, The Alternative To A Lobotomy

When you've got agoraphobia and are thinking in all of the irrational ways I've described in recent posts, then you've got to take one of two options if you want to stop anxiety-producing thought patterns:

A) Get a Lobotomy

B) Practice Thought Replacement

Since option B is the most practical, I am going to discuss the practice of thought replacement in today's post. Thought replacement is referred to as "cognitive restructuring" by most psychologists and is the most basic form of cognitive therapy. Thought replacement is basically just trading your old irrational, anxiety-producing thoughts for more rational ones. The good news is that you can practice it at home by yourself without the supervision of a psychologist.

After having agoraphobia and studying psychology through to the graduate level, I've read quite a few books on cognitive therapy for anxiety disorders and agoraphobia. They all prescribe the same three steps so here is my version (the three R's):

1) Record
2) Replace
3) Rehearse

First, record your irrational thoughts. Being able to recognize your irrational thinking is the first step to changing it. This means tuning into your self-talk on a regular basis and journaling. Each time you notice yourself feeling more anxious than usual, ask yourself what thoughts are causing the anxiety and write them down as one or two line belief statements.

Example: "I have to be liked and accepted by everyone to be a worthwhile person. Since Joe does not seem to like me, there must be something wrong with me."

Do this for about a week and at the end of the week, prioritize between five to ten thought statements to work on. Pick the thoughts that either arise the most frequently or cause you the most anxiety. If you can, decide why they qualify as irrational and categorize them according to the ten categories (check other posts from this month to see defintions and examples of each):

1) catastrophic thinking
2) black-or-white thinking
3) magnifying the negative
4) overgeneralizing
5) emotional reasoning
6) personalizing
7) negative mind reading
8) rigid expectations
9) fatalistic thinking
10) accepting an unreliable authority

The above example falls into the categories of rigid expectations and personalizing. (Some irrational thoughts may fall into more than one category, the idea is just to become aware of how your thoughts are irrational).

Second, replace each irrational thought statements with more rational ones.

Example: "I have to be liked and accepted by everyone to be a worthwhile person" can be replaced by "It's ok if everyone does not like and accept me. Even the best people have a few people that don't like them."

List all of your replacement thought statements and keep a copy with you at all times so you can rehearse them.

Third, rehearse each replacement thought on a regular basis. Pull out your list of replacement thoughts at leat ten times per day and review each one. You can also use these statements as affirmations when you are doing breathing or muscle relaxation exercises. Once you have learned to identify irrational thoughts for what they are and create replacement thoughts that are more rational, confront your irrational thinking in the moment it occurs. Each time you catch yourself thinking an irrational thought that you have rehearsed, immediately say the replacement thought to yourself several times.

Thought replacement does not happen overnight, but if you practice this over a few months your thought patterns will be retrained and will not produce so much anxiety. Remember, cognitive therapy on its own is not nearly as effective as it can be when combined with behavioral therapy (like cue-controlled relaxation, systematic desensitization, and flooding).

If you have agoraphobia, I wish you all the best in your recovery.

Saturday, March 11, 2006

Agoraphobia Thoughts: Rigid Expectations, Fatalistic Thinking

Here are two more irrational thought patterns that people with agoraphobia often practice - holding rigid expectations about how things "should" be and feeling like they have no control over their circumstances.

Rigid Expectations: Thinking of personal preferences, wants, or choices in terms of absolute rules. Rigid expectations are usually expressed with words like “should,” “ought to,” “have to,” and “must.”

This type of thinking leads to anxiety because you end up focusing on something you think is wrong and are likely to becomne critical of whoever or whatever is not meeting the rigid expectation. Because in many cases, the rigid expectations are applied to yourself, this type of thinking tends to promote a lot of self-criticism.

When you hold rigid expectations, you think of anything that falls short of the inflexible standard you have set as totally unacceptable. In effect, you have entered an idealistic fantasy world where everything is supposed to be exactly how you think it should be or you feel anxiety.

Examples of rigid expectations:

“I should be liked and accepted by everyone or I am not a worthwhile person.”

“I have to be able to finish my workout before 7 AM every morning or it won’t be a good day.”

Fatalistic thinking: Thinking of yourself as powerless to make choices or affect the outcomes of your own life. Fatalistic thinking is holding the belief that the forces that govern your life circumstances lie completely beyond your control. This is a way of not taking responsibility for your decisions and behavior.

For people with agoraphobia, it is also a way of avoiding responsibility for doing things that might cause anxiety. People who engage in fatalistic thinking often say “I can’t” when they really mean “I don’t want to,” “I am afraid to,” or “I won’t.:

Examples of fatalistic thinking:

I am supposed to go to a conference for work, but it will mean flying in a plane to get their and I am afraid to fly. I say to a co-worker, “I can’t go to the conference because the company can’t really afford to send another person.”

I don’t want to go to class because I am afraid to take a test. I tell my parents, “I can’t go to school today because I feel too sick.”

Fatalistic thinking may start out as consciously making excuses for things someone with agoraphobia would be afraid to do, you event. However, people who talk this way often start believing that their life circumstances really are out of their control. When you perceive the important outcomes of your life as in the hands of fate, you are setting yourself up for feelings of powerlessness, fear, and anxiety.

For most people with agoraphobia, fatalistic thinking gets combined with rigid expectations to cause even more anxiety. That’s because when people holding rigid expectations for themselves succumb to fatalistic thinking, they live in a world caught between what they “should” do but “can’t” do.

An example of this “should but can’t” thinking would be if someone with agoraphobia experienced the death of her mother and the funeral was to be held out of town and would require a drive of several hours. This person might think to themselves, “I really should make the funeral or I am not being a good daughter. Missing my own mother’s funeral would be absolutely unthinkable. But I can’t make it because I can’t drive. What if I had a panic attack and got into a major wreck.”

The person in this example is caught in the classic bind between rigid expectations and fatalistic thinking. There is something she “should” do but feels like forces beyond her control will prevent her. She is likely to feel guilty about missing her mothers funeral and anxious because she doesn’t think she can do anything about it. She is likely to compound her anxiety with self-criticism.

Most people with agoraphobia experience these binds all the time, and live in a near constant state of self-criticism and anxiety as a result.

Agoraphobia Thoughts: Overgeneralizing, Emotional Reasoning

Since agoraphobia is something everyone hasn't heard of, I want to make sure that anyone reading knows that in my recent posts I have been going through the different types of irrational thinking that someone with agoraphobia would do. Plus, I am putting in some posts about how to get free of these types of thinking.

What I have been calling "Agoraphobia Thoughts" are not actually symptoms of agoraphobia. They are more or less just thought patterns that most people with agoraphobia have, and that contribute to the anxiety someone with agoraphobia feels.

No one type of irrational thinking is fully responsible for agoraphobia. But together they cause enough anxiety to make someone start having panic attacks and hiding in their home.

So anyway, here are a couple more types of thinking that go with agoraphobia - overgeneralizing and emotional reasoning.

Overgeneralizing: Assuming something that happened one time in one place or situation (usually a negative event) will continue to happen in all places and situations. If you have agoraphobia, you will be familiar with overgeneralization because overgeneralizing after your first panic attacks is probably what led to agoraphobia.

Examples of overgeneralizing:

I have my first panic attack and think to myself, “If I had a panic attack at work then I am in danger of having panic attacks every time I go to work or anywhere else.”

I fail one important test and think to myself, “If I failed this I will always fail.”

Emotional reasoning: Using emotions, or how you feel, as evidence to back up irrational thinking. Doing this can lead to inappropriate emotional responses to events or circumstances (such as panic or anxiety) as well as self-defeating behaviors. Emotional reasoning is sometimes done in the face of objective evidence to the contrary.

Examples of emotional reasoning:

I go to a party and don’t see anyone I know. I have trouble getting a conversation started with the first few people I talk to. After a while, I feel self-conscious and anxious. Instead of trying a little harder to be friendly, I start to withdraw and think to myself, “I shouldn’t really be here. I don’t really fit in and the people here would never like me or accept me.”

I approach an attractive woman at a social event. As I start to talk to her I feel shaky inside and like my heart is about to jump out of my throat. Even though she smiles and responds to me politely, I respond to my inner feelings and tell myself, “She really doesn’t like me or find me attractive. She is just being friendly but she is way out of my league. I shouldn’t have approached her in the first place. What was I thinking?” I make short work of the conversation and excuse myself to talk to someone else.

Emotional reasoning compliments overgeneralizing and plays a key role in the development of agoraphobia. Most people who develop agoraphobia interpret the place or situation where they have their first panic attack as dangerous because they don’t recognize what is really happening. As a result, they practice avoidance behavior and stay away from the scene of the panic attack. Once they have experienced multiple panic attacks and deemed an increasing number of places as dangerous, they overgeneralize these feelings and start to believe that it is dangerous to go anywhere besides a few safe places.

Friday, March 10, 2006

Agoraphobia Strategy: The "South Beach" Diet for Your Mind

After talking about the different ways people with agoraphobia think that creates anxiety, I'd like to share the strategy for "restructuring" (replacing) agoraphobic thoughts that worked for me.

This strategy has to do with changing your self talk. Your self-talk is not only a reflection of your thoughts, it can be a tool to change how you think. You can use this strategy to change any of the irrational thought patterns associated with agoraphobia.

Self-talk is the diet of the mind. Whether or not we’re aware of it, all of us are constantly talking to ourselves. Though we can do this with spoken words, much of our self-talk comes in the form of thoughts. The message of this internal dialogue is the nutrition on which our mind feeds.

If you have agoraphobia, ask yourself:

What kind of diet is your mind eating? Is it healthy for you or is it junk?

Just as some diets can make you sick and other diets promote your health, so it is with the nature of your self-talk. Negative messages are destructive to the mind while positive messages heal. Whatever type of messages your mind constantly chews on and digests will lead either to positive or negative cycles in both your thinking and in your life circumstances.

Consider the following suggestions to be like putting yourself on the "South Beach" Diet for your mind.

Tune into your self-talk

Self-talk can be like a radio frequency. There are always radio waves in the air around us, but we don’t hear them unless we tune into them with a radio. My suggestion is to tune into the channel of your thoughts and find out what you are telling yourself all day. You first need to first become aware of the messages that are going into your mind before you can change them.

It might help to set an alarm on your watch to remind you to pay attention to your thoughts. Set the watch to go off at one hour intervals. Each time you hear the alarm, focus in on what your mind is thinking and write it down. Then, at the end of each day, you can go back and read your journal to see what thoughts are accumulating in your head over time.

Personally, I found that a lot of my self-talk was subconscious and was escaping my notice. I heard messages such as:

“You can’t be among other people five minutes without hyperventilating.”

“The house is the only safe place for you.”

“You have to be perfect to be accepted by others.”

It’s not like I was walking around all day purposely telling myself I was a fearful, nervous person who would be scared by most everything. However, when I paid closer attention to ongoing thoughts, I realized I was doing this subconsciously.

Take responsibility for what you are telling yourself

Once you become aware of your self-talk, you can take responsibility for the messages you are sending yourself. This means telling the difference between the messages others are sending you and the messages you are sending yourself.

This was the hardest step for me because I liked to blame my anxiety on others. For instance, once I realized that anxiety over school performance was related to my disorder, I wanted to blame my mom for putting so much pressure on me in school.

My mom didn’t always put pressure on me in words. She usually did it non-verbally through disapproval, implication, and through praising my brother for his academic performance. She displayed our report cards on the refrigerator each quarter which made it obvious that my brother made straight A’s and I did not. In any event, the message I received from her was that in order to be a capable, responsible and lovable person, I needed to take the most advanced classes for my grade, turn in every homework assignment on time, make A’s on all the tests and, of course, an A in every class.

For a while, I thought if only my mom would ease up on her expectations for me in school I would get better and have fewer panic attacks. That was putting the responsibility for my anxiety symptoms on her and handing her control of my mental health.

I eventually discovered that it wasn’t the messages I received from my mom that kept me so anxious about school. It was the messages I sent to myself!

Sure, my mom let it be known that she expected something near perfection from me in school, but I had bought into her way of thinking and was telling myself the same thing! If she had gotten off my case altogether, I would still have been telling myself that I was not a capable responsible or lovable person because my performance in the classroom wasn’t as perfect as my brother’s.

I had even added something to the message. I was not only telling myself that I needed to be near perfect in school, but that I needed to please to my mom to feel good about myself. Listening to my self-talk helped me take responsibility for my own feelings and admit I was putting unrealistic expectations on myself.

Replace self-defeating thoughts with positive ones

Once I identified my self-talk and took responsibility for sending myself the messages that were shaping my beliefs, I started to replace each self-defeating message with a positive one.

For example, I told myself that I was a responsible, capable, lovable person even if I didn’t take all advanced classes, do every homework assignment, and make A’s on everything. I told myself that I could be just as responsible and capable while dividing my time between schoolwork and sports, being truer to my own interests and goals.

I also told myself that I didn’t need to please my mom to feel good about myself or be lovable. Sure, I loved my mom and wanted to see her happy, but not at the cost of the anxiety I felt trying to live up to her standards for me.

Once I replaced my negative self-talk with a diet of more encouraging messages, I was able to form new beliefs about what it meant to be capable, responsible, and lovable. I felt a lot less anxiety about my schoolwork and about pleasing my mom and felt a lot better about myself.

I had to identify and replace a lot of negative messages during my recovery from agoraphobia, more than just the ones about my performance at school. I replaced negative messages I was sending myself about my athletic ability, my appearance, and what God thought of me.

So here are three steps for replacing negative thoughts with positive ones:

1) After you have journaled your thoughts at intervals for a day or two, list the top four or five negative statements you are telling yourself.

2) Next to each negative statement, write a positive statement that is the exact opposite of the negative one.

3) Make it a habit to tell yourself each of the positive statements at least ten different times during the day.

4) Keep repeating the positive statements to yourself until the negative statements fade away. This could take weeks, months, or even years. The important thing is to persist until the negative thoughts are totally extinguished and you are completely free from their influence.

If you have agoraphobia, changing your negative thoughts will go a long way in reducing your anxiety.

Agoraphobia Thoughts: Perfectionistic Thinking

Today I will share two more ways that most people with agoraphobia think that sort of compliment each other.

Black-or white thinking (also called all-or-nothing thinking): Viewing everything in terms of absolutes or extremes. Things are either right or wrong, good or bad, with no in between.

Perfectionism goes hand-in-hand with all or nothing thinking. People who think this way are often perfectionists, putting themselves under a great deal of unnecessary pressure with unrealistic expectations, which increases anxiety and fear of failing. If their unrealistic expectations are not met, they tend to label themselves as “bad” or a failure.”

Examples of black-or-white thinking:

I get a chance for a promotion at work and think, “If I don’t get this promotion at then I am a total failure in my career.”

I find out a friend has lied to me one time and I think to myself, "I should have known he really was a bad person all along."

Magnifying the negative: This type of thinking is a close cousin to black-or-white thinking. Magnifying the negative means dwelling on the negative aspects of something and making it seem much larger than the positive aspects. You will often hear people who think this way making statement that start with "yeah, but."

Examples of magnifying the negative:

After winning a baseball game I think, “Yeah, but since I made an error I really didn’t play a very good game.”

Someone tells me they really enjoyed an article I wrote and I say, "Yeah, but I wrote that in a hurry and there were several mistakes in it. I wish I had a chance to edit it better. Next time I will be a lot more careful."

Magnifying the negative compliments black-or-white thinking. If you are a perfectionist who does both, then you are always able to point out a flaw in yourself, your performance, or a situation, which gives you justification for labeling everything as "bad," "flawed," "disappointing," or otherwise short of perfection.

People with agoraphobia lived trapped between the need to reach perfection and the sheer inability to ever perceive anything as such. As you might guess, the tension between these two is part of what fuels the anxiety that underlies agoraphobia.

Thursday, March 09, 2006

Agoraphobia Strategy: Worst Case Scenario Method

Got agoraphobia, panic disorder or some other anxiety disorder?

Need to get over catastrophic thinking? Then get comfortable with the very worst thing that could happen to you.

When I had agoraphobia and used to worry about panic attacks all the time, my dad taught me this simple mind trick (or cognitive strategy).

One night when I was telling my dad about my fear of sitting in classes at school, he asked me what I thought was the worst thing that could happen. When I told him I was afraid my lungs would stop working or my heart would stop beating, he asked, “What then?”

To that I responded that I might collapse and either pass out or die in front of everyone in the class. Then my dad asked me if I really thought that could happen. I thought about all of my panic attacks and had to admit that I had never even passed out before. I had been through some pretty intense panic so it was unlikely I would ever really pass out. I certainly would not die.

My worst fear was really being so uncomfortable that I needed to leave the class and would be embarrassed in front of my classmates. My dad asked me if I could live with that. I said it would be hard, but it wouldn’t be the end of my life or anything. I eventually reasoned that there was no danger of dying from a panic attack. Once I left high school whatever happened in class wouldn’t really matter.

The more comfortable I became with having a panic attack in front of my classmates, the less anxiety I had about going to class. Ironically, I was able to focus more during class as well. I found that surrendering my mind to the very worst thing I thought could happen freed my mind from worrying so much about it and allowed me to focus on the present moment. Also, once I got used to the worst case scenario I found that most experiences, even the worst panic attacks, did not live up to the worst scenario I could imagine. They seemed less threatening by contrast.

I don't know if this technique officially qualifies as cognitive therapy - but this was one of the methods that helped me to stop having panic attacks and get over agoraphobia.

Agoraphobia Personal Story: Losing Sleep Over a Hot Girl with a Dead Grandmother

After I wrote that last post on catstrophic thinking and negative mind reading I went to the gym. While I was working out tonight, I thought of a time right before I had agoraphobia and did both. Here's the story:

As an eighth grader in first period algebra class, I sat behind an attractive girl I will call Kimberly. Though I had trouble getting up the confidence to talk to Kimberly, she had to acknowledge my presence twice a day. Once when we passed our completed homework up the rows and another time when we passed the new homework back down the rows. Even though we didn’t talk, she at least knew I was sitting there behind her.

One morning when I felt more confidence than usual because of a school basketball game I had played in the night before, I came to class planning to talk to Kimberly. Much to my disappointment, when we passed our homework to the front that day, she reached back for the papers without turning around or looking at me. When the new homework was passed down the rows, she just held the papers over her shoulder without turning around again. This shot what little confidence I had and my heart sank. I left class that day without talking to her once again.

I felt anxious for the rest of the day and had trouble sleeping that night. I was preoccupied with what Kimberly thought of me and why she didn’t turn around to pass me the papers in class. I thought maybe I had done something to make her mad.

The next morning when I arrived at algebra class, I could feel my heart pounding. I waited anxiously for Kimberly to arrive. She never did. I lost more sleep that night.

When Kimberly returned to school a day later, my anxiety over her behavior overrode my fear of talking to her. I found out that a grandmother who was close to her had died. She had missed a day of school to attend the funeral.

I felt relieved and stupid all at once. I felt relieved that she hadn’t purposely ignored me in class and that her behavior had nothing to do with me. I felt stupid that I had forfeited so much peace of mind wondering.

There could have been a million possible explanations why that girl didn't turn around in her seat. But leave it to an agoraphobic like me to think she was mad at me. I didn't know what I was doing back then, but I was not only "negative mind reading" according to the agoraphobia books, but I was also catastrophizing.

Looking back, I can see that this story was probably one of many omens that I would develop panic disorder with agoraphobia by the start of the next school year.

Agoraphobia Thoughts:Catastrophic Thinking and Negative Mind Reading

I would like to share some "cognitive restructuring" strategies that will be helpful in reversing the flow of negative thinking that fuels agoraphobia. First, I'd like to write a few posts to explain some of the cognitive mistakes people with agoraphobia commonly make (and that need restructuring). Then I will share some ways to change faulty thinking that will help you recover from agoraphobia.

Probably the biggest and most common cognitive mistake made by people with agoraphobia is catastrophic thinking.

Catastrophic thinking: Blowing negative events or feelings way out of proportion. Turning small mistakes or minor setbacks into major catastrophes through exaggerated thinking. The magnification of negative events leads to a magnification of fear, anxiety, or panic experienced as a result.

Examples of catastrophic thinking:

I get turned down after auditioning for a part in a play and I think, “This is so awful and embarrassing. I am a terrible actor and had no business even auditioning.”

I am having trouble understanding a math assignment in school and I think, “I am such an idiot who cannot understand anything. I probably won’t make it through college or be able to get a good job.”

Another cognitive mistake made by people with agoraphobia (and other anxiety disorders) is negative mind reading.

Negative mind reading: Assuming that other people are thinking and feeling negative things about you without any real evidence to support your assumption. Some people with agoraphobia live as though they were psychic, always assuming the worst case scenario when interpreting other people's comments, expressions and behaviors. People with agoraphobia suffer from a lot of unnecessary anxiety that comes from always assuming the worst when it comes to how other people might be perceiving them and wondering what they might be doing wrong to cause such negative reactions from others.

Examples of negative mind reading:

I pass someone I know in a crowded shopping mall and try to catch her attention to say hello. She walks right on by and do not even glance my way. I think to myself, "She must be mad at me about something. I wonder what I could have done to make her angry?"

I turn in a report to my boss at work that I have put a lot of effort into and anxiously await his feedback. A week passes and my boss says nothing about the report. I think to myself, "I guess he really didn't like my work. I wonder if he is not talking to me because he is trying to think of a way to fire me?" I go into work every day thinking that it may be my last.

Of course, anyone reading these can probably think of a lot of different explanations for someone passing by in a mall and not seeing you - or a boss at work taking some time to give you feedback about a report. People in crowded shopping malls just might not hear or see you and a boss could be too busy to review a report right away.

People with agoraphobia tend to focus on one possible explanation - the worst one.

Plus, negative mind reading can be compounded by catastrophic thinking as in the example with the boss and the report. Thinking the boss might not be pleased with a report might turn into the certainty of being fired in the mind of someone developing agoraphobia or related anxiety disorder.

Agoraphobia: Why Cognitive Therapy Helps

Cognitive therapy is effective in treating agoraphobia and other anxiety disorders because of the link between thoughts and feelings. Cognitive therapy is based on the principal that thoughts can lead to feelings, and feelings can lead to physical symptoms.

To give an example, let’s say I was going to an interview for a new job. If I were to start thinking self-defeating thoughts such as, “I probably don’t have the skills to be successful in this new position” or “I will probably be asked questions that I won’t be able to answer” then I would be likely to worry more and feel anxious before the interview. The more anxious and worried I felt before the interview, the more likely I would be to experience physical symptoms like being jittery, having butterflies in my stomach, or freezing up during the interview.

At the same time thoughts can lead to feelings and accompanying physical symptoms, feelings and physical symptoms can reinforce thoughts. Going back to the interview example, if I felt anxious and froze up during the interview, my failed interview could reinforce thoughts that I don’t have what it takes to succeed in a new job. Thoughts, feelings, and physical symptoms can form a vicious cycle of negativity.

People with agoraphobia get caught in these negative thought-feeling-behavior cycles all the time.

Cognitive therapy stops this vicious cycle by challenging “cognitive distortions” and correcting them through a process called “cognitive restructuring.” Put in everyday language, cognitive distortions are just faulty ways of thinking that lead to the irrational fear behind agoraphobia. Cognitive restructuring is just changing the way you think, replacing fear-producing thought patterns with more rational, healthy thinking. Replacing fear-producing thoughts with healthy ones helps to relieve the symptoms of agoraphobia.

Wednesday, March 08, 2006

More Agoraphobia Drugs

Benzodiazepines and anti-depressants are the most commonly prescribed drugs for agoraphobia. Tonight I'd like to talk about a few others that some doctors or psychiatrists might prescribe.

The first will be the anti-convulsants which include Valproic Acid and Gabapentin. These medicines were originally developed to treat people with epilepsy because they can control seizures. Later, they were discovered to be good mood stabilizers and were used to lessen the mood swings of people with bipolar disorder.

Very recently, they have been tested on people with panic attacks with some success. Valproic Acid and Gabapentin have both been shown by studies to be helpful in reducing the frequency and intensity of panic attacks.

Valproic Acid has more potential side effects of the two. The most commonly reported adverse reactions are nausea, vomiting and indigestion. Other potential side effects include interfering with blood clotting and liver functioning. There have also been reports of acute pancreatitis occurring in association with Valproic Acid therapy.

Gabapentin has a smaller risk of side effects plus it has been shown by some studies to reduce anticipatory anxiety in people with generalized anxiety disorder. If Gabapentin can both prevent panic attacks and reduce anticipatory anxiety - then it could emerge as the drug of choice for people with agoraphobia.

However, research on the use of anti-convulsants to treat agoraphobia is fairly new and some doctors and psychiatrists will not prescribe them until more studies are done.

Finally, a drug called Buspar has been used to treat agoraphobia and is in a class by itself. It is an anti-anxiety medication but is not a benzodiazepine. It also does not create the same tolerance or cause the same withdrawal symptoms as benzodiazepines.

The only problem with Buspar is that it takes so long to work - that is, if it works at all. You might have to take a prescribed dose for a week or more to start feeling the effects. Some people don't ever feel any effects. But since Buspar does not have dangerous side effects it might be worth a try. Especially if you find out it does work for you.

However, as I said before, I am not a proponent of using drugs as a long-term solution for agoraphobia. I recommend following a recovery program that challenges you to grow as a person and helps you get free of the underlying anxiety that feeds agoraphobia.

In the long run I think you will want to live with the confidence that you would not be totally debilitated by agoraphobia, anxiety and panic if you stopped taking your pills.

Tuesday, March 07, 2006

Agoraphobia Drugs: Anti-depressants

At this point, I should say that I am not personally an advocate of using medication to overcome agoraphobia or an anxiety disorder. I did use a little Xanax to help me in my recovery, but the pills mostly stayed in my pocket as a safety measure.

But...If you are taking the chemical route to treat agoraphobia and you are misfortunate enough to have panic disorder with agoraphobia, then anti-depressants might just be your drug of choice over benzodiazepines.

That's because, unlike benzodiazepines, anti-depressants put a stop to panic attacks pretty effectively (in addition to treating depression).

There are several main classifications of antidepressants:

1) MAOIs (Monoamine Oxidase Inhibitors)
2) TCAs (Tricyclic Anti-depressants)
3) SSRI's (Selective Serotonin Reuptake Inhibitors) and
4)SSNRI's (Selective Serotonin and Noreprenephrine Reuptake Inhibitors).

First off, forget MAOIs. Almost no one prescribes them anymore anyway. They have way too many potential side effects like dry mouth, blurred vision, drowsiness, dizziness, decreased sex drive, skin rash, and weight gain or loss. Plus you can't eat smoked, fermented, or pickled foods or drink certain beverages if you are taking MAOIs (which rules out wine and cheese). MAOIs also have a bad reaction with a lot of other medications and can cause high blood pressure if you mix them with the wrong thing.

Tricyclic Anti-depressants used to be a popular choice but have the same potential side effects as MAOIs. TCAs include drugs like Elavil, Norpramin, Tofranil, and Pamelor. For the most part, since the advent of SSRIs starting with Prozac, TCAs are being used less and less by medical and mental health professionals.

SSRIs became popular partly for their effectiveness and partly because they don't have as many potential side effects. The side effects of SSRIs are manageable for most people and are usually limited to indigestion and/or a reduced sex drive. SSRI's currently in vogue are Prozac, Paxil, Zoloft, Celexa, Luvox, and Lexapro. Besides countering the effects of depression, these all are known to reduce the number of panic attacks a person has.

One of the reasons that SSRIs are so widely prescribed by doctors and psychiatrists is because you can't use them to kill yourself by overdose. This is obviously a good thing because prior to SSRIs, one of the most common forms of suicide was to overdose on the very antidepressants which were meant to cure the depression.

However, there are two serious drawbacks with SSRIs:

1) SSRIs are risky to combine with other drugs. For example, SSRIs can be lethal when taken with MAOIs.

2) Even though you can't use them to kill yourself by overdose, SSRIs have actually been proven to increase suicidal thinking.

A close cousin to SSRIs which have also become popular are SSNRIs. SSNRI's include Effexor and Serzone. The main difference between these drugs and SSRI's is that they effect the brain's levels of noreprenephrine in addition to serotonin and aren't as likely to produce sexual side effects.

The bottom line is that if you are going to take an anti-depressant to stop panic attacks, try one of the newer ones (SSRIs and SSNRIs). Since there are so many choices, you may have to shop around and try several before you find the one that works for you. As you know, different drugs work differently on different people.

Paxil is the favorite of some doctors because they say it makes people a lot calmer than some of the other SSRIs. But there are so many different SSRIs and SSNRIs that if you try one that doesn't work for you, just keep trying until you find one that does.

Monday, March 06, 2006

Agoraphobia Drugs: Benzodiazepines

Tonight I am going to begin talking about one way of treating agoraphobia - using medication. The most common type of medication prescribed for agoraphobia is a class of medicines called benzodiazepines.

Benzodiazepines is basically just a fancy way to say tranquilizers and sleeping pills. You have probably heard of some of the most common types of benzodiazepines which are Xanax, Valium, Restoril, Ativan, Halcion, Dalmane, and Serax.

When prescribed for agoraphobia, the purpose of benzodiazepines is to relieve anxiety symptoms and/or help you sleep. Most will calm you down within a half hour although some may take up to two hours. This can also depend on how sensitive you are to medication.

Benzodiazepines mainly reduce anticipatory anxiety (or catastrophic thinking). They don't usually stop panic attacks. However, the less inhibitory anxiety you experience, the less likely you are to have a panic attack.

The reason benzodiazepines work so well for agoraphobics and other anxiety sufferers is that they enhance the action of a neurotransmitter called GABA (Gamma Amino Butyric Acid). This neurotransmitter inhibits excitement and calms you down.

Benzodiazepines are divided into short, medium, and long acting categories based on how long they stay active in the body:

Dalmane is long acting and stays in the body for days. Valium is also long acting and can stay in the body for over a day. Restoril and Ativan are considered to be medium acting and stay in the body for about one half to a full day. Halcion, Xanax, and Serapax are short acting and stay in the body for only a few hours.

If it were not for side effects, benzodiazepines might be considered an effective cure for agoraphobia and other anxiety disorders. They work really well for most people. The problem is that benzodiazepines can only be taken safely for brief periods of time. If you take them over long periods of time, you are likely to become tolerant and/or dependent. Tolerance means that over time it takes bigger and bigger doses to get the same calming effect.

Besides the problem of developing tolerance and becoming dependent, possible long-term side effects caused by taking benzodiazepines include cognitive impairment, loss of balance, respiratory problems, problems with blood pressure regulation, and sleep disturbance.

Another downside to benzodiazepines is that you experience withdrawal when you try to get off. This is because your body has made adjustments to compensate for the continual presence of the drug. Paradoxically, the withdrawal symptoms are similar to the symptoms of agoraphobia and other anxiety disorders. So when the drug ceases to be effective due to tolerance you can’t just stop taking it easily– and you might end up worse off than when you started because the side effects might be worse than the original anxiety.

Agoraphobia, anxiety, and panic attacks are actually listed among the most common withdrawal symptoms in pharmaceutical literature. Other withdrawal symptoms include breathing difficulties, blurred vision, depression, dizziness, lethargy, feelings of unreality, heart palpitations, hypersensitivity to light, indigestion, insomnia, irritability, loss of concentration, loss of balance, loss of memory, nausea, nightmares, rapid mood swings, severe headaches, sweating, and tightness in the chest. In short - withdrawing from benzodiazepines can have the same symptoms as an anxiety disorder or agoraphobia.

Because of these withdrawal symptoms, getting off cold turkey is strongly warned against. People who need to get off benzodiazepines should do so gradually. A recommended program for getting off benzodiazepines is as follows:

1) stabilize on a normal daily dose an make sure the dose is taken regularly throughout the day.

2) change to short or medium acting benzodiazepine to a long acting one.

3) reduce to a small amount of one dose (10-20% of the overall dose).

4) stabilize on the reduced dose for at least two weeks

5) reduce the dose again

6) take rests during the reduction process if the symptoms become too severe or during a stressful time.

In summary, the most advisable use for benzodiazepines is to help you through a particularly difficult situation. A benzodiazepine may help you get through a stressful event that you couldn't face otherwise. In this way, benzodiazepines are useful for treating agoraphobia when combined with cognitive and behavior therapy because they give the user a window of opportunity to practice entering feared places and situations with a lessened chance of anxiety building up.

The best and safest use for benzodiazepines is carrying them in your pocket. This can give you the security of knowing that you can stop anxiety if you absolutely had to. Just having them at your disposal can give you the confidence to venture out into unsafe territory on your road to recovery from agoraphobia.

Ultimately, benzodiazepines are a useful tool for recovery from agoraphobia when used wisely, and in moderation.