Most people are vaguely aware of agoraphobia and panic attacks, and what they involve. Less well known is that they are often found together, feeding off one another and keeping the individual trapped in a hellish prison, often for years.
Before considering the link in detail, it may help to clarify what agoraphobia and panic attacks actually are. Both seem bizarre to those who do not suffer from them. And those who do soon grow tired of people saying, “there’s nothing to be frightened of, just open the door and step outside – it’s that simple,” or “I don’t know why you panic, nothing is worth getting into such a state over.”
Agoraphobia involves more than a “fear of the outside” or “fear of open spaces.” In general, the sufferer doesn’t simply fear the outside world. What they really fear is being trapped in a situation from which they cannot escape. For example, they may avoid an underground car park, or the top floor of a high building, and they especially fear places in which help would be unavailable.
Agoraphobics often have peculiar little fears as well, like waiting for traffic lights to change, using elevators or being on a bus that stops on a bridge. To the average person, such things pass unnoticed. The agoraphobic dreads them. To help them cope with the anxiety, they then develop safety behaviors. For example, someone may take her bike everywhere, pushing it all the way into town to meet friends (not all agoraphobics are fully housebound; many have “windows” during which they appear to recover). While she pushes the bike, she grips the handles. And she chooses a cafe as close to her bike as possible: she does not want to be trapped and unable to escape back home.
Panic attacks are more common than agoraphobia. Indeed, many people have one at some point (according to the website WebMD, one in ten experience them during an average year and a third experience them during their lifetime). Often, they occur following a trauma, such as the breakdown of a marriage or the collapse of one’s business. Tension and fear build until, trapped in a crowded office or shop queue, they snap: their heart begins to pound; they sweat, tremble and struggle to breathe; they feel dizzy and close to fainting; their body grows hot; finally, as these sensations pass, they realize they are drenched in sweat. For most, the symptoms last no more than a few minutes. For others, they take up to an hour to go.
An actual panic disorder is less common, affecting no more than two percent of the population (twice as many women as men). Someone with a panic disorder experiences panic attacks on a regular basis, usually without warning. And many find this not just distressing but embarrassing. They also live in constant fear of them, especially since they strike at random, often for no reason.
The link is so strong that many prefer the phrase “severe panic disorder” to agoraphobia. Whatever wording you choose, panic disorder is certainly responsible for many cases of agoraphobia.
Some can even trace their agoraphobia back to a specific panic attack, one so overwhelming that they fled home, shut the door and literally stayed there for six months. A hypothetical example may help. Let’s imagine a 40-year-old man named John. John’s wife suddenly leaves him, taking the children with her. He is shocked and endures crippling stress and insomnia. Unfortunately, the company he works for is also in trouble, and his boss pressures him to hit sales targets and spend more time at the office. Then he learns that he must give a presentation. For days now he has dreaded the commute into the city: the angry faces, the fight for space, the crowds, the greed. Since his wife left, the world seems a dark and threatening place.
The day of the presentation he feels sick. His heart pounds all morning and, when he finally stands before those tense, hostile faces, something inside breaks. His heart beats wildly, he can’t breathe and fears he’s having a heart attack. The room begins to swirl, and he can see nothing but shimmering yellow lights. He can also hear whispering and giggling. When he recovers, he is sitting in a chair drenched in cold sweat. He feels suffocated and trapped. He also feels embarrassed. In need of fresh air and safety, he makes an excuse, runs for his car and drives home at top speed. Once inside, he locks the door and sighs with relief. His agoraphobia has begun.
Unfortunately for John, as for many agoraphobics, his mind turns against him. “What if it happens again?” he thinks. “What if next time I’m trapped somewhere and can’t get home? Imagine if the town had been gridlocked or my car wouldn’t start.” Only his house now seems truly safe.
Within the brain, the amygdala stores memories according to intensity of emotion. A certain place becomes associated with panic, fear, dizziness, etc., and so the amygdala triggers those feelings next time you are there. John now associates traffic and the office with fear. The next time he attempts the journey, his amygdala creates a surge of anxiety. He feels sick and faint again. The traffic has penned him into a trap, and the lights seem to be stuck on red. Now he wonders if they’ve broken. “Imagine that,” he thinks, “imagine if they became jammed on red and I just couldn’t get away.” His heart rate increases, he feels sick, and so he turns the car around and heads for home.
John is now in such a heightened, or “sensitized,” state that when his sister meets him for a stroll in the park, he has another panic attack. Soon his amygdala associates everywhere but his house with fear. “Also,” John thinks, “if I have a panic attack at home at least I will be safe – plus there won’t be any witnesses.”
Panic and agoraphobia are also related to avoidance, seen at its worst in the avoidant personality disorder. Most of us fear and avoid something, of course, from public speaking to cinema queues of noisy teenagers. But when you avoid, you reinforce the idea that the world is a dangerous and threatening place. And the more places you avoid, the more fear you experience. In some cases, the fear builds, the number of comfortable places decreases and the world shrinks so much you don’t want to leave the apartment.
It must be stressed that though the vast majority of agoraphobics also have a panic disorder, some do not. A minority simply loathe the world. Due to a mixture of social anxiety, bullying at school and negative messages from a depressed parent, they may simply stop going out. If they are also hyper-sensitive and watch too much TV, this loathing will be reinforced by 24-hour news channels. Some develop agoraphobia without ever having a full-blown panic attack.
First, you need to fully understand your condition. Buy as many books on the subject as you can and make notes. It will also help to talk to fellow sufferers. If you cannot make it to a support group, join an online discussion forum. Do not use such forums as a substitute for real life, however. In themselves they can be addictive. The purpose is not to wallow in your condition – using the forum to complain how insensitive people are, etc. – but to free yourself.
Next, make lots of small lifestyle changes – anything to bring down your base level of anxiety. You could start by changing your diet. Eat more raw, fresh vegetables and fruit. And eat more nuts, seeds and oily fish as well. You should also cut down on sugar, refined wheat and caffeine and drink more water. Obviously, these alone are not going to free you from agoraphobia. But they will reduce your overall anxiety level, and that will increase the effectiveness of other treatments.
Yoga and meditation will also help. Numerous instruction videos are available on sites like Youtube, and there are plenty of DVDs. Yoga and meditation can be done indoors and will ease the cramps and tensions that accumulate in the body. Mindfulness meditation is especially good. With practise, you learn to detach yourself from your thoughts and observe them as you would observe clouds passing through the sky. You also learn to observe your emotions, watching the fear and panic build yet allowing them to be. And equally important you learn to let things go, living in the moment instead of constantly anticipating danger. Some claim to have cured their agoraphobia through mindfulness alone.
More generally, you need to re-wire your brain. Try gradually moving out of your comfort zone, allowing the fear to spike and then subside. Every time you do this, you re-train the mind. Some take this to an extreme, literally standing on the roof of a tall building and allowing the panic attacks to come and go.
Instead of becoming upset, some take a detached, objective view, accepting that it’s just something their body does. “It won’t kill me,” they think, “and if other people make a big deal out of it, that’s their problem.” You could even tell them what is happening: “you’ll have to excuse me. I’m having a panic attack. It happens from time to time. No big deal. It’s just the way my body works I’m afraid”. If you don’t care, neither will they.
Finally there is therapy and medication. Cognitive Behavioural Therapy, or CBT, has proven particularly effective. When the fight or flight response is triggered, the agoraphobic feels in real danger. Considering that the symptoms mimic a heart attack, or even psychosis, that is hardly surprising. In essence then, agoraphobia rests on a false belief: that an elevator, traffic queue, etc., is dangerous. Through CBT, you replace catastrophizing thoughts with more rational, sensible ones. Next time panic builds, your new thoughts click in. Instead of thinking “oh my god, what’s going to happen?” you remind yourself “I am not in danger; these alarms are false.” Put another way, you re-train your inner voice, replacing the hysterical panicker with someone calm and nurturing.
Agoraphobia with panic is a deeply upsetting condition – for many a life changing one. Sadly, it is also grossly misunderstood. Thankfully, a great deal of research is currently underway, and new treatments, such as virtual reality, are on the horizon. In the meantime, courage and determination are key. This is a tough battle, but it is one you can win.