Help For Agoraphobia

Our guest, Paul Foxman, Ph.D., talks about the definition of agoraphobia, the three ingredients in most cases of agoraphobia, and treatment for agoraphobia (anxiety control skills, exposure therapy, visualization, anti-anxiety medications). We also discussed the different levels of fear that agoraphobics experience, from a moderate pattern of avoidance, like avoiding air travel, to a housebound agoraphobic with a severe case of anxiety and an extreme need to be in control.

Audience members shared their agoraphobic experiences and had questions about anxiety disorder relapses, anxiety and depression, how to overcome anxiety, facing phobic situations, and anxiety associated with a medical condition. Some also expressed concern that they had tried various treatment methods to no avail and were worried that they might never recover from agoraphobia.

David Roberts: HealthyPlace.com moderator.

The people in blue are audience members.

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David: Good Evening. I'm David Roberts. I'm the moderator for tonight's conference. I want to welcome everyone to HealthyPlace.com. Our topic tonight is "Help For Agoraphobia." Our guest is Paul Foxman, Ph.D., Director of the "Center for Anxiety" in Vermont. He is a psychologist, in practice for 19 years, who specializes in the treatment of anxiety disorders and trains other therapists on how to treat anxiety disorders. Dr. Foxman is also the author of "Dancing with Fear," a popular book which offers help for anxiety.

Just so everyone knows, Agoraphobia means a fear of open spaces. Here is a more detailed definition of Agoraphobia.

Good evening, Dr. Foxman, and welcome to HealthyPlace.com. Many agoraphobics are afraid to even step out of their homes. They want help. They call the doctor and the doctor says "you need to come to my office." If that's the case, how is the individual supposed to get treatment for agoraphobia?

Dr. Foxman: First, I would like to clarify my definition of agoraphobia. The condition to me means a pattern of avoidant behavior designed to protect oneself from experiencing anxiety. There are many situations people avoid, including, of course, going out into the public. In those cases, getting to a health care professional can be a problem but there are some alternatives. I use a home-based self-help program called "CHAANGE" for those who are truly housebound, with telephone consultations. If we have time, I would be happy to say more about the CHAANGE program.

David: You mentioned those agoraphobics who are housebound. Are their different levels of fear when it comes to agoraphobia?

Dr. Foxman: In my opinion, the housebound agoraphobic is usually a severe case of anxiety because a pattern of avoidance has developed and the person's life is severely limited.

David: So what would be some other "less severe" instances of agoraphobia? What would that look like?

Dr. Foxman: Many "agoraphobics" function in what appears to be a normal way, such as ability to work outside the home, hold responsible positions at work, etc. However, internally, they are anxious and uncomfortable. Typically, there is a still a pattern of avoidance of some kind, such as meetings, travel, etc. There is also a need to be in control, and anxiety is highest when control is not feasible.

David: How does a person develop agoraphobia?

Dr. Foxman: In my view, agoraphobia is a learned condition that develops over time, usually resulting from having an anxiety experience in a particular situation. Thereafter, that and similar situations are associated with anxiety and avoided.

There are three ingredients in most cases of agoraphobia. First is "biological sensitivity": a tendency to react strongly to stimuli outside as well as body sensations. Second is a particular personality type that I discuss in my book. Third is stress overload. It is usually stress overload that determines when a person becomes symptomatic.

David: You mentioned "personality type" as being one of the precursors. Can you explain that in more detail, please?

Dr. Foxman: Yes. The "anxiety personality," as I call it, consists of personality traits, such as perfectionism, difficulty relaxing, desire to please others and obtain approval, frequent worry, and high need to be in control. These traits are both assets and liabilities, depending on whether you are in control of those traits or whether they are controlling you.

The anxiety personality sets a person up for increased stress and anxiety symptoms.

David: We have a lot of audience questions, Dr. Foxman. Let's get to a few of those and then I want to address treatment issues. Here's the first question:

Zoey42: But what causes that first inital anxiety attack for no apparent reason?

Dr. Foxman: Although it seems that the first anxiety attack occurs "out of the blue," it is usually preceded by a period of high stress when other coping mechanisms are strained. Take a look at the 6-12 month period preceding the first attack and see if your stress level and other changes occurred.

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David: So, are you saying that first anxiety attack is a way to "blow off" the high level anxiety?

Dr. Foxman: It would be better to think of the first attack as a warning signal that your stress level is high and earlier signals have been ignored or not attended to. Prior signals include muscle tension, GI symptoms, headaches, etc.

David: Here are a few places that are troubling to some of our audience members with agoraphobia:

Rosemarie: I have problems with airplanes and also crowded areas, such as Malls.

AnxiousOne: Yes, I avoid air travel and crowded places.

jjjamms: To be in large supermarkets, malls, large bookstores, etc., upsets me quite easily but very small stores do not. Why is this?

Dr. Foxman: In my opinion, all these places have something in common. They are places where people anticipate experiencing anxiety. It is, therefore, not truly the place or situation that people fear but the anxiety and loss of control that is anticipated in those situations. This is an important point to understand, as it pertains to treatment approaches.

Danaia: Is it true that Panic Disorder goes hand-in-hand with Agoraphobia? Also, what if there is no reason for agoraphobia? I have spent many hours in counseling for this problem, but I cannot figure out why it has happened to me.

Dr. Foxman: Panic disorder frequently occurs in conjuction with agoraphobia. Before 1994, the American Psychiatric Association would diagnose Agoraphobia, with or without panic attacks. Now, it's Panic Disorder, with or without Agoraphobia.

As for why anxiety or agoraphobia develops, it is helpful to understand the history leading up to it but that, in itself, will not lead to recovery. Recovery requires practice of new skills and behaviors, which we can discuss in more detail.

David: What is the first line of treatment for agoraphobia?

Dr. Foxman: Agorophobics typically "scare" themselves with anticipatory worry. That needs to be replaced with anxiety control skills that are practiced before entering the phobic situation and then the person must learn to face the situation and try those new skills. One needs to face the phobic situation in order to overcome it, but equipped with the appropriate skills.

David: I think what you are referring to is "exposure therapy." Am I right?

Dr. Foxman: Exposure therapy works best when the person has first practiced anxiety control skills, such as the ability to calm oneself at the first sign of anxiety. Only when equipped with such skills can the person hope to have a positive outcome when "exposed" to the feared situation. In addition, exposure should be gradual.

David: Over what period of time?

Dr. Foxman: The time period depends on how entrenched the avoidant pattern is. It is a good idea to make a list of all the avoided or feared situations, and then rank order them in order of difficulty. Then, using "visualization," imagine yourself going through the situation while relaxed. Continue until you can do the whole situation without anxiety. Then try in real life, using small steps. This could take weeks or months.

David: Here's an audience question:

checker: How does one "calm oneself" at the first sign of anxiety?

Dr. Foxman: First, practice relaxation daily when you are not anxious. Think of it as a "skill:" the more you practice it the better you get at it, just as in learning to play a musical instrument or keyboarding on a computer. Then, when you feel anxious, you are more likely to be successful in using this self-calming technique. A good analogy is childbirth preparation class, where you learn how to breathe through contractions. In other words, you practice relaxation in advance so when you need it, it is more likely to work for you.

Our instinct is to tense up when we anticipate something bad happening, such as feeling anxiety in a feared situation. It is important to have the ability to relax so that you can face the situation and counteract the anxiety. The idea is to replace the anxiety reaction with relaxation.

David: A few site notes and then we'll continue:

Here's the link to the HealthyPlace.com Anxiety-Panic Community. You can click on this link, sign up for the newsletter on the side of the page so you can keep up with events like this.

Here's the next audience question:

Tash21567: I have made progress in the past, only to have setbacks (anxiety disorder relapses). Why do we have these?

Dr. Foxman: We have setbacks due to the power of habits. Agoraphobia involves habitual ways of protecting ourselves-usually by avoidance-and we revert to these habits when anxiety is up or stress is high or when we are tired. Try to think of setbacks as "practice opportunities." But be sure you have some appropriate skills to practice when you have a setback. It is also important not to get upset with yourself for having a setback. It is to be expected, just as when you are learning anything new. There are good days and not-so-good days when it doesn't "flow."

David: By the way, I forgot to mention Dr. Foxman's website: http://www.drfoxman.com

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MaryJ: Dr. Foxman, I am most interested in your CHAANGE program. I have been housebound three years and have no help. I don't know where or how to begin. I can't take much more of this and I am depressed all the time.

Dr. Foxman: Mary, you raise a few important points. One is the relationship between anxiety and depression. It is natural to become depressed when your life is so restricted, and when you are not in control of the anxiety. However, there is hope. The CHAANGE program is a 16-week course in learning how to overcome anxiety. The success rate is quite high, about 80% based on patient self-ratings at the beginning, middle, and end of the program. You can learn more about the program from my book, Dancing with Fear.

David: And that brings up another important point, and I know you are not a psychiatrist or medical doctor, but generally speaking, are anti-anxiety medications effective here in relieving the high level of anxiety and depression that many agoraphobics experience?

Dr. Foxman: My position on medications is that they can be helpful in the short run for controlling symptoms and enabling some anxiety sufferers to focus more effectively on learning the necessary new skills. However, medications have many pitfalls, such as adjusting the dosage to get a therapeutic effect, side effects, etc. I do not think medication is a good long term solution to anxiety. Even when they work, some people are fearful that their anxiety will return when they stop medications. I have had some patients come in with the presenting problem being fear of stopping medication.

David: We have some audience questions on whether a medical problem could have resulted in developing panic disorder. Here's an example, Dr. Foxman:

violetfairy: I have a personal question I hope you'll answer. I was a housebound agoraphobic for 3 1/2 years, then recovered (yay!). However, I still experienced major disorientation often. (That was always what set off my panic attacks.) I found out I have a giant cyst in my sinuses and I'm going for surgery next week. It seems to me that this could cause a lot of disorientation (I am particularly disoriented whenever there are barometric pressure changes-- right before it rains). Can you tell me if it's possible that the cyst is what caused the panic disorder?

Dr. Foxman: Yes, a medical condition can trigger panic disorder. However, it is usually the anxiety associated with the medical condition that the person fears. In your case, it is the disorientation that was so distressing, and it sounds like you have developed a fear of disorientation which is a precursor to the panic feelings.

Tess777: I was in my 40's when I had my first anxiety attack, which was after I witnessed my husband having a gran mal seizure. Is it possible that could have caused it?

Dr. Foxman: Yes, you witnessed a "traumatic" event and that may have "scared" you. Once you had the "scary" feelings, you developed a fear of that happening again. Everyone should keep in mind that it is the anxiety that is feared in agoraphobia and panic disorder.

Dlmfan821: I have a terrible problem with feeling guilty. It used to be I was the one everyone could turn to. I have four children, all grown now, thank God, and now I have to depend on them and my husband. My husband was in the military for many years and we moved from one end of the country to another and since my husband was gone a lot, I took care of everything without a problem. Now, when it is supposed to be time for my husband and I to vacation, maybe go on a cruise, etc., I've ruined everything.

Dr. Foxman: I can understand your feelings of guilt and letting your family down. What may have happened is that you worked so hard taking care of your family that your stress level went into overload and you became symptomatic. It is not a permanent condition.

David: I'm sure that many agoraphobics and those with panic disorder, because of their self-imposed restrictions, are unable to go places and family members get very upset. 1) How would you suggest handling the guilt the agoraphobic feels and 2) then how do you deal with friends and family members?

Dr. Foxman: It is always important to maintain balance. When we go out of balance, we become symptomatic. Take it as a learning experience and focus on resuming balance by taking care of yourself. This means addressing your health needs: diet, proper rest, exercise. These are the basics of health and energy. If you are in a deficit due to being out of balance, it may take some time to restore your balance. Just work at it everyday and it will come in due time.

zeena: Can fear of driving be a type of agoraphobia?

Dr. Foxman: Yes, absolutely. Fear of driving is a common form of agoraphobia. However, it is not the car or driving that one fears. It is the anxiety that might occur in the car or while driving that one fears. It usually develops from having an anxiety experience while driving. Many of my anxiety patients say, "I don't get it it. I used to love driving, now I am afraid to drive or I avoid it." The issue, again, is fear of anticipated anxiety, not of cars or driving. The same can be said of other feared situations, such as travel, airplanes, malls, or even being alone. It is all about the fear of anxiety. ga

David: This is from Jean, who has severe agoraphobia. She says she has no family or friends. She is housebound, feeling desparate and developing physical problems. Is it possible to recover from agoraphobia on your own, through self-help?

Dr. Foxman: Yes, it is possible. But as I have been stressing tonight, it is important to have some guidance in learning the approrpriate new ways of thinking and behaving. Some people can learn on their own, using a guidebook or program such as CHAANGE. But most people benefit most from contact with a trained professional who knows what skills are important. Some anxiety therapists are willing to provide telephone counseling to the homebound agoraphobic. That could be a viable option.

David: I'm getting some questions about what if you can't afford therapy?

Dr. Foxman: Naturally, cost can be a factor. Consider using a structured guidebook, such as the Anxiety and Phobia Workbook, or my book, Dancing with Fear. Also, group therapy is an effective form of treatment for anxiety, and usually it costs less than half the fee for individual counseling. I run two anxiety therapy groups per week and find it powerful and gratifying.

The self-help strategies I mentioned earlier are low-cost steps that can make a significant difference. Also, consider a relaxation tape, daily yoga or another form of relaxation, and then use imagery desensitization to prepare for facing phobic situations.

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sandee ane: Were you saying earlier, we fear the anxiety that we once felt due to a traumatic event? A doc told me that my problem is my feelings about my mother's death when I was 5. He said that I should have had help at age 5 and 9. What do I do about those feelings now? I am 53. I witnessed her death in bed at night.

Dr. Foxman: It is not simply the traumatic event that causes anxiety. It is the painful feelings that were so overwhelming. In other words, it is the internal reaction to the trauma that we must deal with. You can deal with the feelings now by discussing them and realizing that they are not life-threatening. What you probably missed was help in dealing with strong feelings. Some skills for that are described in my book in a chapter called, "Feeling Safe with Feelings."

Tash21567: Is it true the longer you live with panic, the harder it is to conquer?

Dr. Foxman: In a sense, yes, because the patterns and habits that develop to cope with panic are so entrenched. But that simply means it may take longer to recover due to the power of habits. It should not mean being discouraged. The keys to success are motivation to change combined with a proper program for recovery. The three factors determining treatment success are motivation, chronicity, and current stress level.

neofairy: Do you think that many agoraphobics have been abused at some point in their lives?

Dr. Foxman: Unfortunately, a history of abuse is common in people who develop anxiety disorders. In such cases, the abuse is the "trauma" that we have been discussing. If you read my book, you will find in "My Anxiety Story," that I was a victim of childhood abuse. Related to abuse is a pattern of low self-esteem in many people with anxiety disorders, including agoraphobia.

David: Here are two similar questions:

Zoey42: In my case, the first anxiety attack was the beginning of the end. Slowly starting avoidance and some good years. Then, when it would hit again, it would come back worse then it was. Then slowly for the next 24 years, continuing on and off, but always coming back. Is this common?

Danaia: What if the situation is not a "typical" situation? I have a strange fear of vomiting in public. How can I desensitize myself from that? I've tried everything from drugs to hypnosis and nothing so far has worked. It gets better for me, and then it gets bad again. Am I stuck with this forever? My fear is, what if this is as good as it gets?

Dr. Foxman: Without knowing what treatment efforts you have made, it is difficult to offer a definitive answer. Generally, however, I am optimistic that people can overcome anxiety with proper guidance. Many therapists deal with anxiety but are not truly specialists and do not understand the condition from personal experience. I have worked with many people who have suffered for years, and have had prior therapy. I usually use the CHAANGE program in such cases because it focuses on new skills rather than on talk therapy. The structure is important, as is knowing that other people with similar conditions have been successful. Never give up hope.

As for the fear of vomiting in public, that is another form of fear of losing control and publicly embarrassing oneself. When you learn to be in control of yourself, you can handle the situation.

David: Thank you, Dr. Foxman, for being our guest tonight and for sharing this information with us. And to those in the audience, thank you for coming and participating. I hope you found it helpful. We have a very large and active community here at HealthyPlace.com. Also, if you found our site beneficial, I hope you'll pass our URL around to your friends, mail list buddies, and others. http://www.healthyplace.com

Thank you again, Dr. Foxman, for coming and staying late to answer everyone's questions.

Dr. Foxman: Thanks for the opportunity to share on this important topic.

David: Good night, everyone.

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Disclaimer:We are not recommending or endorsing any of the suggestions of our guest. In fact, we strongly encourage you to talk over any therapies, remedies or suggestions with your doctor BEFORE you implement them or make any changes in your treatment.

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