SIMPLE EFFECTIVE TREATMENT OF AGORAPHOBIA

Claire Weekes, M.B., D.Sc., F.R.A.C.P. M.B.E. Honorary Consultant Physician, Rachel Forster Hospital, Sydney, Australia.

PRESENTED AT THE EIGHTEENTH ANNUAL FALL CONFERENCE OF THE ASSOCIATION FOR THE ADVANCEMENT OF PSYCHOTHERAPY, NEW YORK, N.Y. OCTOBER 23, 1977 -Given personally to S.W.A.G. by Dr Claire Weeks

SENSITISATION: We hear much about desensitization. The approach is practical and using it for certain phobic people can give gratifying results. However, I have rarely seen the concept of sensitization given value or prominence. For example, in his book ‘Fears and Phobias’, (1) Isaac Marks discusses desensitization at length but I could find no mention of sensitization. In my opinion, to treat the anxiety state, of which agoraphobia is so often one phase, not only the therapist who instructs him but the patient himself must understand sensitization because the most lasting desensitization is self-desensitization. Here, I present the various facets of this approach.

SYMPTOMS AND CAUSES: Heightened Intensity of Responses. Sensitization is a state in which autonomic and somatic sensory nerves react to stress with unusual intensity and sometimes with disconcerting swiftness, so that the sensitized person experiences heightened nervous sensations (thumping, banging heart, ‘missed’ heartbeats, attacks of palpitations, giddy ‘spells’, weak ‘spells’, churning stomach and so on ) and excessively strong and precipitant emotions of responses. (see Fig.1)Mild anxiety becomes acute; a sad events seems tragic; a strange sight may be disturbingly eerie; love may be felt so acutely that the mere sight of the hand of a loved one moves a sensitized person to tears; joy may be expressed hysterically. Above all, mild fear or minor shock, even nothing but a sudden blast of cold air is often felt as flashing, electrifying panic that seems to singe the roots of the sufferer’s hair. The intensity of the panic may increase with each quickly recurring flash (reverberating circuits in the nervous system bringing a heightened response?) so that the agoraphobe fears a crescendo of his panic beyond his control. Unless the therapist understands the over-whelming nature of the panic he will find curing agoraphobia frustratingly difficult.

Emotional and mental fatigue: Recognizing and understanding the effects of emotional and mental fatigue is another key to treating the anxiety state and any concurrent agoraphobia. Sometimes this fatigue and its secondary symptoms are difficult for the patient to identify and add to his bewilderment. Sensitization and the accompanying fatigue need quick practical treatment. I do not spend time searching for hidden, subconscious causes for agoraphobia, neither am I perturbed if I can find no specific conscious cause. So often, when first seen, present sensitization and the habit of fear are the agoraphobe’s main concern. These must be removed but I have rarely found that uncovering an original cause was essential to doing so.

Deep-rooted conflicts: Of course, if an original cause - some problem, conflict, sorrow, guilt, disgrace and so on - is still actively working to keep the patient ill, it must be treated a adequately as possible to help recovery.

Stress: For the majority of 528 agoraphobic men and women in my survey, the precipitating cause of their agoraphobia was stress. Either sudden stress (sudden shock to the nervous system) such as an exhausting surgical operation, sever haemorrhage, accident, difficult confinement and great grief, or prolonged, intensifying stress created by some difficult life situation, excessive dieting, severe anemia, recovering from a debilitating illness, and so on. Only 5% could offer no cause and only 5% complained of sexual problems. Without added stress, sensitization heals itself; however, the sensitized person rarely understands what is happening to him and adds the extra stress of bewilderment and fear to the stress that originally caused his sensitization. He is trapped in a sensitization-bewilderment-fear-more sensitization cycle.

Flash of panic: Perhaps the most bewildering experience for the sensitized person is the sudden, unexpected, sometimes overwhelming, first flash of panic. He may be simply waiting in line for a bus when the panic may, in his word, “strike out of the blue” to be quickly followed by weakness, giddiness, racing heart - the usual accompaniments of panic. The agoraphobe’s history, as mentioned above, often shows stress though perhaps even mild enough to be unrecognized by the sufferer. However, constant tension activates reverberating circuits, so that finally no more than the slight agitation of waiting for a bus brings the grand flash of panic.

EMERGENCE OF AGORAPHOBIA

Agoraphobia so often follows the appearance of the first symptoms of sensitization, especially the first flash of panic. Anxious about what may happen if out alone, the sufferer may not only avoid going out alone, but sometimes even if accompanied.

Characteristics of Patients: Some 80 % of my agoraphobic patients were housewives. A house wife can send a child to do her shopping or wait until the weekend the shop with her husband; whereas, a man usually is obliged to leave the house daily. However, some men’s agoraphobia manifests itself as a city-bound executive syndrome. That is, they avoid traveling to outlying districts, other cities, may refuse promotion, even if it means no more than occasionally traveling out of town.

First Signs of Illness: In the beginning the agoraphobe may ‘bargain’ with his illness and visit certain stores, restaurants and so on, without panicking (there may be a doctor or a hospital in the neighborhood). However, he has only to panic in a hitherto safe place, and his orbit may finally be bounded by his front door. As well as complaining of upsetting nervous sensations, agoraphobes may complain of some, or all of the following disturbances: indecision, suggestibility, loss of confidence, feelings of personality disintegration, feelings of unreality, apathy, depression. It is illuminating to see how much the origin and development of these disturbances depend on sensitization and how they may arrive in the order just given.

 The vicious cycle: 

(a) How it develops. Indecision bring suggestibility and this must inevitably lead to loss of confidence. Also, with no inner harmony holding thought and action together, no inner self from which to seek direction, the sufferer will say, he feels as if his personality has disintegrated. One patient described himself as feeling like a jigsaw puzzle whose scattered pieces must be gathered and place in position before he could be himself again. This logical development from indecision, suggestibility, loss of confidence to feelings of personality disintegration can be appreciated when we understand how a flashing, exaggerated emotional response can confuse and delude the patient. The bewildered sufferer may spend weeks, months in anxious introspection, gradually losing interest in the outside world, until it seems unreal. The more he struggles to get back in touch with his surroundings the more tension he adds the more sensitized, introverted, and unreal he feels. At this point he thinks he is going mad. With so much emotional energy spent in bewilderment and fear, he gradually becomes depleted, apathetic, and finally depressed. Not only will the person have become sensitized, but may gradually suffer from severe mental fatigue. A student knows that concentrating and remembering become difficult after three or four hours study and that he must rest. The nervously ill person rarely stops anxiously studying ‘the state he is in’, and mental fatigue can come so insidiously, he usually fails to recognize it in his slowed, tortured thinking. The mind has lost its resilience, thoughts come slowly and seem to cling. It is as if these anxious thoughts make ruts in the mind and new approaches to a problem cannot forge a new path. Flashing, exaggerated emotional response to stress from sensitization and ‘inflexibility’ of mind from mental fatigue may give rise to obsession and phobias. One mentally fatigued sensitized mother happened to be near a window and thought, “What if I were to throw my baby our of the window!” This thought brought on an overwhelming flash of panic and because of mental fatigue the thought would return again and again to finally become an obsession. She then developed a phobia about passing windows.

(b) How it can be broken. In my opinion it is unnecessary to seek a specific cause for each experience. Understanding sensitization and explaining how it works to create these sensations has been enough to cure some people. One man telephoned me in Australia from the United States. Hs had suffered for nine years from sever agoraphobia, had undergone extensive psychotherapy including hospitalization, electro-convulsive therapy and had sought advice from twenty-five psychiatrist, in his words. ‘To no avail.’ After hearing explanation of sensitization and its treatment, he was playing tennis one month and two days later. He now makes frequent inter-continental flights and flies solo within his country. Explanation and self- desensitization alone cured him, as it has others. Recognize the origin of some obsessions as unusually intense emotional reaction coupled with severe mental fatigue. I planned a program of recovery from obsession by ‘glimpsing’ that sometimes cured where other more orthodox methods have failed.

PROGRAM OF RECOVERY

Four Steps. For Agoraphobes who need more help than just explanation of sensitization, I teach a four-step program of FACING, ACCEPTING, FLOATING and LETTING TIME PASS. This approach may sound too simple to be taken seriously, however it is enlightening to see how many people sink deeper into nervous illness by taking the opposite steps. The nervously ill person usually notices each new symptom with alarm, yet is afraid to examine it too closely for fear of aggravating it. He may attempt to distract himself or ‘to forget’. This is running away not facing. Many try to cope with unwelcome feelings, especially panic, by guarding themselves with the thought, “I mustn’t let this get the better of me! This is fighting not accepting. Floating resembles accepting but implies moving forward with the sensations and feelings without offering tense resistance, as one would when floating on gently undulation water. I have sometimes cured a patient with the simple words: “Float, don’t fight!” The nervously ill person keeps looking back apprehensively because so much time has passed in illness. He is impatient with time, not willing to ‘let time pass.’ Agitated avoidance, the tension of fighting, impatience with time increase stress and thus increase sensitization and prolong illness. In my opinion, panic is the most upsetting symptom that must be faced by the agoraphobic person. To recover, he must know how to face, accept, and go through panic until it no longer matters. THIS IS THE ONLY WAY TO PERMANENT CURE. It is not enough to learn how to avoid panic or subdue it with tranquilizers nor will ‘getting used’ to leaving home without panicking, as many lay therapists recommend, permanently help agoraphobes. The suggestion: ‘See if you can go a block further today!’ does not teach the agoraphobe how to face and pass through panic the right way and leaves him thus vulnerable to returns of panic, however far he may think he has progressed toward recovery. Marks says: “Patients who had sometimes overcome their fears sometimes reported that a single panic attack might undo the effects of weeks of treatment.’

Two Fears. To enable the patient to face and pass through panic (where true recovery lies), I explain that when he panics he feels not one fear, as he supposes, but two separate fears, a first and a second fear. Most of us have felt the first fear in response to danger. It comes quickly, is normal in intensity and passes with the danger. However, the sensitized person’s first fear is so electric, so out of proportion to the danger causing it, he usually recoils from it and at the same time adds a second flash - fear of the first fear. He is usually more concerned with the feeling of panic than with the original danger. And because sensitization prolongs the first flash, the second may seem to join it and the two fears are experienced as one. Hence the agoraphobe’s bewilderment at the duration of the panic and his inability to cope with it. The importance of recognizing two separate fears cannot be over-emphasized. While the sensitized person has little or no control over the first almost reflexive flash of fear, he can control the second flash and it is the second flash that re-sensitizes and keeps the first fear alive. It is easier to recognize the second fear when the patient realizes that it can usually be prefixed by “Oh, my goodness!’” or “What if?”. The agoraphobic woman at the school meeting has but to feel the first fear as she discovers that she is hemmed in far from the exit, to immediately follow with the second fear as she thinks, “Oh, my goodness, if I have a spell here, I’ll make a fool of myself in front of all these people! Let me out of here quickly!” Panic (second fear) mounts until she wonders how much longer she can hold on. Trying to check intensifying anxiety even for a short time is exhausting and difficult for anybody, yet this agoraphobic woman demands it of herself for an hour or more. Small wonder that, as the panic mounts, she senses a crisis in which ‘something terrible’ will happen. She does not understand that it is the succession of second fears she adds herself that may finally drive her to find refuge outside the hall. She goes through every moment heroically, but she does it the wrong way. As agoraphobe should be taught to clearly differentiate the two fears and understand that he cannot hope to control the first flash. How can he promise himself, as he so often does, that he will not panic when he goes out, when simply tripping in the dark may cause the flash of first fear?

Acceptance of Panic. The agoraphobe must go out prepared to panic but he must know how to go through the panic when it comes. There is a special technique for doing this: he must be prepared to accept the panic as willingly as he can manage, at the same time breathing in deeply, then breathing our slowly and letting the panic flash without withdrawing from it. It is useless to go through 99% of the panic and then withdraw from the last 1%. Recovery lies in going through that last 1%. It is withdrawal that is the jailer. Acceptance relieves enough tension to take the biting edge off the peak of the first fear and to blunt the impact of the second fear. This is the beginning of recovery. A word can make a great difference to a patient. One woman said: “I hate panic so much, I’ll never be able to accept it and go toward it willingly!” I asked: “Could you go toward it resignedly?” She thought she could. Since the selection of one word may prove so important, the doctor has to be careful in his choice of lay therapist as helper. After accompanying one woman on journeys away from home a lay therapist said, “You’re much sicker than I thought you were!” She was set back for weeks. An agoraphobe may have to go through panic many times during the some meeting or journey; however, if he approaches it the right way, the panic will not mount and he will be able to see the occasion through. Panic will return as long as sensitization last. As soon as intensity and frequency of second fear diminishes, sensitization will lessen. While alive, each of us must feel the symptoms of stress from time to time. The nervously ill person so often thinks that recovery means a peaceful body at all times. Recovery means reduction to normal intensity, not absence of nervous sensations and emotions.

Learning to Cope.  Practicing to go through panic, even the right way, usually increases sensitization for a certain time. In the early stages of treatment, I therefore sometimes prescribe mild tranquilizers to be taken after practice. This prevents unnecessarily increased sensitization. I rarely prescribe tranquilizers before practice because the patient must experience panic to learn going through it the right way, and so be able to cope with its unexpected returns. The doctor should encourage the agoraphobe to practice even if he “does not feel like going out today!” In the future, even when cured, he will not always feel like going out but may have to, so the sooner he learns the better. The agoraphobe should be taught to understand that he must cope with himself and not with a particular situation, that is, he should not try to “do Penn Station” or “ the George Washington Bridge.” For example, at a seminar at the London hospital a young nurse - therapist showed a videotape of his treatment of a middle-aged agoraphobic woman. The therapist persuaded the woman, who had not traveled alone for years, to walk around the block by herself. On her return he inquired how she had managed, She said, “I didn’t panic at all ! ”He answered “Good! Now I want you to do it again!” When asked “Why?” He said, “It’ll do you good!” She set off reluctantly and returned afraid and shaky. He asked her to repeat the journey several times, each time answering her bewildered “Why?” with “It’ll do you good!”

Role of Therapist. To show necessary understanding, this therapist should have explained to the woman that she felt no panic the first time because she had walked on a cloud of part dream, part exhilaration at achieving the hitherto apparently unachievable. He should have cautioned her that on the second journey the dream would fade; that she would be only too aware of being out on her own; the distance would then seem greater and that she would probably panic. He should have explained that to panic would be natural, not the defeat she felt it to be; that it was this panic that she must learn to go through, rather than consider walking around the block her main goal. Not only would this explanation have given her more understanding of her illness, it would have earned her more willing co-operation during the even more difficult tasks ahead. In private practice I encourage each new patient by telephone until I have him moving successfully from home alone. In the beginning this may mean almost daily contact for a week of more. Before the agoraphobic woman (it is usually a housewife) leaves the house, I ask her to repeat to me how I want her to approach the difficulties while outk above all how she is to go through the panic. It is essential to make sure that she understands how she is to cope with herself and her reactions, before she starts off to practice. There must be no bewilderment. I also ask her to telephone me on her return. This gives her incentive and encouragement and gives me an opportunity to discuss her journey with her - rewarding to us both, because if she thinks she has failed, I can point out her mistakes and often persuade her to go out again immediately and turn failure into success. This treatment may sound too demanding for some therapists, but I had no chronic agoraphobes taking up time or seats in my office. I also suggest a helpful home exercise called right reaction - readiness. Because the agoraphobe remembers past failure so vividly he has to unlearn wrong reaction-readiness. Right reaction-readiness means that he rehearses in his mind to meet stressful situations so that he is primed for the right approach when he faces such situations in reality. The following remark by a patient illustrates right reaction -readiness. He said: “When I mentioned being on guard some weeks ago, I know now I was on guard watching to stop myself listening-in and bringing on a spell. I should have been on guard ready to relax and accept anything that might come. It’s not like that now. I’ve learned to see a spell through without reaching for the pill bottle. I can even work with the panic there. I’m not saying I don’t mind it. I do. It’s still horrible. But is doesn’t throw me the way it did. I’ve learned what you mean by letting go.” To practice right reaction-readiness, the agoraphobe should sit as comfortable as possible in a chair and imagine he is facing one of the situations he fears most: for example, boarding a bus alone. Let him suppose he is at the bus stop waiting for a bus. As the imaginary bus approaches, he should try to feel as if he were there; he should make his reactions severe and when he experiences them he must strive to relax as much as possible and let the fears all come. He should be prepared to meet the bus with the fears there, not try to avoid them or switch them off. Though he imagines that his legs wobble, he should still direct them into the bus. In other words, move forward in imagination with utter acceptance.

Overcoming Panic by Acceptance.  As mentioned, some people are discouraged by the word ‘accept’. I then suggest that they move forward prepared to “react freely,” that is to give free rein to all feelings and let them all come without trying to brake any of them. Many agoraphobes fear that by doing this the feelings will be so overwhelming, they will be immobilized. I point out that the word “freely” saves and eventually cures, because it releases enough tension to encourage movement. All the symptoms that accompany prolonged stress - pounding heart, churning stomach, and so on - are first fears because they come unbidden; it is certainly the patient who adds the second fears. Each nervous symptom has a simple explanation and it is essential that the therapist supply this explanation instead of simply saying, “It’s your nerves!” The therapist must understand so much before he can help a patient to cope with the strange nuances in recovery from agoraphobia. For instance, in the beginning, even no more than boarding a bus for the first time in years may seem so unreal, that when successful the agoraphobe may feel no sense of achievement, only a feeling of strangeness, as if the experience were happening to somebody else. Indeed, his illness may seem more real than the early stages of recovery. The bus journey, or any other potentially panic-producing undertaking, must be completed successfully many times before it conveys any sense of real, lasting achievement, yet he should not be too disappointed if success is occasionally followed by failure. Acceptance means accepting even failure as part of recovery. When the agoraphobe fails he should be encourage to go out and practice once more, but he should be sure to practice not to test himself. So many agoraphobes will think: “I did so well yesterday, I hope I do as well today!” and then be disappointed if they are more afraid than they had been yesterday. Anxiety created by wondering whether one will do as well today as yesterday generates enough tension so that a minor incident might trigger panic with ensuing disappointment. The thought of testing makes demands where as during practicing failure simple calls for further practice. The agoraphobe should take the first practice-steps at a moderate pace. Rushing to ”get it over quickly” increases agitation and prepares, therefore, the way for panic. He must try to proceed slowly and gently; he must not shy away from noticing how he feels nor from thinking of himself by concentrating on something else. He must be prepared to feel bewilderment, fear, and tension in the beginning - how could he not feel strange and unreal - and not expect acceptance to work wonders immediately. I assure him that his reactions are normal under the circumstances and that they are not necessarily sick reactions.

Setbacks.  Memory often recalls old fears so vividly, the sufferer easily mistakes memory for reality and may think he is ill again. He has suffered in those streets or shops so often, that very sight spells despair, stress -sensitization. I use homey similes to help the patient cope with memory. I tell him that the smell of hot muffins automatically makes me think “Grandma!” (she used to bake hot muffins for me sixty years ago when I came home from school). I explain to the patient that his flashback memory of his illness resembles my flashback memory of grandma - it means no more and it to be expected. Today, hundreds of people travel in places where they have not ventured for years helped by the thought of grandma’s muffins when disturbing memories threaten to drag them into a setback. Setbacks are most distressing because the peace enjoyed during a good spell highlights the suffering felt in a setback. The agoraphobe thinks that as he recovers, setbacks should become rarer and less severe. So they may, but it does happen that the severest setback comes just before recovery, which makes the experience particularly shocking and frustrating. One of the upsetting aspects of setbacks may be the return of all the symptoms in quick succession, because the sufferer will equate the number of symptoms with the severity of the setback. I explain that the quick return of so many symptoms is a response to a chain of related memories, very much as if by thinking of his cousin John his thoughts would turn to other members of the family. Since the symptoms of a setback are the symptoms of stress, their reappearance simple means that the sufferer is once more under stress - possibly from worrying about the setback. The agoraphobe should be taught to give as much time to a setback as it demands and not try to rush through it to test himself each morning to see if he is feeling better. Instead he should try to accept himself as he finds himself in the morning and know that a difficult morning does not necessarily mean a difficult day. In other words he must try to float with a setback, not fume against it. The patient should also be taught that he can make more progress toward recovery in a setback than in a peaceful spell. In a good spell he gathers hope, has respite, but in a setback he has another opportunity to practice facing his fears the right way and each time he comes successfully through a setback he becomes less afraid of facing another. He begins to know the way out so well, he finally no longer fears the way in. When understanding and acceptance slowly succeed in lessening sensitization, flashes of panic will follow thoughts less swiftly and less intensely and the agoraphobe will be able to reason with his feelings. Confidence comes only with experience and sine if tge nist trying and therefore, most rewarding experiences lie in coming through setbacks.

Conclusions. The treatment described here may sound too simple. It may sound simple but it is not easy. Very little worth having is gained easily. Self-desensitization, in my experience, is the only treatment that allows the agoraphobe to face the future with confidence. Recovery is in his own hands, not in drugs, not in avoidance of panic, not in “getting used to” difficult situations, nor in desensitization by suggestion. Permanent recovery lies in the patient’s ability to know how to accept the panic until he no longer fears it. During 1966-74, I treated (in addition to patients in private practice) approximately 2,000 agoraphobic men and women mainly in the United Kingdom, Canada and the United States of America, by remote direction in the form of books and tapes as well as a quarterly magazine of direction and encouragement. Summary- The therapist has a very special role in helping his patients to understand sensitization and to guide them toward self-sensitization. To achieve successful self-desensitization the agoraphobia has to identity the two fears, namely the first fear, which is a legacy of sensitization, and the second fear, which he himself adds to the first fear. He has to learn how to break this fateful chain by passing through the first fear without superimposing the second one. In this way the intensity of the first fear and thus the sensitization will lessen. Recovery means experiencing normal intensity of nervous reactions to stress, not their abolition. The logical progression from sensitization through indecision, suggestibility, loss of confidence, feelings of personality disintegration, feelings of unreality, apathy and depression is outlined.

 
References:
Marks, I.M. Fears and Phobias. Heinemann, London 1969
Weekes, C A Practical Treatment of Agoraphobia, Br. Med. J.,pp. 469-71 “ Simple, Effective Treatment of Agoraphobia. Hawthorn Books, Inc., New York, 1976; Angus & Robertson, London 1977
Peace from Nervous Suffering. Hawthorn Books, New York, 1972; Angus & Robertson, 1972
Hope and Help for Your Nerves. Hawthorn Books, New York, 1969; Angus & Robertson, London, 1962 (under the title Self Help for Your Nerves). 
Hope and Help for Your Nerves. An album of two L.P. recordings. U.S.A. Worth Productions, Washington. D.C. Angus & Robertson Australia .