Editor’s Note: Many thanks to our Associate, Michael McManus, LPC, for providing a therapists’ viewpoint of working with debilitating anxiety conditions. His “story” format allows a more personal take on how a therapist will engage such a complex circumstance.
“There are scary monsters looming in the darkness; where we can only feel them”
The gentleman sat straight on his chair. He barely made a move. There was something about him that was hard to pinpoint. He introduced himself and said there was something seriously wrong with him. He wasn’t sure about exactly what was wrong but said that he could feel it in his bones, in his head. He wasn’t sure when or where it started. He proceeded to explain how his first encounter with his “monster” was. He said: “I was driving to my house, I think. Everything was normal; it was a perfect day. Suddenly the day turned dark in my head. I don’t know what happened. I could see, I suppose. I began to sweat profusely. I was holding the steering wheel as tight as I could, but my hands were so sweaty that I could barely steer. I noticed that my hands were shaking as well, sometimes more than others. I couldn’t drive anymore! But I had to because I was in the middle of a highway. I stopped the car in the middle of the highway; I couldn’t drive anymore. I got out of my car and began to walk away. A little later I was feeling better, I think. Well, I wasn’t trembling anymore or sweating and for me, that was a good sign. Then I noticed that people were yelling at me from their cars; tons of obscenities that I could not hear before. I tried to go back to my car, but I couldn’t. I sat on the grass and finally someone came next to me and asked me if I was ok. Truth be told, I didn’t know. All I knew at that moment was that I could not go back to my car. That was the beginning for me. I have never felt as bad as that day. I have always been very healthy, but the way that I felt that day was out of this world. I have never been so scared in my life and the worst part is that I didn’t even know what it was!”
Of course, we went with the obvious questioning: What happened that day?, Are you having problems at home?, Have you seen your doctor lately? Gentleman X couldn’t tell any “abnormal” stories up to that point. I remembered a professor stating: “When interviewing a client, don’t be afraid of the questions; ask them all, however strange and impossible they sound. Once you eliminate all that is possible, whatever is left, however impossible is your answer”. So back to the drawing board we went. We embarked in a guided discovery voyage designed to find the impossible. Suddenly, there it was. Hiding in plain sight. Gentleman X said: “well, I don’t know if this is important, but I went to see the doctor and he recommended I had an MRI done. So I did. It was a horrible experience; terrifying. For some reason I was left there alone in the dark. I kept calling for someone, but nobody came. I couldn’t deal with the situation, so I got out as I could, got dressed and left the office.” Voila! There it was, staring at me; the impossible! We spent some time exploring how he felt about the situation, that by that time affected him enough, to prevent him from going into an elevator (of course you needed to use one to get to my office). I believed that we found the “reason”. The MRI was the turning point for Gentleman X. Now it was my job to figure out what was wrong as well as how I would help Gentleman X to go back to premorbid functioning. This is what I found: “Agoraphobia is a condition where sufferers become anxious in unfamiliar environments or where they perceive that they have little control. Triggers for this anxiety may include wide-open spaces, crowds (social anxiety), or traveling (even short distances). Agoraphobia is often, but not always, compounded by a fear of social embarrassment, as the agoraphobic fears the onset of a panic attack and appearing distraught in public. Most of the time they avoid these areas and stay in the comfort of their safe haven. This is also sometimes called “social agoraphobia”, which may be a subtype of social anxiety disorder.
Agoraphobia is also defined as “a fear, sometimes terrifying, by those who have experienced one or more panic attacks”. In these cases, the sufferer is fearful of a particular place because they have experienced a panic attack at the same location at a previous time. Fearing the onset of another panic attack, the sufferer is fearful or even avoids a location. Some refuse to leave their homes even in medical emergencies because the fear of being outside of their comfort areas is too great.
The sufferers can sometimes go to great lengths to avoid the locations where they have experienced the onset of a panic attack. Agoraphobia, as described in this manner, is actually a symptom professionals check when making a diagnosis of panic disorder. Other syndromes like obsessive compulsive disorder or post-traumatic stress disorder can also cause agoraphobia. Essentially, any irrational fear that keeps one from going outside can cause the syndrome.
Agoraphobics may suffer from temporary separation anxiety disorder when certain other individuals of the household depart from the residence temporarily, such as a parent or spouse, or when the agoraphobic is left home alone. Such temporary conditions can result in an increase in anxiety or a panic attack or feeling the need to separate themselves from family or maybe friends.
Another common dissociative disorder of agoraphobia is Thantophobia, the fear of death. The anxiety level of agoraphobics often increases when dwelling upon the idea of eventually dying, which they may consciously or unconsciously associate with being the ultimate separation from their emotional comfort and safety zones and loved ones, even for those who may otherwise believe in some form of afterlife. Agoraphobia patients can experience sudden panic attacks when traveling to places where they fear they are out of control, help would be difficult to obtain, or they could be embarrassed. During a panic attack epinephrine is released in large amounts, triggering the body’s natural fight or flight response. A panic attack typically has an abrupt onset, building to maximum intensity within 10 to 15 minutes, and rarely lasts longer than 30 minutes. Symptoms of a panic attack include palpitations, rapid heartbeat, sweating, trembling, nausea, vomiting, dizziness, tightness in the throat, and shortness of breath. Many patients report a fear of dying or of losing control of emotions and/or behaviors”.
Without treatment it is uncommon for agoraphobia to resolve. Now we had to deal with the “what to do” question! What did I have on the tool box that could help Gentleman X to go back to his driving and into the elevator? It wasn’t surprising to find out that Cognitive-Behavioral strategies were the most common and successful when dealing with Gentleman X’ dilemma. Of course, by then we knew that there was nothing physical going on with him (so did his general practitioner said). So we went with his faulty cognitions first. We implemented “Guided Discovery” as well as “Challenging the Absolutes” strategies” first. Our broad goal was to assist Gentleman X to find out that nothing was wrong with him. In a way, “your mind is playing dirty tricks on you” kind of thing. Of course, he needed to first believe that it was a possibility. Gentleman X worked like a champ! Once that possibility was implanted in his thinking (cognitions), we moved to “normalize” his life. We implemented yet another strategy, “Decatastrophizing” to help him accept the idea that there was no negative outcome that could affect him more than the status quo. I have to admit that it was this part that was the most challenging (for me more than him). Now, we need to work on his resulting behaviors, because repairing his dysfunctional cognitions alone would not get him in that car, that highway or that elevator for that matter. We implemented “In Vivo Exposure” strategy to assist him to do just that. We spent who knows how long, “driving” and “riding that elevator” down the highway and up and down until the big day came. Gentleman X would drive his car down the highway and he would ride the elevator up to my office; alone. That afternoon, I opened my door to receive Gentleman X. He was already waiting for me. He wasn’t smiling in victory, which sent a chill down my spine. Instead, he look at me with a tear in his eye and said: “I did it!”
Michael McManus, Licensed Professional Counselor, is a Clinical Associate with Family Guidance Centers in our Chesterfield office. He provides individual, child, family, and marital therapy. Mr. McManus has experience reaching over 20 years. He can be reached at 804-743-0960 or can be emailed at contact@familyguidancecenters.com.