I had a panic attack at the grocery store Again. This seems to happen every single month now. I generally do my grocery shopping in one fell swoop, on payday. I am not a person who enjoys leaving my house. I wasn’t always this way, but I am now.
A Basic Definition of Agoraphobia
I’ve struggled with agoraphobia since puberty. Agoraphobia, literally means fear of the market place. If you’ve read Plato or Aristotle or any of the Greeks, the Agora is somewhat a hub of commerce, but more. It’s where people hung out.
In modern times, the DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorder – Text Revision 4) classifies Panic Disorder as either existing alone or with Agoraphobia. The notion is extrapolated to include the anxiety that a panic attack might come, especially in certain circumstances. This leads to avoidance. It can cause debilitating anxiety that has major consequences. Some of the consequences of my agoraphobia have been:
Costs of Agoraphobia
- I dropped out of college. I was at the top of my class. Panic attacks made the classroom an impossible environment. I was only three courses and a fieldwork placement away from earning my diploma. Subsequently, I have a lot of student debt and no piece of paper on the wall.
- I quit several jobs. I can tell you that I am a smart and capable person. But, talent, aptitude, and brains only count for so much. It is more true to say that to be successful in a job, the most important thing is merely being able to show up. I’ve done every sort of job including fast food, telemarketing, library clerk-ing, volunteering for mental health groups, insurance sales, pumping gas, landscaping, construction, bakery employee, shipping and receiving and the list goes on. Some of these jobs lasted for a good amount of time, and some had me sneaking out, never to return, by my first lunch break.
- I have lost friends and I feel forgotten. This is particularly difficult to think about. Apparently, we are some variety of social creature. And this socializing often involves going out and doing activities, attending parties, drinking, dancing, amusement parks and carnivals, seeing movies, shopping, dinner parties, restaurant hopping, road trips and travel, time at the beach, going to exhibits, concerts, plays, and playing sports. It is hard on a friendship when one person has certain expectations to share in activities and the other person can’t make a commitment to attend a function, or really enjoy an outing if they’ve gotten that far. Eventually, even if you have a heart of gold, people start looking elsewhere for activity partners and one day you find yourself secluded in a tiny apartment in a far away town and you know that people have forgotten you.
Really, agoraphobia is a thief. It steals one’s interacting with the world. Places become no go zones. There is the ominous feeling of gut sinking terror to imagine oneself in certain circumstances. Everyone around you seems to be having a fun time. You are not. You are trying to hold yourself together and not let everyone see that you feel sea sick and overwhelmed and that you are trying to breathe normally and avoid hyperventilating. You are trying to seem normal and not run — which is exactly what all body systems are priming up to do. Eventually, you stop trying to fight these situations and you start finding excuses to just not be there. Maybe you decide to start a blog and your cat becomes your best friend. Maybe you don’t go to the doctor when you know you need to. Maybe you retreat into memories of when you could travel and do things.
As I hope is obvious — this results in depression. It results in feeling guilty. It results in isolation. And for many, it ends in suicide.
About Panic – Fight or Flight
There haven’t been any novel treatments for this disorder in my lifetime. The basic approach is behavioural therapy. Exposure therapy in particular. The idea is that you face the situation, you feel the anxiety in its entirety, and eventually the anxiety loses its power.
What psychology skips over is that this is a pretty tall order. Addicts experience a physiological response when they engage in their addiction. The brain changes over time as a result of the neural pathways being influenced. A panic attack, in the same way, is a physiological response to anxiety and fear.
Panic attacks can generate in two ways — one is from our thoughts – anxiety. The other falls under ‘chemical imbalance’ in the brain.
The parasympathetic nervous system activates for no reason in panic sufferers. The body goes into a fight or flight response. Apparently, at some point in evolution, this was adaptive — it got you away from dangerous animals and made you hypervigilant to threats. In the modern world, we are not constantly in actual physical danger, but the psychological mechanism still exists.
The body gets ready to either fight the threat or run like hell. Both options involve concentrating resources to certain body parts and shutting down things like digestion. The senses are on red alert — and the brain stops being its usual nuisance and starts tracking stimuli and data and finding threats everywhere. The cortisol and adrenaline are spewing through your veins. You start to feel sick as your body gets ready to rid your stomach’s content so it doesn’t hold you back. Your hands and face tingle like pins and needles. Your breathing is shallow and fast.
And then you’ll have some good-intentioned person say to you, “Just relax. There’s nothing to be anxious about.” That just makes it worse.
You feel embarrassed, naked, ashamed, guilty, and that you can’t control a single darn thing. Ironically, there is more truth to life and the cosmos being uncontrollable than people realize.
Treatment Options – Medication
Medication has been one answer. When I was first diagnosed, decades ago, psychiatrists were still liberally giving out anti-anxiety meds. Sedatives / tranquilizers, central nervous system depressants — basically the entire catalogue of benzodiazepine medications were used.
The problem — they were and are addictive and the body builds tolerance requiring higher and higher doses. You also can’t just stop taking them — dependency, both physiological and psychological develops. This class of medication featured powerful drugs that worked, but that did not work in the long-run, often requiring frequent dose increases and switching to or adding other benzodiazepines.
The body becomes so dependent on them that benzodiazepine withdrawal is a serious medical situation that has led to death, seizures, and other complications.
Medicine currently uses benzodiazepines for short term, acute situations. To give an example of a non-anxiety usage, benzo’s are given to rehab patients going through delirium tremors as they withdraw from alcohol and other drugs like cocaine and heroin.
Since Prozac, an SSRI antidepressant, came out, there have been a myriad of different antidepressants and antipsychotic drugs that have become popular. The name is somewhat misleading, as you’d expect an antidepressant to address depression and antipsychotics to address psychosis (hallucinations and delusions — departures from reality).
Really, these drugs all work on the chemical imbalance theory. Antidepressants change the level of serotonin and how it is absorbed and transmitted by the brain. Norepinephrine, GABA, and dopamine are also brain chemicals that these meds monkey with.
The problem is that doctors know that they work for some people, but they don’t know why. It’s not a solid science and according to some it’s a very irresponsible because the causes and effects are not known. The potential for long-term effects aren’t well known.
Each of these medicines, used for psychiatric conditions, comes with a warning that people need to be monitored because there are indications that these medications cause suicides and in other cases homicides. The world of psychiatry has no qualms about playing with the fire that is meddling with things that science doesn’t yet understand.
Treatment Options – Psychotherapy
Then of course, there is therapy. I already mentioned behaviour therapy. To a degree, cognitive-behaviour therapy is effective in treating anxiety. By and large, therapy is the best option but it requires a committed team approach from a qualified therapist and the patient. Therapy is often not pursued because it is expensive and time consuming. Many people, even those with generous private healthcare plans, can’t find adequate coverage for the costs of intensive treatment. It is thus that most people are steered toward medication because it is affordable, very profitable for the drug companies, and it doesn’t place huge time burdens on doctors.
Is there hope?
Well, somedays I feel there is no hope for treating panic disorder and agoraphobia. There definitely is no cure. I have by no means even touched on many other losses that are the result of the condition. I grieve my own losses and as well as empathize and grieve with others who suffer.
Perhaps, hope needs to be seen in a Stoic sense. Life is going to be hard. Life is going to have challenges. Change is inevitable and no one gets out alive. We err when we believe that life must always be comfortable and that if we live a certain way, we’ll be happy, at peace, and feel fulfilled. And the truth is — that isn’t often the case.
And so our challenge is to find a quality life despite the discomfort and losses and tragic things. This is existential territory and I don’t believe there is just one correct answer. I would make the point that, while we suffer horribly, we also have moments of joy, peace, and the sharing in compassion and intimacy with others. We can still find things to value despite deep pain.
Ultimately, there is wisdom in that the human spirit is geared toward survival. I don’t believe this is an accident. There is hope because we want there to be hope. We don’t come into this world and kill ourselves at the first opportunity — no, we can imagine and we can dream and we can keep swimming against the strength of the tide. Sometimes, the big picture is the only answer to how to thrive within our limitations.
Can you relate?