Part One
Medical Problems that Sometimes Mimic Anxiety, and What's Going On in the Body When Anxiety Symptoms Come On
Holly thinks:
Emma's given me some interesting psychological information, but I think I'll take her advice and go to the doctor first, just to make sure I haven't got a physical problem causing my symptoms. I am worried he'll just put me on drugs, but I can say I want to try other things first if it's only anxiety causing my panic sensations. But I'll ask if he'll arrange for tests to be done on me to make sure I haven't got a medical problem.
Physical Problems that can Mimic Anxiety
Emma said her friend said she's read that it's most likely that symptoms like mine are being caused by anxiety, because anxiety can produce horrible symptoms, but there are physical illnesses that can mimic them, although they're fairly rare. I'm glad she wrote down a list for me of physical problems that can cause things that feel like anxiety: a thyroid disorder, certain types of heart problems, hypoglycaemia, adrenal disorders, and some other things. She said that with most of these things, there won't be much to worry about and they're easily treatable.
But she said the thyroid and the adrenal glands can both release too much hormone, if a person has disorders of them, which can cause symptoms like panic. And hypoglycaemia can cause them. She said There's a test for hypoglycaemia where people can be given a drink of glucose, which raises the blood sugar levels temporarily, but the disorder makes them fall quickly, and as it does, someone who has it will feel increasing symptoms that seem like the symptoms of panic, like sweating, shaking and a more rapid heartbeat. This is because adrenaline and other hormones will be released as a substitute for the chemicals the body's beginning to miss because of its falling blood sugar levels, and they're what cause the symptoms.
She said that anyone who knows what's going on will quite possibly not mistake it for a panic attack, but if they don't know they've got the condition, the symptoms it gives them from day to day will make them anxious about what's happening, and the symptoms along with the anxiety will feel like a panic attack.
The same kind of emotional reaction can happen because of worry about the same types of physical sensations when they're sometimes caused by certain medications, some illegal drugs, alcohol and caffeine.
We Can Think a Panic Attack is Beginning When the Body's Really Trying to Tell us Something Else Entirely
It's funny that Emma said the therapist said that other things that can cause symptoms that feel a bit like the symptoms of a panic attack when it starts are things like falling in love and watching your loved one coming towards you, watching something exciting on the television, or getting angry.
She said the reason people get the physical sensations is because the body releases adrenaline, to increase excitability. When a person sees someone they've fallen in love with, their heart beats faster, and they might breathe a bit faster and shake a bit. But if we think those symptoms mean we're going to have a panic attack, we'll get anxious about them, and then we'll get more physical sensations because the more anxious we get, the more adrenaline's released, because part of the brain thinks there must be danger around and so it puts us into fight or flight mode, which is what adrenaline does in large quantities.
So we might end up having a panic attack when our bodies were really trying to tell us something totally different at first. So panic attacks can have a lot to do with the way we interpret the symptoms and how anxious we get after we do.
I'll tell my doctor I think I have agoraphobia but I just want to make sure it isn't something else.
Emma said it's fairly rare for medical problems to cause symptoms like panic, but that it's best to get tested just in case.
The Reason the Symptoms Happen
I'll ask the doctor if the panic attacks could be doing me any harm. If there's something physically very wrong with me, they just might.
But Emma said her friend's therapist said that just anxiety on its own can cause really horrible symptoms, and that panic attacks on their own aren't dangerous. She said they're meant to help us get the energy to run away or fight an attacker. She said they would have come in useful in the old days when people were far more often faced with wild animals who might want to eat them. If panic attacks were dangerous, people wouldn't have survived those days, so there might not be many people left.
But when there isn't any real danger, but the panic symptoms come on anyway, maybe because we're too stressed about work or something, it naturally isn't appropriate to use them as the thing they were meant for, as motivation to do something dramatic that really needs doing right then, so we just have to put up with them, and that's why we find them so uncomfortable.
It's interesting what the therapist said about why panic attacks happen. She said that when we're stressed, our brains can release adrenaline, which is how they tell our bodies to get ready to run away or fight, which is what the part of our brain responsible for releasing the adrenaline thinks we need to do because it thinks it can sense danger. This might be for one of several reasons:
- It can be because the situation we're in has some familiarity to one where we felt fearful before and our brain remembers we felt fearful then, so it supposes we must have been in danger then and might be in danger there this time as well;
- Because we've worried so much that we might have a panic attack there that we've made ourselves anxious enough to have one;
- Or it can be because things are happening in our lives that have made us really stressed.
She said the part of the brain responsible for making such judgments is the emotional part of the brain, which doesn't think in a sophisticated way like the part of our brain we use for thinking things through consciously; it makes snap decisions about what chemicals to release before we have time to think with the more sophisticated part of our brain about whether we're really in danger and need to have the chemicals released, and without us realising it's doing it. It has to do that quickly, because if we really are in danger, we might not have time to think things through before we need to get out of the way fast or fight.
She said the adrenaline that the brain sends out makes the heart beat faster, so it can pump blood round the body more quickly. It does this because oxygen is always carried round in the blood to where the body needs it for fuel, and it thinks it needs more than usual for the energy it will have to use to fight or run away. When the heart beats faster, more blood containing oxygen will be sent to the muscles and brain, because when the oxygen gets to the muscles, it'll give them energy to help them use their strength better, and when more oxygen gets to the brain, it'll give it fuel to help it put its emergency responses into operation faster.
But because the body thinks the brain and the muscles of the arms and legs which will be used most when the person has to run away or fight need more oxygen, the adrenaline also causes less oxygen to be sent to other places that it thinks can do without so much for a while, like the skin and the digestive system, so that the oxygen they were using before can be sent where it's supposedly needed instead. The blood vessels in the muscles and the brain enlarge, so oxygen-carrying blood can flow around them faster to make sure the oxygen gets to where the brain wants it to be used as fuel as quickly as possible. But at the same time, the blood vessels of the skin and the digestive system get smaller, so they can push blood out from there, so it can go to where it's supposedly needed. That's why people go pale with fear, because blood's being sent away from the skin so it can carry oxygen to the parts the brain thinks need it right then. And the blood being pushed away from the stomach so it can be sent to the muscles and brain instead is what causes butterflies or cramps in the stomach.
The adrenaline also causes the tubes of the lungs to expand, so more oxygen can be taken into the system. That's why people want to breathe faster during panic attacks. The trouble is that when we do, we breathe out too much carbon dioxide, which we need a certain amount of to stay feeling normal. So when we breathe out too much, the shortage of carbon dioxide makes us start feeling dizzy and disorientated, and we can get cramps and tingling sensations in our hands and feet because of it. It can help to breathe into a paper bag, because then we get back the carbon dioxide we're losing. But if we try and breathe slowly, that can also help. If we don't do anything, the body does know how to restore the balance after a while, so things will get back to normal by themselves. But we can speed up the process by breathing slowly.
Another thing that happens with a panic attack is that because our salivary glands don't need much blood, they shut down temporarily so the blood they were using can go to our muscles and brain; so we can get a dry mouth.
The pupils of our eyes dilate, to enable us to take in as much information from around us as possible, so we can find out as much as possible about the danger that the brain thinks is coming.
Wow! I didn't have any idea that all that was going on! Perhaps in future, instead of getting scared I'm going to faint or have a heart attack, I can think things like, "Oh, my heart must be trying to pump blood around my body faster now so more oxygen will get sent to my muscles". Or when I'm feeling as if I'm desperate to get more breath, I can think, "Oh, my body's trying to get more oxygen in it because it thinks it needs to send it to my muscles and brain, the poor thing", and that kind of thing. Maybe I could even talk to it in my mind, saying things like, "Come on, body! I'm not in any danger here; you don't need to do all this stuff. Calm down."
Drugs that can Cause the Release of Adrenaline
The therapist said that some drugs can cause more adrenaline to be released into the system, or can behave like adrenaline, so it's best for people who have panic attacks to avoid them. She said they include caffeine, and drugs that are often found in cold medicines, dental anaesthetics and energy-boosting drinks found in health food shops, like ephedrine, pseudoephedrine, epinephrine, norepinephrine, and others like them. I'll have to beware of those. She suggests that If we need a dental anaesthetic, we tell the dentist we might not be able to take anaesthetics with epinephrine or norepinephrine in them.
Well, I hope they have other ones that don't contain those then! I wonder if the anxiety I've felt before at the dentist's was at least partly caused by the anaesthetic. Or perhaps it was just caused by the dentist.
The Reasons Panic Attacks Can Come On in the First Place
Emma said the therapist said that when we start to feel the things we recognise as fear sensations, we can accidentally make them come on more by worrying about them, feeling sure they mean we're going to have a panic attack, or worrying we're going to have a heart attack and die because they feel so unpleasant. Then the anxiety we start to feel makes the brain think there's even more cause for alarm than it did before, so it sends out more adrenaline, which increases the physical sensations we get. That makes us even more certain we're going to have a panic attack or a heart attack, so we get more alarmed, and the brain picks up on that, thinks there's even more danger, so it sends out more adrenaline, which gives us more symptoms, that make us more anxious, and it very quickly spirals upwards like that until we do have a panic attack.
Why People Can Have Panic Attacks in More and More Places
When we do have a panic attack, the brain desperately searches the environment to find the cause of the danger it thinks we're in. After that, when we're in a similar environment, it'll recognize it as one where it thought we were in danger before, so it'll assume there must be danger there again, so it'll send out adrenaline which will give us nasty fear sensations. So we'll start avoiding places like that, because the fear sensations we get in them are so unpleasant.
But she said that because the brain took in several things when it was searching for where the danger was, it'll send out alarm signals when anything in the environment's similar to where we first had a panic attack. So if our first one was in a supermarket, we might start getting panic attacks in the bank or post office, or in cafes, because there are crowds and queues there just as there were in the supermarket, and the brain thinks they might be danger signals. So we start avoiding more and more places to protect ourselves from the panic attacks we think we'll get there. And because we're so worried we'll get panic attacks there, if we do go there, all the anxiety we're feeling will be more likely to bring them on.
The Length of Time Panic Attacks Can Go On For
I sometimes think my panic attacks are going on for hours. But Emma said the therapist said that panic attacks don't really do that. She said the most they can last is about an hour, and usually, the most they'll last is about twenty to thirty minutes, because most people's bodies can't keep releasing and reacting to adrenaline for very long, because otherwise, we'd get desensitised to it, like people can to larger and larger amounts of alcohol if they drink it often enough.
She said that when people who think they've been having a panic attack all day or for days really examine what's happening, they realise their hearts haven't really been pounding for that long, and they haven't really been hyperventilating all the time, or they would have passed out and their bodies would have gone back to normal. She said that what tends to happen instead is that people have panic attacks for a short time, but it might seem like hours because the symptoms are so unpleasant, or it can happen that because we're so anxious, our bodies might calm down, but then we might keep working ourselves up into more panic attacks, because of the worrying thoughts we're thinking.
I think that might have been what's happened to me sometimes.
I could test that one out. I'll try timing my panic attacks. I'll keep a notebook with me, and make a point of looking at the time and remembering it when I feel one coming on, and then look at the time again when it dies down, and write them both down. Then I'll know how long they last, and how long there is between each one. I might be relieved if I discover they don't go on for as long as I think.
Physical Differences There Might Sometimes Be Between Agoraphobics and Non-Agoraphobics
It's interesting what Emma said the therapist said about the physical differences that seem to have been found between agoraphobics and non-agoraphobics. But it's nice to know they don't mean we're stuck with agoraphobia.
She said that research is finding that people who have panic attacks may be especially sensitive to adrenaline. She didn't know how scientists found that out. I'm not sure how they'd be able to tell the difference between being biologically more sensitive to it, and being more sensitive to it because we've learned to be more alarmed by the symptoms of it being released so we react to it more quickly and get more anxious about it, because we know how horrible panic attacks are.
She said that evidence of a genetic contribution to agoraphobia might be that if someone has a relative with it, they're more likely to have it than people who don't. But I don't know if scientists have developed a way of telling how much of that is biological and how much is because anxiety can be learned from people around us. I mean, if someone's scared of certain places, a child who spends some time with them is more likely to get scared of them, because they'll assume they must be scary. Emma said that scientists do say that some people develop agoraphobia or panic disorder when they haven't got any relatives with it. And not everyone with relatives with it gets it. So they're still working on finding evidence.
Well, I know no one in my immediate family had it.
But it's interesting what she said about how physical differences from other people have been noticed in people who have panic attacks, though not everyone with panic attacks has them. She said that a chemical called lactate is known to often cause panic attacks in people with panic disorder. She said a chemical called sodium lactate is very often used in hospitals as the solution they put other fluids in when they give people a drip to get medication into the bloodstream, so it's important to discuss with our doctors the possibility that it might be best if we aren't given it.
She said there's a condition called Mitral Valve Prolapse Syndrome which is estimated to be found in over 50% of agoraphobics. She said that means the heart allows some blood to go backwards. She said it's not usually a harmful condition, and it happens to most people to some extent, but when it happens to the extent that people get odd sensations, it can be uncomfortable and very worrying. It can cause the chest to feel kind of floppy, or it can feel as if a person's heart's beating in their throat. She said that often, people go to the doctor with such feelings, but are reassured there's nothing wrong. But that doesn't mean they're imagining things. The feelings are caused by the condition. But in most cases, it's harmless. Very rarely, people will need treatment. She said that for people who are worried, it can be diagnosed with an ECG.
I might have had feelings like that on a few occasions, but I don't have them all the time.
She said that also, people with panic disorder have been found to be much more sensitive to hormone changes, so it means that hysterectomies, pre-menstrual syndrome, and the release of thyroid hormone and adrenal hormones like cortisone can all make people more likely to have panic attacks.
And she said that people with agoraphobia have been found to be more sensitive to bright lights, especially the fluorescent lights that can be used in big shops. They've found that out by using technology that measures brain waves.
Emma said the therapist said she thinks more differences will be found between people with agoraphobia and people who don't have it because of the new brain-imaging technology they've got.
But she said that other physical differences have already been found.
She said that people with panic disorder and agoraphobia have been found to have a much higher sensitivity to medication than other people, like those who just have depression, so things like antidepressants ought to be prescribed in much lower doses, because the side effects will often be more extreme. So if people are prescribed them, doctors ought to start them off on low doses, and then increase them gradually if necessary.
I wonder how reputable the studies that found all these things out were though. I know some studies sometimes say they've discovered one thing, but then when people do other studies, they don't get the same result. So perhaps it'll be worth investigating whether the biggest and most reputable studies agree with those findings.
Emma said it's been found that agoraphobics are much more prone to becoming disorientated and their bodies release adrenaline more quickly when they're exposed to a range of stimuli all at once, like lights, sounds, conversations, heat and bodily sensations.
I'm not sure what that's supposed to prove, since there's no way of knowing whether that's something to do with body chemistry and it's the reason some people start off by having panic attacks in places like that, or whether they're places agoraphobics have learned to associate with fear because they first had panic attacks there for other reasons, and so they worry that the panic attacks will come again as soon as they go to places like that, so adrenaline's released more quickly there.
Or maybe if people don't go out of the house that often, places like that will seem more confusing and frightening because agoraphobics aren't used to them.
But she said that whatever the reason is, they can indirectly make agoraphobics have panic attacks as well as making that more likely for physical reasons, because if we feel a bit disorientated and confused, we can start worrying that there's something wrong with us, maybe even that we're seriously ill and the doctors haven't found out, or that we're going mad, since other people seem to be able to cope, but not us. We can have more and more anxious thoughts until they bring on a panic attack.
She said it can be good to think of our sensations as natural instead, just something agoraphobics have to put up with, that doesn't have to mean anything serious is happening at all.
So when something like that happens, I'll try to think, "Oh, here's another typical agoraphobic sensation."
I'll go to the doctor to try to get tested for physical problems that can cause symptoms like anxiety, but if I get cleared, I'll be fairly sure I don't need to worry.
I'll write down all the panic attack symptoms I can think of that I have, as well as roughly how often I get them and how long they last. Then I'll tell the doctor.
Emma did say the therapist said that biology won't be the whole story.
Part Three
Panicking When We're Feeling Trapped by Life Situations
Working Out When Panic Attacks Have Been at their Worst
Emma said her friend's therapist said that panic attack sufferers and agoraphobics often have panic attacks when they feel trapped in a life situation, particularly one where they feel pulled in two directions, as if they feel they must do something, but at the same time, they feel they can't. She advises agoraphobics to write down in a notebook when in our lives we've had panic attacks, and says that then we can try to remember what was going on then or just before they started, and work out whether we were feeling trapped by life situations at those times. Then she said that every time we have a panic attack in future, we can think about whether we're trapped in a life situation, and try to work out ways out of it if we are.
OK: I'll write down when my panic attacks started, at what times in my life I didn't have so many or if they stopped, at what times of my life they've been worse, and when the ones I'm currently getting started or got worse. I'll have to think over my memories.
I know my panic attacks first started when I was about seven. Mum and Dad used to go out drinking or partying in the evenings at weekends, and even at such a young age, I was left to baby-sit my baby brother and little sister, John and Debbie. Our parents had dropped us off with other people when I was younger, but I think those people must have moved away or something. And my parents would often invite friends around in the afternoons and shut themselves in the sitting room, perhaps to drink, telling me how good I was with kids and so I should play with them upstairs. I know I liked being told I was good with kids. It made me proud that they said that in front of their friends. So I was willing to do what they said, and even volunteered to look after them sometimes when we had visitors. But sometimes, I wanted to go out and play with my own friends, but felt I had to look after John and Debbie instead, because that was what my parents expected me to do. So my friends would come to the door asking if I could play, but I wasn't allowed, because I had to look after the babies.
And sometimes when my parents would go out for the evenings, I had trouble getting the babies to sleep, especially if they didn't want to go to bed. I suppose that was like a trap really, with me thinking things like:
"I can't put the kids to bed because they don't want to go.
But I must, because otherwise, they might be awake when my parents come home, and then Mum and Dad will be angry.
But I can't, because they're not tired.
But I must, because if they stay up much later, they won't get enough sleep, and then they'll be grumpy tomorrow, and get shouted at by Dad more.
But I can't, because they never go to sleep when I ask them to.
But I must, because if I don't and my parents find out, they'll punish me and stop telling people I'm good with kids."
And so on.
I think it was a bit like that when my friends used to call to ask if I could play, because I had the dilemma:
"I can't play, because my parents want me to look after the younger ones.
But I really want to, because otherwise, I'll feel as if I'm missing out on all the fun.
But I can't, or else who will look after John and Debbie?
But I really want to, because if I don't, my friends will stop calling round after a while and might not want to be my friends any more.
But I can't, or my parents will stop telling people I'm good with kids and will be cross with me.
But I really want to, because I really feel like going on the swings in the park."
And so on.
I know my panic attacks stopped for a while when I was about ten. I think a doctor told Dad he'd better stop drinking and get his life sorted out, or he might not have too long to live, and he did change his lifestyle after that and got a good job. It was nicer, because they didn't go out in the evenings and leave me in charge of the younger ones for a while. And we sometimes went out to nice places as a family.
But when I was about thirteen, Dad started coming home complaining about how he couldn't get on with people at work, and soon after that, he lost his job and started drinking heavily again. Mum worked long hours for a while, and Dad spent most of his time in the pub, so I had to baby-sit the kids a lot more again. My panic attacks came back again when I was about sixteen. I knew I needed to work hard at school if I was going to get anywhere, but I had to look after the kids instead a lot of the time. But when I did badly at school and my teachers complained to Mum, she was so scornful and critical of me, that I felt as if I was in another near impossible situation, thinking:
"I can't look after John and Debbie because I need to be doing my own schoolwork.
But I must, or something bad might happen to them.
But I can't, or I might fail my exams.
But I must, or my parents will lose their tempers.
But I can't, otherwise I won't get my work done, and my teachers will complain to Mum again, and she'll despise me for it, and I'll be letting the family down by doing badly."
And so on.
My panic attacks got worse a couple of years later, when I wanted to leave home, but I felt I really ought to stay there, because John and Debbie would come to me for comfort every time Dad started behaving like a savage and smashed any of their things that happened to be in his way when he lost his temper, or when he threatened to hit them. He never did hit them or me or Mum, but I was always worried he would one day. And John and Debbie relied on me to help them with their schoolwork. So that was like another life trap, with me thinking something like:
"I can't leave home, because the younger ones need me.
But I must, because this atmosphere's just making me depressed.
But I can't, because if I do, I won't be able to comfort John and Debbie when they're scared and upset.
But I must, because I have to make a life for myself.
But I can't, because if I do, bad things might be happening that I won't be able to do anything about because I won't know they're happening because I'm not there."
And so on.
A few years later, John and Debbie moved out themselves, so I felt I could go as well. I didn't do too badly, and had some happy times. And then I met Gary. He was just starting the small business he runs. My panic attacks stopped for a while after that. I enjoyed being with him for a while, and we got married. But he turned out to be quite controlling. He didn't like not having his way. Or maybe I just wasn't assertive enough with him, which, looking back, might have been one of the things that attracted him to me, because it suited him.
So when Suzy was born, and I wanted to stay at home and be a full-time mum, he didn't like it, because he said if I gave up work, there wouldn't be so much money coming in, and we needed the money so we could impress people we wanted to do business with by entertaining them expensively, and by keeping up appearances, so they'd think the business was in good shape and we were respectable people. Besides, we were in a bit of debt, and he said I needed to work so we could pay it off more quickly. So that was like another life trap for me, with me thinking things on the lines of:
"I can't stay on at work, because I don't want to trust my children to a child minder who might mistreat them or a nursery where they might not get proper care.
But I must, because if I don't, Gary's business might suffer, because he won't be able to entertain people the way he does now, and we won't be able to afford so many new things, so Gary might not get so much business, because people won't be so impressed with us.
But I can't, because then, I might not bond properly with Suzy, and then we might not be very close.
But I must, because we're getting into debt, and our debts will only get worse if I don't keep bringing the amount of money in I am now."
And so on.
I stayed at work, but I wasn't happy. My panic attacks started again. Then they got worse, after a few times where friends invited me to places, like to start dancing classes, but Gary said I couldn't start dancing classes, because that would be a weekly commitment, and it might mean that I was out when he needed me to make meals for the guests he was entertaining. So I felt trapped again a bit, thinking:
"I can't go to dancing classes, because then I wouldn't be at home to help entertain Gary's guests.
But I have to have some fun of my own.
But I can't go, because how would Gary cope if I wasn't there? He might not be able to entertain his guests after all, and then they might not be interested in doing business with him.
But I must get out more, because I'm not happy staying in every evening apart from when I go out with Gary to meet his business acquaintances, and I'd love to learn that kind of dancing.
But I can't, because what will his business acquaintances think when he tells them I'm not there and they think I wasn't willing to support him?"
And so on.
I'd always been a bit agoraphobic before then, but after that, I got worse. I started having panic attacks on the way to work and while I was there, so I did give up my job after that. It turned out that Gary seemed to manage allright after all.
It was nice to be at home when Suzy came back from school. But it meant I couldn't take her there any more in the mornings, because I started having panic attacks in any crowded area, anywhere where I felt trapped because I wouldn't be able to get away quickly or it would be really embarrassing to. That meant she had to go on the bus, and I thought she was too young to do that really, so it made me more anxious. But I just couldn't face going with her, and Gary said he was too busy. I had panic attacks at the shops, so I stopped wanting to go there. So Gary had to start doing more for me.
Then my panic attacks and agoraphobia got even worse for a while, till I didn't want to go out of the house at all. That was at the time when Dad was ill, and he said the doctors had told him he might not have much time left to live, and I wanted to start visiting him regularly to make sure he was allright and see if he needed help. But I didn't feel safe going on my own because of my agoraphobia. I would have felt better if Gary had gone with me. But he refused. He said he'd hate anyone to discover he was associating with an old drunk like my dad, and he wouldn't want me to go on my own even if I was well, because he knew how abusive my dad could get, and he knew I had come back from visiting him feeling miserable when I'd gone before, and he didn't want me to put myself through that. And he needed me at home to be with Suzy, and to spend time with him when he'd finished after a hard day's work or when he had a break at weekends. So I felt as if I was in another life trap, as if I was thinking:
"I can't just leave Dad, because he can't cope as well as he used to, and he might need my help.
But I must, because no one will go to see him with me, and if I try going on my own, I might start having panic attacks, and then I'll feel humiliated because people will see me doing embarrassing things like running away for no good reason as far as they can see.
But I can't leave him, because I'd feel so guilty if he died and it turned out he hadn't been looked after properly before he did, and I could have been there to help him but wasn't.
But I must, because I know that when I go to see him, he often says horrible things, and I just end up depressed, and then I feel miserable for days afterwards."
And so on.
I didn't go to see him in the end. I felt bad when he died. But after a while, my panic attacks died down a bit. I can go out to places very near home now and not feel too bad.
I'm going to think through the past week to work out what traps I've had in my life that might have contributed to my panic attacks. Even if they've only been small ones, they might have done it. So I might have forgotten about them soon afterwards, but they still might have caused me to have a panic attack.
Well, there's the trap I often have, where Gary would like me to go out to a meal with him where he's taking someone out to entertain them, but I usually end up not going, because I think thoughts like:
"I can't go, because if I do, I might have a panic attack and want to get away, and then what would people think of me? And it would be disgracing Gary as well.
But I must go, or what will they think if they get the impression that his wife isn't supporting him or that I'm snubbing them?
But I can't go, because if I have a panic attack, it will make him look bad, so they might not want to do business with him any more."
And so on.
But actually, I think it might do his ego a bit of good when he tells people I'm not with him because I've got agoraphobia, because it makes him feel like the strong one, which is ironic, given that I had to be strong all through my childhood to support the others. So perhaps I don't really have to worry about not being there.
I'll go through the week thinking of what's been happening on each day, so I can hopefully remember what traps I was experiencing when I had the panic attacks, if any.
Oh yes. Another one is that recently, Gary's been complaining that I've been getting too fat, which he says makes me less presentable to his business colleagues when they come here to be entertained. He tells me I need more exercise. But I can't go out of the house much now, so I can't. So I think:
"I can't exercise, because what if I went out of the house and had a panic attack? What would people think? How would that make me feel?
But I must do more exercise, because I'm letting Gary down looking the way I am.
But I can't, because I don't feel safe in many places outside the house.
But I must, because what will Gary's business colleagues think of me if I don't?
But I can't, because when I start exercising, my heart beats faster, and it makes me worry that I'm going to have a panic attack, and then one will come on."
And so on.
And just a couple of days ago, Suzy asked if I'd come to her Christmas play at school, and that put me in another trap, because I'd love to, and I think I need to be there to support her, but what would happen if I had a panic attack there and caused a scene?
Working Out What Traps We're In from Day to Day
The therapist said that if we can work out what traps we're in now, we can work out how to get out of them.
Whenever I have a panic attack, I'm going to think back over the past few days to work out what traps I've been in. In fact, there's no reason why I should wait till I have one, since I know I probably will. So I could try to think through what's happened at the end of each day or something to work it out. They might only be little traps, so I'll think through days from beginning to end, to see if I can work it out. It may be that other people will have observed things about my life that could be traps. Maybe I'll ask them if I can't think of anything myself. But to help myself work it out if I think I need to, I could think through each of the last few days in turn and ask myself questions like:
- Did I really want to do everything I did?
- Have I been comfortable with each of the plans I've made?
- Have I allowed myself to be pushed into making a commitment to go somewhere or do something I'm not really happy with?
- Have I had strong feelings about anything, feelings that I thought I couldn't or shouldn't have or express?
I'll think about each of the last few days in turn to see if I come up with something.
Working Out What Emotions Make Us Feel Trapped
The therapist said that when we've worked out all the things that have sparked off our phases of panic attacks in life, we can try to work out what's common to them all, and then we can better work out what kinds of situations are likely to spark them off.
I think the emotion that's common to all the traps I can think of that I've had is frustration, not being able to do the things I wanted to do. Maybe I'll be on the lookout for frustrating situations in the future, because I'll know they're likely to be traps for me that might make me have panic attacks, so I'll try to work out what to do about them before I get trapped by them if I can.
The therapist said that other emotions that can cause people to have panic attacks if they have to do with traps are:
- Sadness
- Grief
- Anger
- Embarrassment
- Humiliation
- Fear of Death
- Fear of Injury
- Fear of Loss
- Fear of Failure
- Longing To Be Loved
- Helplessness
- Feeling Smothered
- Feeling Abandoned
- Feeling Overwhelmed with Responsibilities
- Not Having Control
- Addiction
But the therapist said that it all boils down to two things:
- Being without someone or something we want to be with;
- Or being with someone or something we want to be without.
So she said that another way of working out what our traps are is by asking ourselves:
"What am I without that I want to be with;
or what am I with that I want to be without?"
So the first of those could include people we're without but who we'd like to be with, security we'd like to have but haven't got, wishing we had more power to do something, wishing we had decent health, success, and other things.
Or secondly, we could be with people we don't like, with too many responsibilities, the embarrassment of feeling we made a fool of ourselves, or with someone we feel smothered by - all kinds of different things.
She said that other questions we could ask ourselves to help us work out what our traps are are:
"What do I feel I must do but can't?"
If we ask: "What do I feel I must do in my life but can't?" it might help us determine what life trap we're in at the moment.
If we ask: "What do I feel I must do today but can't?" it might help us work out what our immediate, day-to-day Trap is. That might be the same as our life trap, or something much smaller.
Getting Out of Traps
Maybe I can get out of a lot of my traps more easily than I think if I put my mind to it. I'll think about it. Whenever I think through the last few days and realise I've been in a trap, I'll try to think of a way out of it. I'll probably learn to see traps coming after a while. I'll know certain situations will be traps for me, and perhaps won't allow myself to get in them in the first place. Then, if the therapist's right, maybe most if not all of my panic attacks will stop.
The trouble is, the reason I haven't got out of traps in the past is because I thought the drawbacks of doing that would be more than getting out of them was worth. I mean, I can just imagine how angry Gary would have got if I'd insisted we go to see Dad before he died, or if I'd come home telling him I was giving up my job to look after Suzy whatever he thought.
But the therapist said that sometimes, we can imagine things will be worse than they really will be, either because we underestimate the amount of skills we have or the amount of help available to us if we try to get out of a trap, or we over-estimate the effect it will have on us or how other people will react, maybe because of our thinking patterns.
I'll have to think about that.
She said that panic attacks are a way of telling us we're robbing ourselves of satisfaction by not getting out of our traps. She said that traps mean we're not being true to ourselves, and the hours we spend not being true to ourselves are hours that are gone forever from our time on earth. So panic attacks are often an urgent message from an inner part of ourselves that we need to start doing what's really going to be best for us. And if we ignore the message, it just keeps being sent over and over again, sometimes more often, and often with more and more intensity, as if it's trying harder and harder to get our attention.
She said that one thing we can do to help us sort out our feelings about whether we want to get out of the traps we're in is to think about each trap, being honest about the benefits of leaving it and why we don't want to leave it, even if some of our motives make us feel ashamed because if people knew about them, we'd worry that they'd think we were weak or something.
A Method For Thinking Through What Traps We Need to Get Out of
She's suggesting we help ourselves think things through by first choosing one trap to work on, and getting a piece of paper and putting a line vertically down the middle. At the top of the paper, we can give our trap a name signifying what it is.
So one of mine could be called, "Dilemma Over Whether to Leave the Trap of Always Giving In to Gary's Demands", which seems to be a life trap of mine nowadays.
We can make two columns, one called "Pros", and the other called "Cons". In the Pros column, we can write down every way we can think of in which life would be better if we left our trap. And in the Cons section, we can write down all the reasons we don't want to leave the trap, even if it makes us feel uncomfortable.
She said we're not doing this to help ourselves decide whether to stay in the trap or not, but just to clarify our thoughts about it. So we probably won't be influenced by which list is longer or has the best arguments, but once we've written things down, it'll free our minds from all the worries of puzzling over what's best, because our thinking might not be all that clear when our worries are just in our heads, since we might forget things, or jump from one issue to another and back and forth without having any of them that clear in our minds. Having them on paper will relieve the pressure of having to keep all the options in our heads. And then we can get out of our traps, or not get out of them, depending on what feels right to us.
So perhaps on my page about the pros and cons of leaving the trap of always giving in to Gary's demands, I could put in the pros section:
- I'd Have more freedom to do what I want;
- I'd be able to do what my conscience thinks is best;
- I'd Feel more confident in my abilities;
- I might stop having panic attacks;
- I'd stop losing chances to be fulfilled in life;
- I'd feel more in control;
- I wouldn't feel frustrated about
sacrificing my needs
to his demands.
As for the cons of leaving the trap:
- Being in it avoids conflict;
- It keeps the business running smoothly;
- His decisions might be best anyway.
I'll put more things down as I think of them.
Maybe I could have got out of some of the traps I've been in recently if I'd stood up for myself more. Maybe I could have tried to compromise with Gary about going to see Dad, promising we'd only be there a short time to lessen the chances of him being seen with him and me getting depressed. Maybe we could have worked out compromises about other things as well if I'd tried to get him to do that.
But the therapist said that agoraphobics have typically learned to ignore what they want over the years, in favour of what they think they ought to do. She said that agoraphobics often come from homes where they were expected to be the strong one, maybe the one people turned to in a crisis, like sometimes the one who looked after the house while a single parent went to work, or the one who looked after ill parents or younger brothers and sisters, and sacrificed their childhood in favour of what they knew was required of them, because they knew that if they didn't, their parents wouldn't be happy with them, and the person they really were or wanted to be, a playful child or someone who didn't feel under pressure to live up to other parental demands, just wouldn't be acceptable to their parents, because they wouldn't be doing what the parents wanted.
And since they wanted their parents to be happy with them, they would feel unacceptable to themselves if they weren't making them happy. So they become door mats as they go through life, rejecting who they really are or what they really want to do in favour of what other people want them to be or do, thinking they won't be acceptable to themselves if they're not making other people happy, because they think it's the only way they can be any good.
Yes, my life's been a bit like that.
She said that often, agoraphobics don't feel they can get out of their life traps, or even afford to think about what's happening and realise it's a trap. So panic attacks don't happen at moments that would make us realise they've got anything to do with our life traps, but they come out when we have smaller traps that we do think we can do something about, like when we're in the supermarket and there's a huge queue, and we're being irritated by the time it's taking to get through the check-out and the child having a tantrum just in front of us, perhaps, and we feel too hot, and then we have a panic attack, and want to avoid the supermarket in future because we're scared we'll have another one there. So someone has to do the shopping for us. But if we could work out how to get out of all our life traps, we wouldn't be stressed so much by the little traps, and so we'd stop having panic attacks.
The therapist said that panic attacks and anxiety are actually our friends. That sounded a bit hard to believe when I first heard it, but she said they're telling us something isn't right with our lives and we need to sort it out so we don't waste any more of the opportunities we have to make life go better for ourselves while we can.
Thinking About What we Want In Life
The therapist said we can learn to make sure we get more of what we want out of life in the future, and to develop the attitude that we have the right to get what we want, and we don't always have to sacrifice it because of the demands other people are making on us.
But she said that sometimes, we might be so accustomed to not thinking about what we want that we don't go for things we'd like even though it might turn out that other people don't mind us having them.
I think I'll try the exercise the therapist set for Emma's friend to help her find out more about what she wanted out of life: I'll keep my notebook with me all through the day, and write down all the ideas that come into my head about what I'd change about life if I had the power to make it perfect for me, everything I'd like to do, to be or to have, every change I'd like to make in my life, my circumstances, in other people, and in the world. I'll add to the list of things every time I get a new idea, to try to make the list as complete as I can. Even if I get ideas that at first might seem unrealistic, or would get me disapproved of now, I can still write them down, like if I'd like to eat ice-cream all day, even though some people might think I'm greedy.
The therapist said we can write things down for as many days as it takes us to run out of ideas. We can always add to the list later if we think of more. Just thinking about what we want might well make us feel better.
When we know the things we'd like to do, we can work out little steps that will help us gradually work towards getting them, or at least getting as near them as we can. The therapist said that one way of doing that is to plan to do three things differently every day, even little things.
She said that after we've spent several days writing down what we'd like to change about life each time we think of something, we can spend several days writing down what we wouldn't change whenever we think of things, like if we'd like to keep the same husband even though we'd like him to change in several ways, or if we'd like to keep our love of the beauty of nature or other things that give us good feelings, or if we're glad of certain experiences we've had in our lives. We can write down everything we can think of that we like about ourselves, like any good characteristics we have. We can write about anything about our surroundings that we like, and anything that's been done for us recently that we're glad about, and anything else we can think of about our lives that we like or are pleased about, or wouldn't change.
We can do this for several days as well, until we run out of ideas. Then we can pay attention to whether we're feeling different for having done it. It might be that we realise we're better off in some respects than we thought we were, and we start feeling grateful, with our mood uplifted because of it.
Part Four
How to Stop Bringing on Panic Attacks and Fear by the Way we Think
How Worries Can Bring on Panic Attacks
Emma said her friend's therapist said that something that can even be worse than the panic attacks for agoraphobics, and can help to bring them on, is all the worrying we do about how terrible it would be if we got them in various places, or how terrible it would be if we let ourselves down in other ways.
Yes, it can be like that for me sometimes.
She said we might think things like:
"What if I make a fool of myself by having a panic attack in front of my husband's friends?"
"What if I humiliate myself by having a panic attack at my child's school?"
"Whatever will people think of me if they know I'm too scared to do the shopping?"
"Won't people think I'm stupid if they know I often feel like running home in a panic when there really isn't any danger."
"What if I did go out but then had a panic attack and was too scared to make the journey back home?"
And so on and so on.
The therapist said that's called catastrophic thinking, or catastrophising, because we're imagining the worst.
She said that thoughts can cause unnerving physical sensations, because if we think something that makes us anxious, it'll make our bodies release adrenaline, because they think we need to be ready to fight or run away from whatever we're anxious about. When we feel the physical sensations, that worries us more, and that makes the body release more adrenaline which gives us more physical symptoms, and so on.
The therapist said that a common scenario is that someone wonders whether to go out for the evening to a get-together they've been invited to, but they feel unsure about going because they worry they'll have a panic attack. So they check on how they're feeling just to see if their feelings are telling them they could be a bit panicky, and they can already feel butterflies in their stomach as they imagine it being hot and noisy. They think their feelings have confirmed to them that they'll feel panicky, and they feel worse just thinking about it, and soon, they think the physical sensations they're getting feel like the beginnings of a panic attack already. That makes them more anxious, and they focus on their physical sensations more to see if they really do feel like the beginnings of a panic attack. Their anxiety might have made their body release more adrenaline, which will be making their heart beat faster. When they feel that, they'll think they're beginning a panic attack right now. That'll make them more anxious, causing more release of adrenaline which causes more feelings, and sure enough, they end up having a panic attack right then.
Yes, that kind of thing's probably happened to me before.
Ways of Stopping Panicky Thoughts
Ordering Them to Stop
She said that one way to stop that kind of process is called thought stopping. She said that whenever we catch ourselves having catastrophic thinking, like thinking a little anxious feeling we have might mean something much worse might happen, it can sometimes help if we stop ourselves and focus on something else instead, to keep the catastrophic thoughts out of our minds. She said one way of doing this is to imagine we're seeing the kind of stop sign they use for traffic on the road, and shout in our minds, "Stop!!" She even suggested we shout it out loud if we're alone.
I'm not sure about shouting it out loud, but I could try saying it firmly to myself.
She said that after a couple of days practising imagining this every time we catch ourselves having a thought that makes us feel worse, it might well become fairly automatic. And then, our bodies will stop releasing so much adrenaline, so we won't be so worried by it, so we won't get so panicky.
Distracting Ourselves
She said another way we can stop our panicky feelings and thoughts is called refocusing. We pay attention to our thoughts, and whenever we catch ourselves having catastrophic thinking, we focus our thoughts on something else, like maybe planning what to do the next time we go away on holiday, thinking of a name for a baby coming up in the family, trying to remember a favourite recipe - anything we can think of that will distract us from our catastrophic thinking. She said it works well with panicky feelings as well, if we can catch them in the early stages. So if we're worried because our hearts are beating faster, we're feeling short of breath, and we're worried we're going to faint, or whatever feelings we've got, we can make the feelings go away if we focus all our attention on something else, like counting the number of ceiling tiles in each row or something, as if that was the single most important thing in our lives right now. She said we should give every bit of attention to it, provided we're not doing something else that needs attention, of course.
She said it can help us to focus attention on whatever we're counting if we count out loud. Or we can focus on a repetitive sensation that's coming from our environment, such as if we tap ourselves or something else and think about what we're feeling as we do that.
Or we can use more than one sense, using each in turn. So we don't just focus on what we can see, but think about that first and then turn to focusing on what we can touch afterwards, like the texture of the chair we're sitting on, or the way it feels on our backs. Or we could count the number of surfaces we can touch from where we're standing, or count the number of red cars we see per mile as we go down the road, if we're a passenger in a car. We could click our fingers or bang our hands on the seat or tap our foot on the ground or something every time we notice one, or we could focus on how many times we can tap our foot between each red car we see, perhaps tapping it once per second. Or if we're going through a tunnel, we could focus on how many times we can tap our foot between each light on the tunnel wall, tapping it once per second or two. That will also help us measure the number of seconds it takes to get from one light to another, so we feel we're making progress through the tunnel. Counting things is a good way of taking the mind off panicky thoughts.
Challenging Ourselves to Attempt the Near-Impossible
She even recommended we try to reduce panicky symptoms by focusing on one of them and trying to make it worse, saying that the more we do that, the better it'll probably get, because we're not focusing on the thoughts that make it worse. So if our hearts are beating faster, for instance, she said we could try to mentally push them to go even faster, not by worrying about them going faster, because that's bound to do it, but by just trying to make them go faster simply by an effort of the will. We can try it with other things, like trying to collect more butterflies in our stomach, trying to will our knees to become more rubbery, and so on.
But the symptoms do have to be ones we can't really control by an effort of the will. Breathing faster wouldn't be a good one to try, because we can do that if we want to. But ones it's unlikely we could control by an effort of the will are good to try with.
But she did say that we should only focus on one symptom per panic attack, because distracting ourselves from our concentration by stopping giving attention to one symptom to focus it on another will just make it difficult for us to get absorbed enough in what we're doing, so it won't distract us from the panicky feelings so much, so there will be more room for worries to come into our minds and make us feel worse.
If we're not focusing properly but worrying about something, like that we might have a heart attack, or how humiliated we'll feel when we next have a panic attack somewhere public, our heart's bound to beat faster because of our anxious thoughts. It's best if we try to focus entirely on the one goal of making whatever symptom we've chosen to work on worse, purely by an effort of the will, not in the normal way we manage it. If we've been cleared by our doctor, we shouldn't need to worry that that'll be dangerous.
I'll have to think about that!
Other Ways of Thinking that Can Cause Anxiety
She said that besides catastrophising, another way we can ruin any sense of well-being we have and make ourselves feel more anxious is by thinking things that we can realise are obvious mistakes, when we come to examine them.
One form of this is what they call "black and white thinking", when we think that if something isn't going well, it must be going very badly, or if one thing goes wrong, everything must be hopeless. For instance, if we made one mistake in a job, we might think everything we've done's a mess, or if we made a meal and one thing didn't turn out to be quite as nice as we wanted, we might think we let everyone down and they must think we're no good at cooking. After that, we might not have the confidence to cook anything else for people.
She said some people who've thought they must be socially inadequate just because they weren't the life and soul of a party have even stopped meeting people and have ended up never marrying even though they might have wanted to, and living lives of loneliness and regret about the way their lives have gone.
She said another mistake we can make in our thinking is called over-generalisation, where we assume that just because something's happened in one situation, it's likely to happen in all similar situations. And that's how agoraphobia can be born, because if we have a panic attack once in one supermarket, we can assume we're likely to have one every time we go to that supermarket, or even in any supermarket or similar shop. The panic attack might have been caused not by the supermarket but by some life trap we were in then that we've managed to get out of since. But if we worry that we'll get one next time we go into the supermarket, we'll either avoid going, or we'll be worrying and worrying about it all the way there, making ourselves more and more anxious because we're so worried we'll have a panic attack, until we get into the supermarket, and we're so anxious by then that we do have a panic attack.
Changing the Way we Think
She said we can stop those kinds of things happening by paying attention to what we're thinking and correcting any mistakes we notice we're making in our thinking. So if we notice ourselves thinking we're hopeless at cooking because some potatoes were a bit over-cooked, we can stop ourselves and think, "Aha! This is black-and-white thinking. It's one of those mistakes people often make in their thinking that I've heard about. What's a more realistic way of looking at this? Well, just because one of the things I cooked went a bit wrong, it doesn't mean I'm bad at cooking. After all, everything else turned out allright, didn't it. And people have often told me how much they like what I've cooked. So I've got no real reason to stop being confident about cooking. If I went to someone else's house and had a meal and liked most of it, but just thought one thing was a bit over-cooked, I wouldn't think they were a hopeless cook. So why am I calling myself one and losing confidence just because I did one thing wrong?"
As for over-generalisation, we can again try to pay attention to what we're thinking as we go through the day, and when we realise we've made a mistake such as assuming we're likely to have a problem more often or in similar places to the one where we had the problem before, we can correct the mistake. So if, for instance, we realise we're out of bread, and we know people are going to want some the next morning, we might think, "Oh no, not a trip to the supermarket. I'm sure I'll have a panic attack there because I had one there before"; but then we can think, "Oh, caught myself! I'm over-generalising again. Just because I had a panic attack last time I was in the supermarket, it doesn't mean I'm going to have one every time I go there. I think the reason I had one there last time was because I was stressed about what I was going to do that evening. The panic attack wasn't really to do with the supermarket. So if I don't start worrying about it, there's no real reason to suppose I'll have one there this time."
When I'm on the way to being cured, I'll have done other things that'll make me more confident in supermarkets, so I won't need to be nearly as worried as I might think.
Other Mistaken Thoughts we Can Have
She said that there are several other mistakes we can make in our thinking that'll make us more depressed and anxious. One is called "dwelling in the dark", and it's where we focus exclusively on a negative aspect of a situation until everything seems bad. Like if our child fails one exam, never mind that they passed the rest of them; if we focus on the one exam they failed and get more and more worried about it, we'll make ourselves feel depressed when there isn't really any need.
Or if a relative of ours says they can't come over for Christmas, we might dwell on how disappointed we are, to such an extent that never mind all the other people who are coming, we won't enjoy ourselves.
So it's important that we catch ourselves thinking that way and correct those mistakes as well.
She said another mistake we can make is called "feeling out reality", which is when we decide how we should think of things based on our feelings. So if we notice we've got butterflies in our stomach and our heart's beating faster, we might think something bad's happening and get much more anxious. But it might really only mean we're in excited suspense because we're wondering what's going to happen next in a television programme we're watching, or someone we're physically attracted to's walking towards us.
So we can remind ourselves that there are several reasons we might get those kinds of feelings every time we catch ourselves worrying about them.
She said another mistake we can make in our thinking is called "rejecting the light". It's a bit like "dwelling in the dark", but we dismiss positive experiences as if they just don't count. So if we've been out to a certain place before several times and really enjoyed ourselves, we might imagine that those experiences don't have any significance compared to our negative experience there, and feel sure we'll have a panic attack if we go there in future, because we had one there once.
I'll have to reason with myself if I catch myself doing that.
She said another mistake we can make is thinking as if we imagine we're psychic, because we take it for granted we know people are thinking badly of us, even though they might not have said anything or done anything to give us that impression. For instance, if we've had a panic attack in a certain place, we might assume all the people there must think we're crazy, when we don't have any evidence of that, so we don't really know what they think at all.
Another way we can make that mistake is by feeling sure something bad's going to happen in the future, when we haven't got any good reason to think that, like feeling sure we're going to make a mess of the cooking when we're next asked to make a meal for guests, even though we haven't got a good reason for being able to predict that. After all, we might have over-cooked a few potatoes once, but why should that mean we'll make a total mess of things this time?
We can reason like that with ourselves whenever we catch ourselves thinking negatively like that.
She said another mistake people make is exaggeration, where if both a bad thing and a good thing happen, people imagine the bad thing's of more importance than it really is, and think of the good thing as having less significance than it deserves.
So if someone compliments me on the way I look, but on the same day, Gary complains that I'm getting a bit fat, I might not feel any good about the compliment, but feel much worse about the complaint than I need to. Yes, actually, I've noticed myself doing that.
She said another mistake people can make is to blame themselves entirely for things they were only partly responsible for, or to blame other people for things that they were only partly responsible for. For instance, we might blame ourselves for ruining a family day out because we just couldn't face going so they didn't go either, when actually they could have gone on their own, but decided not to. So we feel worse about ourselves than we need to.
Or we can blame our upbringing for all our problems, so we think we haven't got any responsibility to change the way we are in order to get better, so we just feel as if we're stuck with our problems and that there's nothing we can do, so we just get more and more depressed.
Learning to Reject Mistaken Thoughts
She said the reason we make such mistakes in our thinking is not because we're silly, but that we fit what happens to match our already existing beliefs. So if we already think we're getting fat, a confirmation of that will hold more weight than a compliment about the way we look. Or if we think we're no good, then we'll attach much more significance to any evidence of that, like when we over-cook the potatoes, than we will to all the evidence that we're a good cook most of the time. Or if we feel sure we're bound to face problems wherever we go, we'll think it much more likely that we'll have a panic attack when we go out than that we won't.
She said that fitting our thoughts to pre-existing beliefs might make us unhappy, but at least it makes things seem predictable, and we'll think it's at least better than the uncertainty of not being sure about things. But really, the familiarity isn't worth the misery it causes. If we try living with a bit more uncertainty, we might discover it's not so bad after all.
So when we catch ourselves thinking something that we realise is a mistake, it can be good if we ask ourselves why we thought it.
So if I catch myself thinking I must be getting ugly despite having been complimented that day, or thinking it was my fault that everyone missed a family day out, or thinking I'm a bad cook, or whatever, I could ask myself each time what my belief is behind that thought, or what it was that made me take the thought seriously.
And if it turns out that the belief that made me take the thought seriously is something like, "I'm a no-hoper and a burden on everyone", I can ask myself how that belief influences my mood from day to day. And if it's just making me miserable, I ought to challenge it, because abandoning my beliefs about myself might be quite a relief in the end.
So I could think through any evidence that I am a no-hoper, but then think through all the evidence I can that I'm not one. I could even write the evidence down.
I might be able to find a lot of evidence that I'm not a no-hoper, if I think of all the things I've done well over the past week, month and in my life, and all the things I did to cope with bad circumstances to stop them getting worse. If I can think of several things I did that helped me cope better, and several things I've done that I can be proud of in life, I can ask myself what those things really say about me, and come up with some new descriptions of myself based on those things, that might be very different from no-hoper, and much more positive, and they might help me think about myself in new ways that'll make me feel better.
The therapist said it can help us work out where we need to change our thinking if we write out a list of all the thinking mistakes she listed, and carry it with us in a notebook, together with a pen. As we go through the day, we can write down at least five of those mistakes that we catch ourselves making, and ask ourselves what they mean about our beliefs about ourselves. If our mistakes are written down, we'll be more aware of the way we keep making ourselves feel about ourselves by the beliefs we keep going, and more aware of things we ought to challenge with evidence to the contrary.
Then later each day, we can think about and write down the evidence that challenges our negative beliefs, evidence that might help us develop new and much more positive beliefs about ourselves.
She said we shouldn't allow ourselves to feel bad if we still catch ourselves having negative thoughts after some time. Hopefully, they'll lessen more and more as time goes on. But every time we catch ourselves having them, we can think of it as a learning experience, one more opportunity to practice challenging our mistaken beliefs with more realistic ones, so we'll get better and better at it.
She said that when we catch ourselves feeling anxious, we should also ask ourselves what the anxiety's telling us:
whether it's telling us we're in a trap that we need to pay attention to working our way out of,
or whether it means we've been making mistakes in our thinking that we need to correct.
If we decide it means we're in a trap, we can write down what it is. Then when we have time, we can write down all the pros and cons of leaving the trap, to help clarify things for ourselves.
If we decide our anxiety's been brought on by a mistake in our thinking, we could write down which mistake it is, why it's an example of that mistake, and what the undistorted truth of the matter is.
So, for instance, if I caught myself thinking I'm hopeless because I didn't manage to get to Suzy's school play, I could think, "Oh yes. That's black-and-white thinking. The reason it's an example of that is because I'm thinking that not being able to do one thing means I can't do anything good so I must be hopeless. The truth is that I might not have been able to get to the play, but I know I do lots of other things well. I play with Suzy; I help her with her schoolwork; I do lots of things well for the family."
The therapist said it's also good to remember to try to identify the belief that made us take the mistaken thought seriously, and challenge that as well.
She said that when we have, writing about why it's an inaccurate belief will help us remember why it is, so we're less likely to take mistaken thoughts based on it seriously again than we would if we just thought about it briefly, since when we just think about things, we can easily just forget all about them soon.
So, for example, if I realise that the belief behind the thought that I'm hopeless is that having agoraphobia makes me incompetent, I could challenge that by thinking that I've got it for a good reason and not just because I'm incompetent. And there are still lots of things I do well in my life; and I'm going to work on recovery from agoraphobia, which will lead to quite some achievement if I succeed, since it might take some doing.
She said it can be good if we keep track of our anxiety every ten minutes or so after we've worked out what's caused it and thought about how to stop it, and if it's not going down much, it can help if we do a relaxation exercise.
Part Five
A Relaxation Technique
Emma said the therapist said that one way we can relax ourselves is by doing a form of meditation. She said that when we're more relaxed, our bodies are more healthy as well as our minds. She said the immune system works better, since stress weakens it. Blood pressure and heart rate go down to healthier levels, we can get less headaches because some are caused by tension, and other things can function better as well. We do better at mental tasks when we're not stressed, and can concentrate better and remember more.
And she said that emotionally we're better off as well, because we're happier, we can be more loving, more forgiving, less frustrated and more able to laugh.
She said that the type of meditation she recommends also makes us more aware of the individual thoughts we have from moment to moment, because we practice making a mental note of what each of our thoughts has been as it passes, which might come in handy, because it could get us into the habit of doing that, so we begin to take more notice of individual thoughts during the day automatically, and that'll help us when we try to catch ourselves thinking thoughts that are mistakes in our thinking that make us feel bad, so we can correct more of them.
So she recommends we start by sitting in a comfortable chair with our feet flat on the floor and our hands resting in our lap. We ought to be as comfortable as possible so we can just forget about our body as much as we can. So it's best if we sit in the most comfortable position for us.
After that, she recommends we choose something to focus our attention on the whole time, refocusing on it every time our thoughts drift away from it. Then we'll notice individual thoughts more, because we'll catch ourselves thinking something different from what we're focusing on every time our thoughts stray from it. Then we can bring our attention back to what we're focusing on, and do that repeatedly every time our thoughts stray and we notice we're thinking something different.
She said we can maybe focus on the rise and fall of our abdomen as we breathe in and out, or a word we keep saying with each breath, like "peace" or "relax", or maybe a phrase, like, "This will help me relax". She said some people prefer to focus on a part of their bodies, like the bit just above the bridge of the nose or the sensation of breath going in and out of the nostrils. She said we should experiment with focusing on different things until we find something we're comfortable with, and then we should stick with it unless we really want to change it, and definitely not change it during the meditation, because that'll be too much of a distraction.
She said that when we've found a focus for our attention to rest on during our meditation, we should set a timer or an alarm for the length of time we've chosen to meditate for. She said we can just try it for ten or fifteen minutes once or twice a day at first, and then build up to a bit longer, maybe eventually getting to thirty minutes twice a day.
She said that when we're about to start our meditation, we should close our eyes, and let our attention rest on what we've decided to focus it on.
She said our thoughts are bound to drift off onto other things, or we might start thinking about our views on the meditation practice itself, like thinking it seems silly or whatever, but we don't have to worry about what our thoughts are. Or we might start focusing on sensations, like our nose itching or whatever, or plans, like what we'd like to do when the meditation's finished. Or we might start thinking of sounds we can hear, like people talking outside, or wonder whether we're doing things right.
She said it's OK to think whatever we like, but when we do, we should always try to notice that our thoughts have drifted away from our focus of attention as soon as we can, and notice what we're thinking, and then bring our attention back to what we're focusing on. Even if we have a really interesting thought or start having a good day-dream, we should still make sure we don't get involved in it, but just notice we're having it and then pull our attention quickly back to what we're focusing on. Even if we feel bored quite a lot, we should just notice we're feeling bored and then bring our attention back to what we're focusing on. Bored thoughts will probably pass after a while like the others.
So maybe we might start by realising, "Oh, I'm thinking of what we're going to have for dinner". Then we'll pull our attention back to what we're focusing on. And then our thoughts might drift away again, and we should quickly catch them and might think, "Oh, I'm thinking of how nice it'll be when the weather gets warmer." Then we should quickly pull our thoughts back to our focus. Then they might drift off again and we'll notice where they've strayed this time and might think, "I can hear someone talking in the next room". Then we should pull our attention back to our focus. Then we might think, "Oh, I notice I'm feeling bored." Then we should pull our attention back to our focus, and so on.
We might not be all that efficient at pulling our thoughts back to our focus as soon as they stray, especially at first, because it's bound to be difficult, but it's the ideal we ought to be aiming for. But she said that if we don't do very well, we shouldn't start feeling bad about it or contemplating how well we're doing, but if a thought like that comes into our minds, we should just treat it like any other thought, noticing it and then just letting it go by as we move back to our focus.
She said the more effort we put into noticing our thoughts and then dismissing them and moving back to our focus, the more relaxed we'll feel afterwards. I suppose that'll be because we're not getting worked up by our anxious thoughts but letting them go as if we don't consider them of that much importance.
She said that doing meditation for periods of just a few minutes when we've got a few to spare throughout the day, besides doing our set sessions of it, can be very useful. It can bring us back from being caught up in catastrophic thinking or something and help calm us down, which might help us get things in perspective. So when we notice we're feeling anxious, or when we know we're just about to have to go into a situation that's likely to make us anxious, we can decide to meditate for a while before we get more anxious.
When we get used to just letting anxious thoughts go, maybe we'll be able to do that automatically when we get them sometimes, so we don't get so anxious anymore.
The therapist said that if even exposing ourselves to the first stage of something makes us feel so anxious we don't feel we can do it, there is a less painful way. We can do the desensitisation in our imaginations.
We sit down in a quiet, comfortable place where we won't be disturbed by anything. We can close our eyes. Then, we can first just imagine going a little way towards doing something that makes us anxious.
It's best to try to make it as realistic as possible, adding in sights, sounds, and what we would be physically feeling, like the temperature, the warmth of the sun and the wind on our face, and any smells or tastes. It helps if we imagine who we would be with, what we would be wearing, what we would be doing, whether walking, carrying something, sitting down, or whatever.
She suggested that we could make it even more realistic by asking ourselves how we know it's not happening for real, and whatever our answer is, we can imagine things aren't like that. So if we know it's not real because we can feel ourselves sitting in a chair, we can imagine we can't. Then we can ask ourselves the question again, and whatever answer we come up with, do something to alter that. So, for instance, if it's that we know we're really in the room, we can try to imagine we're not really conscious of being in it. And so on.
When we've got the experience as realistic as we can make it, the technique is to do the same in our imagination as we'd do if we were desensitising ourselves to what gives us panic attacks in reality, first imagining taking the very first step we'd take, then carrying on going until the point we begin to feel anxious. When we feel a bit anxious, we can open our eyes, bring ourselves back to the room and do some form of relaxation exercise. Funny, but we might need to close our eyes again to do the relaxation exercise.
When we've calmed down, we can close our eyes, and imagine doing the step again up to the point we were at before when we became anxious. Then, whether we're anxious again or not, we can open our eyes and bring ourselves back to the room again, and do a relaxation exercise again. And it's best to carry on the process until we feel bored imagining doing the step.
Then we can imagine going further, till we begin to feel anxious again, and then bring ourselves back to the room and calm ourselves down. And so on, until we can go through the whole experience without feeling anxious at all.
After that, when we do the experience for real, it won't be so bad.
The therapist said that sometimes, people make the desensitisation in their imagination so realistic that they can do what used to make them feel panicky in reality all at once without having to go through it bit by bit first and without it making them anxious at all.
She said this technique can be especially useful for situations where people won't get the opportunity to practice in reality, like if they've got a fear of flying and they need to go on a flight. They could first imagine setting out on the way to the airport, calm themselves down when they begin to feel anxious, then go back to the beginning and imagine going to the same point again and again till they get bored of it, and then imagine setting out and going further, calming themselves down each time they get anxious in the same way, and so on, till they're happy to imagine being on the plane feeling bored.
The therapist said that if we do have a panic attack somewhere in the future, after we've started going out again without any problems a lot of the time, we shouldn't start avoiding the place again like we did before, since then we'll be allowing the fear to begin to take over our lives again. So we can do that desensitisation technique, and then get straight back there, to stop that happening.
She said that besides going to places where we need to go, it'll be good if we try going to places we'll enjoy going to, not necessarily desensitising ourselves to them first, but going with people in a group if we like and can arrange it, which will be good practice at getting out as well as hopefully making us feel like there's safety in numbers and giving us more of an incentive to beat the agoraphobia. So we could look in the local paper to see what events are on, find out about any attractions in our neighbourhoods like museums, or anywhere to enjoy nature and so on. Or we could go out on picnics or to the local park, or anywhere we think we'd like to go. We might learn that the world's a friendlier place than we think.
The therapist pointed out that people who have panic attacks are usually very unlikely to faint anyway. But the person who took the agoraphobics out was hoping they'd conclude that anything they did that they worried people would think was weird quite possibly wouldn't be looked on as badly as they thought or noticed.
Another reason she pretended to faint in front of everyone was that she wanted the agoraphobics to challenge their thoughts of embarrassment, by thinking things like, "What if all the strangers around us think we're weird? Well, it doesn't seem as if they're thinking of us at all. But so what if they do think we're weird? Why should we care? Are we worried they won't speak to us in the street if we ever walk past them? Are we worried they'll call the police? Are we worried that word will get back to the government and they'll stop our pension? What's the worst that could possibly happen? Why should what they think matter to us?"
The therapist said it can help us if we deliberately do things that will break the hold on us of the image of ourselves that we've been feeling so under pressure not to tarnish all this time. So if we're people pleasers who are worried about saying "no" when people ask us to do things, for example, we should practice saying no when they ask us to do things we're not keen on doing, because it will help us to learn to stand up for our rights more. We can think of doing that as a kind of therapy. It's really learning to be more assertive and to get more of what we want out of life.
The therapist said we can practice not pleasing people by thinking up things to do where we mildly inconvenience them, like buying one item in a supermarket and then asking the people in the queue if they'd mind us going straight to the front since we've only got one thing. If most people are friendly or indifferent, it might make us bolder about standing up for ourselves elsewhere.
She said that if we feel anxious about the idea of doing that, we could first play through scenes like that several times in our imagination, imagining we feel confident.
Part Nine
If It Seems Best to Get Help from a Therapist or Go on Medication
Hopefully, I'll be able to cure myself of this agoraphobia on my own. I know if I persevere at the recovery techniques, and adapt them if necessary to suit me better, and I know if I stick with them if they don't seem to be working at first because they might take practice, I'll hopefully see good results after a while. But if I do get into difficulties and think I ought to have professional help, I know there are some things I'll need to take into consideration when I'm choosing a therapist, because I know that not everyone who claims to be a therapist who helps people with anxiety disorders would really be good for me.
Things to Consider when Choosing a Therapist
I think one thing that'll be important if I do decide to choose a therapist is that I get recommendations from as many people as I can before I go for one. If I know someone whose agoraphobia has improved a lot with a particular therapist, I'll be more confident about choosing theirs. It would mean getting to know other phobia sufferers though. That could be nice anyway, because then I wouldn't feel so isolated. It'll be nice to try to find a support group. But I might have to wait till I get a bit better for that, unless we can speak to each other over the phone.
I'd want to find a group where people are working on overcoming agoraphobia though, not one where people just commiserate with each other but don't have any ideas on how to get better. That would just be depressing.
We could help each other get better by encouraging each other, and going out to places of interest together to help us get used to going out again.
I know another thing to consider is what credentials any therapist I choose to go to has. I've heard that anyone can set themselves up as a therapist or counsellor no matter how little training or experience they have. And I've heard that impressive-sounding initials after a person's name doesn't necessarily mean the courses they've been on were any good, or that they actually taught about the treatment of anxiety disorders. The initials could even just mean a person simply attended a very short course, not necessarily given by anyone reputable, which they mostly slept through anyway, but which they got a certificate at the end for because they attended it.
I know people have to have proper degrees to call themselves psychologists or psychiatrists, but that still won't necessarily mean they've had much experience in treating anxiety disorders. I know it's also very important to ask what kind of treatment they offer, because some psychiatrists will think that everyone with an anxiety disorder ought to be on medication, or some therapists will just sit there, imagining you're going to get better just by talking to them.
I've heard that if you ask a therapist questions and they make you feel stupid for asking, you can have a fair idea of one of the ways they'll make you feel in therapy. But if you tell them they've just made you feel stupid for asking and they apologise and say your question was a sensible one, you'll know you can talk to them, whereas if they get annoyed with you for saying it and make you feel as if it's your fault, you'll know they'll behave like that in therapy as well, so it's best to avoid them and try to find another therapist.
I've heard that if a therapist says they practice a therapy we haven't really heard of, it can be good to ask them about it, not only because we'll know more about what we might be getting ourselves into, but also because it'll help us find out how much sense they make when they're talking to us, since some therapists make it a habit to try to answer questions by giving the least amount of information possible, so people end up feeling confused.
I've also heard that if we start therapy, but then we're not happy with the treatment, it might be best to tell the therapist first to see if things can be sorted out; but if they aren't, it's probably best to change therapists, because if we don't, we might very well just get more of the same.
What People Should Expect From a Good Therapist
I've read a list of things that people ought to expect from a good therapist.
- It says that therapists should be able to help people with anxiety disorders in a fairly short amount of time, giving them hope and ideas in the very first session.
- And therapy shouldn't have to make things worse before it gets better, and we should avoid therapists who tell us therapy has to be painful, because it doesn't have to be.
- They shouldn't encourage people to dwell unduly on the past, but should be focused mostly on how people can make their lives better in the future.
- They shouldn't use psychobabble.
- And they should help their clients to discover skills they have that they can use to heal themselves.
It'll take assertiveness to ask therapists all the questions I'm going to have to ask them to find out about all these things, if I do decide I need therapy. I know I have problems with being assertive, so I might get a bit anxious about asking them questions like that, but I think I'll need to. And I know I need to practice being more assertive anyway, so it would be good practice for me.
Anxiety Medication
Emma said her friend's therapist said that while medication can sometimes help a lot, it has drawbacks, one of them being that it can stop us being motivated to deal with the root cause of our problems - it's far better to cure our panic disorder by learning to stand up for our rights more so we get more of what we want and so on, than it is to take medication and carry on being a door mat. Another drawback, of course, is that some drugs can be very difficult to come off because of their withdrawal symptoms.
The therapist said that if people want to start taking medication, that's fine, but she says that often, the best place for medication, tranquillisers anyway, is in a person's pocket, just one or two. She said that tranquillisers work by reducing the amount of anxiety people have about how they're going to cope if things get bad. They can't stop panic attacks when they're in progress. But they can reduce stress. So if the tranquilliser's in the person's pocket, it can work just as well as if they've taken it, because they'll think, "Well, if I get really anxious, I can always take that tranquilliser", and that will assure them that they do have a way to cope, and so it will calm them down, just like the tranquilliser would have done if they'd taken it.
But she said it's best for people to stop carrying tablets when they think they're on the way to recovery, so they don't start relying on them to make them feel safer. She said there are people who've been cured for years who still carry them around, but then one day they forget to take them out, and realise they haven't got them, and worry they'll need them and start panicking, and the whole agoraphobia process starts off again. So once we start to become confident we can handle panic, it's best not to have such things.
She says that if people want to take tranquillisers on especially stressful occasions before they start to recover, there's nothing wrong with that, but it's best to avoid taking them two days in a row, (unless they're taking them regularly already) to prevent a build-up of dependence on them.
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