Only two things need to be learned
Doctors do not like to talk about cure. Too many illnesses are remitting and relapsing—that is, they seem to go away only to return again at a future time. Psychiatric conditions in particular tend to be chronic. Besides, they are not as well-defined as other medical conditions. Some are plainly illnesses, similar in every way to other medical illnesses. But others seem to be only an exaggeration of qualities of mind—mood and thought—that are present in everyone to a varying degree. They are, in short, an exaggeration of normal. So it is not surprising that someone who is diagnosed with an emotional disorder—and treated apparently successfully–might show similar symptoms later on. These disturbances are part of the human condition. Patients who are unduly anxious, for instance, may become anxious once again. Someone who was seriously depressed in the past can become depressed again for all kinds of different reasons.
The anxiety disorders, in particular, tend to be long-lasting; and yet particular fears, if they are specific and readily definable, can be dispelled. For example, those individuals who suffer from health anxiety have mistaken ideas about the prevalence of serious illnesses, about the significance of certain common physical symptoms, such as headaches, about the danger of germs, about the need to sleep and eat and go to the bathroom regularly, about the importance of laboratory tests that fall out of the normal range, about the dangers of drugs; and, especially, they are inclined to believe with no evidence that they have a special vulnerability to illness. All of these ideas are attacked one after the other in the treatment of this disorder. The other anxiety disorders can be defined similarly in terms of the particular fears that characterize them—for example, the importance of doing something exactly right, which is a hallmark of obsessive-compulsive disorder.
There are a number of ideas that underlie panic disorder and the agoraphobia which usually accompanies it. Some of these are present in the other anxiety disorders also:
1 The thought that the world is a dangerous place—and more dangerous the further one gets from home.
2. The idea that strangers are likely to be untrustworthy—even predatory.
3. The idea that constant vigilance is required to avoid accidents. And so on.
The particular ideas that are critical to panic disorder and agoraphobia, however, are two:
- The idea that feelings can become so powerful and so disordered that the individual can lose control of his/her behavior or mind.
- The idea that people can be trapped in ordinary places, such as elevators and airplanes, or driving across a bridge or through a tunnel, or even sitting quietly in church or in a restaurant. Or while simply standing and waiting on a line.
And so, In order for the panic disorder and agoraphobia to be cured, only two things need to be learned.
- 1. The panic attack, no matter how severe it is, no matter what the circumstances, will not cause the affected individual to lose control of himself/herself. That person will not drive a car off a bridge, or scream, or do anything dangerous or embarrassing (other than leave the phobic situation peremptorily.)
In all the years the Anxiety and Phobia center has been in existence, no panicky person has ever had an automobile accident during a panic attack. Although certain phobic individuals can faint—such as those who have a blood and injury phobia—they cannot during a panic attack because blood pressure rises during a panic attack.
Two particular patients come to mind. I saw an elderly woman who had been housebound during most of her married life, and, remarkably, during the entire time her children were growing up. Despite never leaving the house, she ruled the family. When they were all grown, she decided for some reason that she was fed up with staying at home forever. On her own, with no treatment, she entered into the outside world and over a period of time overcame her fears. She would never have come for help at all, except that she decided to learn how to fly an airplane. In her first solo, she had a panic attack. Subsequently, she came to see me to ask if I thought it was safe for her to fly. I told her it was, and she proceeded to obtain her pilot’s license.
Another man was a motorman on the subway.
“Doc,” he said to me, “hundreds of lives depend on me when I drive that train. Are you sure it is safe even though I get panic attacks?”
“Yes.”
- 2. It is possible to escape from any of the situations in which a panic attack can occur.
Most situations in which panicky persons feel trapped are obviously easy to escape from: a restaurant, a conversation in a back yard, a church pew, a line at a bank. They feel trapped primarily by social conventions. They have trouble just getting up and leaving. A stuck elevator seems more difficult, but even then the elevator can be opened with a key from the outside. Someone confined in an airplane can move about freely most of the time and is not really any more trapped than is someone walking up and down the hallway of a building. It just seems to the phobic person that he/she is trapped.
Even in a more literal sense, people are not really trapped within the physical confines of an airplane. One extraordinary man told me he had to fly cross-country to his home—but the airline did not have a direct flight. So, when his plane to Los Angeles came close to the airport he preferred, he pretended to have a heart attack! The plane landed at the nearest airport, as he intended. Unfortunately—or perhaps, fortunately—most phobic persons are too scrupulous to resort to such a tactic.
Psychotherapy is from beginning to end a learning experience. It may require—as it does in the case of phobias—practicing in the phobic situation, or it may rely to some extent on more information and education, which grows in part out of the therapeutic relationship. But only these two lessons need to be learned for the condition to fade away.
How learning these two lessons are accomplished:
Of the two, the easier lesson to learn is that the phobic person is never trapped. Simply being in the phobic situation over and over again makes that particular situation less frightening. Someone can get up during lunch to go to the bathroom. Someone can leave a classroom, or a theater or church. Someone can get out of a car. And within a few minutes, or hours, someone can exit an airplane.
But the second lesson is harder. In order for a patient to really come to believe he/she will not lose control, the patient has to purposely enter the phobic situation and hope to become panicky—as he/she will sooner or later. Then that person must remain in that place until the panicky feelings wane—a matter usually of five or ten minutes—or less. After the panicky person has had the experience of calming down without leaving the phobic situation on at least ten or twelve occasions—that person no longer has to take anyone’s word that he/she will not lose control. Those experiences are convincing.
All right, what happens next? What does a cured panic disorder look like? Once the panicky person learns to be blasé about being panicky (such a thing happens) his attacks come at increasing intervals and for a shorter period of time. Usually they disappear forever only after the patient is no longer paying attention to them. For that reason, when I ask patients when they had their last panic attack, they cannot remember!
Once the two Bad Ideas described above have lost their hold, the panic disorder disappears and that phobia that comes out of being afraid of being trapped also disappears. But other fears do not. The affected person can still be afraid of germs or of a serious illness. These fears represent other anxiety disorders that have to be treated separately, although similarly, by confronting those particular fears systematically until they too can be seen to be unrealistic. (c) Fredric Neuman These issues are taken up in more detail in “Fighting Fear: A Guide to Treating Your Own Phobia