Overcoming Panic Disorder and Agoraphobia, and Then Encountering Health Anxiety.

The treatment of an idea.

In order to recover from agoraphobia and panic disorder, only two things need to be learned:

1. No one is ever trapped, truly, in any of the settings phobics dread, obviously not in restaurants or on a line at a bank, or standing about at a party or at a shopping center, but also not in elevators or airplanes. There are always ways of escaping. There is a keyhole on the outside of elevators; and a stuck elevator can be opened from the outside. Even airplanes can be induced to land. In this connection I report a singularly determined airline passenger who wanted to travel as quickly as possible to his home in Utah. There was no direct flight, so he booked a flight to Los Angeles; and when he was flying close to the airport near his hometown, he pretended to suffer a heart attack so the airplane would be forced into an emergency landing at that airport. He actually committed this antisocial act.

But in a more fundamental way, no one is trapped in an airplane any more than he would be in a movie theater. He can move up and down the aisles. He can go talk to someone else, or go to the bathroom. Indeed, modern air travel is like sitting in a movable movie theater.

1. More important, the phobic person must learn that he/she will not lose control during a panic attack, no matter how bad it gets and no matter what the circumstances. It is that thought that terrifies the phobic person. Loss of control means, in this context, a worsening of the panicky feelings until the phobic person does some awful thing: something embarrassing—such as fainting, falling to the ground, screaming, or vomiting—or dangerous—such as driving into a crowd or off a bridge. None of these things happen, but the phobic person can only be persuaded once and for all that that is true by having repeated panic attacks without leaving the phobic situation.

Still, there usually comes a time, after repeated panic attacks in different settings, that the fear of such attacks fade away; and the phobic person is cured. And yet after helping such patients to recover, it became clear to workers in our clinic that some patients continued to have other irrational fears. They were afraid of physical illness, usually a fatal illness, afraid of drugs and, sometimes, afraid of doctors. A few said they were afraid of dying, others said they were afraid of being dead. We called them “health worriers” and their condition, “health anxiety.”

It turns out they did not fit comfortably into conventional diagnostic categories. Some were especially afraid of germs; and they had symptoms of obsessive-compulsive disorder. Others had physical symptoms whenever they were anxious. They developed headaches or stomach aches, or any sort of pain—or a fast heart beat or a wobbly feeling. They fulfilled the criteria of “somatization disorder.” More typically, some of these patients, in the face of relatively ordinary physical symptoms, jumped to the conclusion that they had a very serious illness. The most common conditions were those that were insidious, without much in the way of symptoms, but which could kill nevertheless. Examples include brain or pancreatic cancer, H.I.V. , heart attacks, or multiple sclerosis. These patients could be diagnosed as hypochondriacs. But most of our patients overlapped these categories. The one common denominator they shared was their recognition that they worried too much about their health, and sometimes about the health of others in their families. It turned out that many of them shared certain ideas:

1. About physical illness. That any illness, perhaps most of them, is potentially serious. That such an illness must be treated urgently to avoid dire consequences. That most illnesses do not go away untreated. That the ordinary physical symptoms of anxiety, including stomach distress, light-headedness and vague physical pains are more likely in their case to be caused by a serious illness. They feel that they are likely to get sicker than other people, and sicker more often. No matter how rare the disease might be, they figured “with their luck,” they would get it.
2. About the importance of sleep and diet and the regularity of other bodily functions, such as daily bowel movements.
3. About doctors. They were inclined to think that doctors were not reliable. If they were to get sick, they thought doctors would not take their complaints seriously and would be inclined to dismiss them as “emotional” or even imaginary.
4. About drugs. In their opinion drugs were always potent and dangerous. All things considered, it would be better not to be on drugs, and certainly not more than one at a time. They felt they were more likely to have drug side-effects than other people.
5. About physical examination and laboratory tests. They tended to think a good physical examination looked at “everything;” and would pick up any disease if it were present. Laboratory tests that fell out of the normal range, had to mean something, usually something bad.
6. About death and dying. They imagined the process of dying to be marked by awful pain. Underneath the fear of death were two other fears: of being alone and being helpless; and they imagined death in a hospital to epitomize those experiences. They imagined what the experience of their death would be on their children and on others who would survive them.

Finally, they imagined their health as precarious.

These ideas and others had to be attacked for such patients to feel less afraid once and for all. Just as the panicky patient has to learn not to fear the panic attacks, the health worrier has to learn how to approach illness realistically. As it often does in other emotional disorders, treatment comes down to testing out the world in certain ways—by confronting one’s fears. There are a number of things to do, and other things to avoid doing. For example, the patient cannot search out endlessly for reassurance. One more test will not comfort, any more than washing one’s hands compulsively and endlessly makes the obsessional person feel clean at last. Treatment summarizes to a kind of exposure therapy. It is the treatment of certain bad ideas. (These matters are discussed more fully in “Worried Sick?”)  (c) Fredric Neuman 2013