Panic Disorder: Final Steps in Treatment

Confronting the final challenges.

The process of recovering from a panic disorder and agoraphobia is straightforward, but difficult. The affected individual has to experience panic attacks over and over again, purposely, and then remain in the threatening situation long enough for the panic attacks to go away. There are different ways of provoking a panic attack, such as by inhaling carbon dioxide which causes shortness of breath, but our practice at the Anxiety and Phobia Center at White Plains Hospital is simply to place the phobic person repeatedly in those situations in which he, or she, is likely to feel trapped and, therefore, more likely to feel panicky. Inevitably, sooner or later, that person does become panicky. If he, or she, can be persuaded to remain in the phobic situation until the panicky feelings subside, the condition will evaporate. But that situation needs to be replicated many times before that feeling is seen to be just that, only a feeling. The panicky person does not lose control. Usually, this treatment is prolonged and involves the phobic person going further and further into the phobic situation. One example, would be a person who is afraid of driving first driving in a driveway or around a block, and then in the streets of the neighborhood and, finally, on a highway and then farther and farther along the highway. Panic attacks will occur unpredictably along the way.

Sometimes the phobic person will arrive at a place or a set of circumstances beyond which he, or she, seems unable to go—at least, temporarily. These are called “stuck points.” Stuck points can be overcome by coming at the phobic situation in a different way. For instance, if the phobic cannot get past a particular intersection, approaching that intersection from a different direction may work. Sometimes just stopping and waiting before entering a particularly difficult phobic situation, such as crossing a bridge, makes it possible eventually to drive across.

This is advice I give phobics towards the end of treatment:

  1. A panic attack will not incapacitate you no matter what you are doing, no matter where you happen to be. Ordinary people confront similar fears. There are a few endeavors which  commonly bring with them extreme anxiety-giving a musical performance or taking an important examination, for example. The only effective way to cope with such “stage fright” is to engage in that particular activity repeatedly until it becomes somewhat accustomed. Those medications that temporarily reduce anxiety to a more satisfactory level may interfere with performance because of their other effects. This is more a problem of professional performers than of people prone to panic attacks. But the principles of treatment are the same. Panic attacks also recede with repeated confrontations. The fear of phobic situations fades with repeated encounters.
  2. If you are afraid of a particular place because you think it is inherently dangerous–such as the subway, even though two or three million people ride on it every day-then you should not go there. Do not ride the subway. But if you know very well that you avoid it because in that setting you feel trapped or anxious for any other irrational reason, then there is no alternative to riding it. You should ride it until it no longer matters to you whether you ride it or not. Then you can stop. At this late stage of treatment two or three rides are usually enough. A similar rule can be set down for every sort of phobia. Someone afraid of heights should not stop short of going into a tall building, indeed, the tallest building around. If you are especially afraid of traveling, you should not delay indefinitely making that single, prolonged trip you haves always dreaded, whether it is to a relative in another state or to Europe. Of course it is not always possible to put everything aside to take a trip to Europe, but these final confrontations should be undertaken as soon as possible. They often prove to be anticlimactic.

Having dealt with your anxious feelings over and over again, you may find yourself more or less calm during these ultimate trials. You may no longer be phobic, but until you go past the last obstacle, you cannot be sure. Is it necessary for someone afraid of heights to throw himself out of a plane skydiving or, short of that, climb a mountain? No. These are activities far removed from ordinary life. They are potentially dangerous or likely at least to become unpleasant for reasons having nothing to do with a phobia. Similarly, one need not drive on icy roads, walk through bad neighborhoods, hang out a window, hurtle up and down a roller coaster, handle poisonous snakes, juggle on television, or ride in a submarine. However, do not try to convince yourself that there is a danger looming in front of you when you really know there is none.

  1. Try to get panicky! In a way this is what you have been doing all along. By entering into phobic situations, getting panicky and remaining to deal with those feelings, you counter the basic causes of the phobia: the fear of being overwhelmed and the urge to withdraw. Early in treatment, or before treatment has begun, you may have been able to frighten yourself just by imagining yourself in the phobic situation. You could feel peculiar just by thinking, “What if I begin to feel peculiar?” But no longer. In order to get panicky at this stage you may have to go further into unfamiliar situations than you ever thought would be possible. If indeed you cannot get panicky no matter what you do, you may be well along to a cure. Even so, you will surely get panicky spontaneously once again sometime in the future. Count on it. It is in the nature of the condition.
  2. Try to get lost! Get into a car and drive a distance by yourself down unfamiliar roads. Enjoy the trip if you can. Then find your way home. Look at a map, if you like, and by all means ask directions. This is not an exercise in survival techniques but a simple demonstration of what everyone else already knows: In this day and age of sprawling cities and interconnecting highways, it is impossible to get lost for more than a few minutes at a time. Nor is it possible be truly alone when a telephone is never more than a few feet away (not to mention cell phones). Of course, with the use of GPS, it is more obviously impossible to get lost. The fear of getting lost or finding yourself forever alone must be seen once and for all for what it is: an illusion.
  3. Begin slowly to reduce your use of tools in the phobic situation. If you have been carrying around a can of soda in case you should choke or a paper bag in case you should hyperventilate, leave it behind. If you have managed to drive places by calling people from time to time, turn off the phone. If you have been calling someone on the telephone before going to see him–in case you should become incapacitated along the way and need help–now is the time to prove to yourself that you can manage all by yourself. You may feel more comfortable giving up these devices a little at a time, for example, by substituting a small can of juice for a can of soda, then liquid-filled candies for the juice. More often, just putting them aside all at once is easiest. Medication, unless it is needed for some other purpose, should also be put away. Even the list of tools you have been carrying with you can be discarded. If you get panicky, the tools you are accustomed to will come readily to mind. After a while even these become unnecessary. You will then do simply what anyone else does in the face of a distraction: turn your attention back to the business at hand. If there is still some place you can go only with a helper, now is the time to go there by yourself. If you work with a helper, you can keep in touch with him or her indefinitely, as you would with any friend; and if you experience a setback, you may need to work with him again for a while. In the end you must be free to do whatever anyone else can do with no more help than anyone else needs–which is not to say without any help at all. We are, none of us, so independent. But we do not rely on others all the time. We need them as people, not as someone simply to stand nearby.
  4. Now, at last, is the time to plan for the future. No one can presume to say how someone else should live, so what follows are suggestions only, but they are reasonable suggestions. Plan on not being phobic. If you make special provisions for being incapacitated, you will limit your achievements and satisfactions and at the same time make a relapse more likely. Do not insist on living within sight of your parents’ home. Do not choose a job on the basis of it being nearby and convenient. Make application for challenging jobs if they are interesting. Even if you are busy with important matters such as bringing up children, plan as soon as you can to get a job, even if only part-time. Experience indicates that phobics are less likely to become symptomatic again if they are obligated to satisfy the demands of a daily job. Do not hesitate to attend school, go on vacations, or meet new people. Do not choose your friends solely by their willingness to tolerate your canceling appointments at the last minute. Do not marry or stay married simply because you are afraid of living by yourself: In short, do not settle for a life any less satisfying than that to which everyone else aspires.

Try to be open in your relationships with others. You may not be phobic, but like the rest of us you still have weaknesses and occasional failures. Try not to hide them, for then you will be hiding from them. You cannot become the kind of person you would like to be without first accepting yourself the way you are. Try to express your feelings openly. If the panic attack represents a welling-up of unconscious impulses, expressing them in an appropriate way should lessen their severity. But saying what is on your mind should not require special justification. It is the only way others can know what you want and need. Even more important, perhaps, speaking freely is one way of finding out who you really are; and it is the final standard of true independence: being able to state your opinion and your wishes no matter who is present and no matter what they may think.

Remember the goal should be: to live an independent, assertive and joyful life.

Excerpted from “Fighting Fear. An Eight Week Guide to Treating Your Own Phobias” By Fredric Neuman M. D., Director, The Anxiety & Phobia Treatment Center. © Fredric Neuman