Exposure Therapy For Agoraphobia

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What is Exposure Therapy?

Exposure therapy is a technique used in treating anxiety disorders by exposing patients to feared situations or objects until the fear is extinguished.

What is Agoraphobia?

The literal meaning of the word is fear of the marketplace or open spaces but in the context of an anxiety disorder, this definition falls short.

Agoraphobia is a fear of experiencing a panic attack in places or situations from which escape might be difficult or socially embarrassing. (Stuck in traffic, driving over a bridge or through a tunnel, crowded theatre, etc.)

At their core, agoraphobics fear feeling trapped, helpless and/or exposed to public scrutiny.

Exposure therapy for agoraphobia is a little different from exposure therapy for PTSD or specific phobias. Since the root of the problem is essentially a fear of panic attacks, exposing the patient to feared situations will not work.

"The agoraphobic is afraid of the upsetting physical feelings he feels within himself when in certain situations. He must be taught to cope with these and not with a situation, otherwise he may manage one dreaded situation after another only to panic in a new one."

The above quote is taken from Dr. Claire Weekes' book Simple, Effective Treatment of Agoraphobia, published decades ago but in my mind the best and clearest explanation of what agoraphobia is and how to overcome it. That's not to say that it's easy. It's simple but difficult. You have to pass through panic. Not fight it or simply bear it until it passes. In Dr. Weekes' words, "[i]t is essential that the patient be taught how to cope with panic." The fear that fuels agoraphobia is the belief that you cannot cope when panic strikes.

Sensitized panic rarely vanishes by simply ceasing to come. It goes only when the panic is taken out of panic; that is, by the patient’s seeing panic through the right way so often, without adding second-fear, that eventually panic loses so much of its fire that the remainder no longer matters.

When I first read this book I couldn't believe that someone who had never experienced agoraphobia could write such a spot on book. I think it's fair to say that among agoraphobics, Dr. Weekes is regarded as a godsend for her clear and simple explanation of a bewildering anxiety disorder. 

I believe the book is out of print now and copies are not readily available. My local library had some of her other books, which are worth checking out, but didn't carry this particular one. I searched online and bought an old paperback from eBay, if memory serves. I haven't been able to find digital editions of it but physical copies are still available on Amazon. Shop around if money is an issue. There are some charging exorbitant prices, in my humble opinion. On Amazon.ca a paperback will run you about $8 CAD. 

These prices are beyond fucking ridiculous. I wouldn't pay this much for the first edition of Wuthering Heights. Ok, I probably would. But only because it's my all time favourite book.

At only 135 pages, the book is slim but packed with information. A second and possibly third reading is a must in order to process everything. At least for me. It's a lot of information to take in for a person suffering from panic attacks and agoraphobia. I once read a review where a reader stated that every time he read the book, he got something new out of it. 

In my next post, I'll talk about two key concepts--First Fear and Second Fear--that I found incredibly helpful and eye-opening. Concepts that I haven't come across in other more recent books.

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Amitriptyline For Insomnia

Same drug, different dose, exactly 7 years apart. My old GP put me on Amitriptyline (aka Elavil) for insomnia back in 2009 at a dose of 10mg, which I figure was the lowest. I don't remember for how long I took it but I did write a post about withdrawing from it.

Original Post June 24, 2009
Panicked-Chick.blogspot.com

Amitriptyline Withdrawal

I felt like crap today and I had no idea why. I had a headache, hot flashes, stomach cramps, felt tense and dizzy. I thought I was getting my period but then I remembered that the night before I purposefully didn't take my medication that was prescribed for my insomnia. I'm only on 10mg so I didn't think I would have a hard time if I stopped. I didn't tell my doctor I was stopping the medication, which is always a bad idea. I just got fed up with the Amitriptyline (generic name: Elavil) because it's not doing anything. I feel like my insomnia had gotten worse. So last night I just didn't want to take it.

I still feel dizzy and nauseous and I have a headache. The withdrawal is too horrible so I'll have to continue taking it until I can see my doctor. Tapering off is the way to go. I'll insist on that this time. Last time, my doc didn't even tell me about the withdrawal symptoms when he took me off Effexor XR (at 225mg/day) and put me on Celexa.

I think the withdrawal symptoms are similar to the side effects. Side effects of taking amitriptyline include:

• nausea
• vomiting
• weakness or tiredness
• nightmares
• headaches
• dry mouth
• constipation
• difficulty urinating
• blurred vision
• pain, burning, or tingling in the hands or feet
• changes in sex drive or ability
• excessive sweating
• changes in appetite or weight
• confusion
• unsteadiness

Luckily I haven't experienced any of these side effects while taking it; only when I miss a dose. The worst part must be getting off medication. I'm a little scared of what that will feel like. I'm afraid that if I increase the amitriptyline it'll be harder to taper off if the increase doesn't help. I don't know what to do.

Last week when my current GP suggested amitriptyline again, I balked. But then I thought, anything's gotta suck less than Seroquel (an atypical antipsychotic). Don't get me wrong, it works great for bipolar and schizophrenia but I was using it for insomnia. And even at a low dose I would feel drugged out, foggy, a little stupid. Those are the known side effects. Not to mention gaining about a 100lbs while on it. Part of the weight gain was probably due to my own laziness but Seroquel sure helped with that. The other reason I went off was due to long term risks such as diabetes. My mom has type 1 diabetes and her dad had diabetes so I don't want to push my luck.

So, I started amitriptyline again but this time the dose was 25mg. The 10mg one was a little round blue pill. The one I picked up at the pharmacy was yellow, twice as thick and 2.5x the old dose. I was having a hard time falling asleep with 25mg. Even at 50mg (my doc just upped it) it wasn't sedating enough. It felt pretty weak. I had to add 5mg of melatonin to finally get some sleep.
What I need, apparently is a fucking horse tranquilizer. Or that old school shit they gave schizophrenics. Thorazine?

I'm too worried about discontinuation syndrome as I can lower the dose slowly if I had to and last time, if my memory serves, the withdrawal went away after a day or two. I'll give it a few weeks at the 50mg dose. May even go as far up as 150mg. But that's it.

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The Grim Reaper

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Hermits United

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Academic Failure Due to Mental Illness - Clean Slate?

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I graduated from high school in 2002 by the skin of my teeth. In late 2001 as I started my senior year, my panic disorder worsened. Daily panic attacks at school took their toll and by winter break, I broke down and left school. Fortunately for me I was able to apply for Correspondence and continued my senior year from home. The feeling of relief was quickly replaced by a despairing depression as I sat at home while my friends were busy with school, enjoying their status as seniors, planning for prom and after prom celebrations at Whistler and of course graduation and prepping for colleges or universities.

I barely graduated. I dropped every course that wasn't a graduation requirement, leaving me with only two courses; English and Biology. I passed English easily but failed Biology because the Provincial Exam was held at my old high school. I freaked out about ten minutes into the exam and wanted to leave but the invigilator would not allow me. No one was allowed to leave the exam room within the first half hour. I panicked. I couldn't concentrate on the exam questions. I couldn't even breathe, I was so desperate to get the hell out of there. Luckily, the invigilator seemed to understand what was happening to me and she talked me through some deep breathing until she could officially allow me to leave. It was the longest twenty minutes of my life. With my friends and others looking over at me, thinking hell knows what.

That exam was worth 30% of my grade and even though I had a B in Biology, failing the exam brought my grade down to a D or whatever the equivalent is of a final grade of 51%.

I made it to my prom (somehow) but not my graduation. After graduation things went from bad to I'm-so-disgusted-with-myself-I-wanna-die bad.

I spent the summer after graduation in therapy (which started back in grade 10) but worsening panic attacks resulted in avoidance which turned into full on agoraphobia. I didn't leave the house in over a year.

I was finally able to attend college in the fall of 2004. Already two years behind my graduating class, I pushed myself so hard to catch up. I piled on 18, 21 credits per semester and didn't take breaks during the summer months. The anxiety and panic attacks were still a major issue. I couldn't concentrate on the lectures in class because I spent the entire time fighting back the rising swells of panic. Sitting through an entire lecture was an accomplishment of the highest order for me but instead of concentrating on the positive I derided myself for being weak, crazy and intellectually dumb.

Taking on so many units, trying to prove I was like everyone else, backfired. I failed miserably. Failed more courses than I passed and had numerous unsuccessful semesters, was placed on academic probation. The Registrar even got involved, telling me she had been keeping her eye on me, so to speak, and after two semesters of me taking on a huge course load and being unsuccessful, she banned me from taking more than three courses at a time.

But it didn't help. I was going downhill fast but refused to acknowledge that I just could not crack it at school. I had something to prove. To myself. To my immigrant parents. To everyone who expected so much from me. I was the smart one. The one who loved school and academics. Who wanted to go all the way up to a PhD.

By the time I left school in 2008, I had graduated with a worthless Associate's Degree in General Studies that took four bloody years, a 1.67 GPA and about $40,000 in student loan debt. Most of the debt was not for tuition but for living expenses as my parents couldn't make ends meet without my contribution to the household.

It was a complete waste of time and money. I couldn't work even if I wanted to. I couldn't go back to school either. Not financially, as the government had basically cut me off due to so many withdrawals. It didn't matter that I had a mental health disorder. You only get three chances. After that you're on your own. I couldn't even do it mentally nor could I physically attend classes.

I wish I could wipe the slate clean and start again. That shitty degree is actually a hindrance to further education. It will follow me. Wherever I apply, that shitty GPA will disqualify me from any decent university.

The bottom line (money, bloody money) is what matters. There is no incentive for individuals struggling with mental health issues to persevere. Three strikes and you're out. And you can't even pay off your student loans because you can't get a job. And if you could get some shitty minimum wage job it would probably take you 50 years to pay it off but the maximum in Canada is sixteen. And you can't even file for bankruptcy for at least 5 years. It used to be 10. If you can get your loan forgiven, you will never again be allowed to take out another one. The whole thing is just fucked up.

So without funding, there is no way I will be able to pay for it myself. I can barely get by with my disability benefit and part time job. There is nothing left over to put aside.

It depresses the hell out of me. It's just fucking money. But higher education is a business. It's not a right. It fucking should be.

Unless I win the lottery or the book I'm writing becomes a bestseller (the odds of that happening probably no better than winning the jackpot), I will never get my degree.

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Agoraphobia

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Government Harassment

Revenue Services of British Columbia is harassing me. Their constant phone calls and threats are exasperating my already unmanageable anxiety and panic attacks. I can't sleep. I can't eat. I can't concentrate on anything for longer than a few minutes. And there they go again. Calling me today, telling me they will garnish my wages. I'm on disability. Receive about $900 a month in assistance in a city where the median rent for a one bedroom is more than my monthly disability cheque. And they are threatening me with garnishment of my measly $250 a month part time job.

They don't scare me. Well, now that I've taken my Ativan and can think semi-clearly, they don't ;) Now they're just pissing me off. First they sent me some documents to fill out as proof of my financial circumstances, which I did and I sent in all the supporting documents. But then they call last week to say that they received some of the documents but not some others. How the fuck is that possible. I sent it all in a single fucking envelope. And this is not even the first time I've sent them documents that they never received. And today they called me again to tell me the same thing I was told last week. I haven't sent the damn paperwork yet. Give me time, for fuck's sake. If I have to choose between paying for the postage and buying a loaf of bread, I'll fucking buy the bread. They can wait. They're the ones who lost the paperwork in the first place.

This is what they want and what they want from me is impossible. Namely, the repayment of a $16,000 student loan, which just keeps on accruing interest making it impossible for me to ever pay it off. And that's just the provincial student loan.

The federal one is about $40,000 and I will never be able to pay that back. Not least of all because I didn't finish my university education due to my disabling panic and agoraphobia and also because the government has cut me off from any further funding for the rest of my life. Basically, I'm blacklisted because I had to withdraw from school a couple of times due to my mental health issues.

My only recourse is to apply for forgiveness of the loans. Which I have done but haven't picked up the form from my doctor because I have to pay for it. So I was waiting for my paycheque which I didn't receive on time due to clerical issues. Pretty shitty luck, I know. If approved, I will never qualify for government funding again. At this point I don't give a flying fuck anymore.

If I'm not approved, then the only thing that remains is bankruptcy. I don't want to have to go through that. I can't physically or emotionally deal with that. I hope it doesn't come to that.

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Physical Versus Mental Illness

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Insanity

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Don't Panic: How to Breathe Your Way Out of a Panic Attack

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Rapid and shallow breathers, myself included, have been found to be more passive, fearful and shy according to a study of 160 women and men.

Slow and deep breathers, on the other hand, were found to be more confident, emotionally stable, physically and intellectually more active.

As a chronically anxious agoraphobic, it describes me to a t. Most anxious people are probably unaware that their breathing patterns contribute to their anxiety. I was one of them. I thought the whole "breathe through your belly" thing a load of crap and a total nuisance. Breathing is automatic. Why should I have to change the way I breathe? My anxiety has nothing to do with my breathing technique.

Maybe not but once I tried deep, slow belly breathing, I experienced a sort of natural high. A floating calm. Sometimes it works and sometimes it doesn't. It all depends on the severity of one's anxiety and the ability and motivation to concentrate, something that I find extremely difficult when highly aroused.

Being naturally curious and needing to know exactly how things work, I set out to find out the anatomy of breathing. So, I googled "breathing oxygen co2" and after reading a number of articles I was even more confused than before.

My understanding--in simplest terms--was that we breathe in oxygen and breathe out carbon dioxide. Which is true. But what I wanted to know was how the level of oxygen and carbon dioxide in the bloodstream affects our emotions, ie. feeling calm or feeling aroused.

What confused me was this article on LiveScience. The headline To Stave Off Panic, Don't Take a Deep Breath threw me. From reading numerous CBT books and attending CBT sessions, breathing deeply was recommended. This study didn't make any sense.

“Panicking people are often told to calm down and ‘take a deep breath,’ Meuret said. But for someone hyperventilating during a panic attack, deep breathing is a bad idea. That's because hyperventilation happens when people breathe so quickly and deeply that they expel an unusually high amount of carbon dioxide, which in turn causes symptoms like dizziness and numbness. Those symptoms tend to make people feel like they're suffocating, so they breathe quicker and deeper, further exacerbating the problem.”

That makes no sense to me. I thought that breathing quickly and shallowly (chest breathing) is what causes too much CO2 to be expelled. Is it possible to breathe quickly and deeply through the chest? Doesn't deep breathing imply using the diaphragm? If someone better informed can explain this to me I would really appreciate it because I feel a little dumb right now. ;) 

If I'm understanding this correctly, the crux is that breathing out too much CO2 causes the level of CO2 in the bloodstream to fall, thus making our bloodstream too acidic or is it too basic which makes our nerve cells more excitable. Bah, why is this so confusing, damn it. 

Finally, I figured it out. Or more accurately, Lars Refling over at Quora explained it.

“In a healthy person, the CO2 level in your bloodstream is kept in a narrow range and determines the automatic breathing rate via the respiratory centre in your brain stem. If the CO2 level in your blood increases for any reason, the brain stem responds by increasing the number of breaths per minute to blow off the increased CO2. If the CO2 level becomes too high, coma results. If your CO2 is below the normal range, the respiratory centre does the opposite. For example, this is part of an acute panic attack. If the individual over breathes due to anxiety or fear, the respiratory centre responds by sending a signal to not take a breath. This results in the individual getting even more panicked, ‘I can’t breathe’. Thus the advice to breathe from a paper bag.”

Thank you, Lars. :) 

When experiencing a panic attack, do take a deep breath but do it slowly. The slower you breathe, the less CO2 you expel. That way your body won't have to send signals to your brain to slow down your breathing in order to maintain the optimal levels of oxygen and CO2 in the bloodstream. 

How To Breathe During a Panic Attack

Breathe in through your nose to the count of 3. Hold it in for a second and then exhale slowly, also to the count of 3. You can count as high as it's comfortable for you. Start at 3. It will be much easier if you're breathing rapidly due to a panic or anxiety attack. Increase to four and then five for a deeper calm.

To ensure you're breathing deeply, place your hand over your belly and as you exhale, your belly should rise if you're using your diaphragm.

Check out the gif's below.

Image via In Pursuit of Yoga

Image via In Pursuit of Yoga

When breathing deeply (belly breathing) the diaphragm contracts and relaxes while the ribs remain stable unlike during shallow chest breathing where the ribs are being lifted.

Click on the images above for a more detailed explanation of belly vs chest breathing at In Pursuit of Yoga.

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About This Blog

I've retired my first blog that I started back in 2007. I thought about keeping the old blog and just starting anew but decided I needed a fresh start. Ergo, this blog. I've learned a lot about panic disorder, antidepressants and agoraphobia since then and my overall views about mental health disorders and treatments that I thought it appropriate to retire that old blog and start fresh.

In my own treatment, I'm starting fresh--in a way--and this blog will be mostly about my renewed journey out of fear and anxiety that has held me back from living life.

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