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Here is Article 6 from "Freedom
From Agoraphobia." The book is now available in the U.K.! Bookstores
can order copies of it for their customers from their distribution partners.
In the U.K., these are: Bertrams * Paperback Bookshop Amazon.co.uk Blackwell Cypher Coutts Dawson Here is the sixth article based upon the book, “Freedom From Agoraphobia.” It will give you more understanding of how the mind works together with the body to create the panic attacks and the avoidance pattern of agoraphobia. As you read, I hope you will take the time to think about your own experience and see how the article applies to what goes on inside you.
As always, since I am an M.D., I cannot express my point of view without being concerned about liability. So please note this disclaimer before reading further: Any medical information in this article is not intended as a substitute for informed medical advice and you should not take any action before consulting with a health care professional.
Catastrophic Thinking and Anticipatory Anxiety (Living Through Disasters Before They Happen)
The world abounds with “I-Can’t-But-I-Must” double-binds (see Article 5). And, as you know all so well, many of them involve the belief that you “must” not have a panic attack in this or that place. “What if I have a panic attack in a restaurant and faint right there in front of everybody?” “What if I have a panic attack while driving and lose control of the car and injure or kill everybody?” “What if I make a fool of myself?” “What if people see that I have this ridiculous condition of not being able to go into a grocery store?” “What if I get stuck somewhere and can't get back home?” And on and on -- you know the drill.
This fear of having a panic attack or of something else terrible happening is called "Catastrophic Thinking" or “Catastrophizing.” In other words, it is the process of thinking up catastrophes. Some people call these thoughts the ‘What-Ifs.”
When we think this way, we make ourselves anxious. This is called “Anticipatory Anxiety.” That is – the anxiety one feels in anticipation of something awful happening. Many agoraphobics are aware of this process and refer to it when they talk about the panic attacks “I worked myself into."
It is very natural to fear panic attacks. One of the characters on M*A*S*H once said: "I hate being scared -- it terrifies me." This is true. We not only have the panic attacks, but we have the fear of having panic attacks. And panic attacks are frightening. The "fight-or-flight response" that we have as a result of all the adrenaline pouring into our systems causes us to feel that something terrible must be happening. In fact, one study found that people having anxiety or panic accounted for 50 percent of all visits to cardiologists. It feels terrible. No doubt about it. So agoraphobics get “a double whammy” – the panic attacks themselves plus the Anticipatory Anxiety.
Actually, the Anticipatory Anxiety is often a bigger problem than the anxiety of the panic attacks. This came home to me in the first year of my residency training – some thirty years ago. I was seeing a patient who had panic attacks while driving on the highway to work. He would develop the feeling that a wall of fog was following just behind his car and that he was therefore cut off from the rest of the world. Also, this caused him to feel that he couldn’t go back since the world behind him was sort of erased by the fog as he went. These thoughts and feelings would escalate until he had a panic attack.
My teachers and I did not know much about Agoraphobia in those days (for instance, I hadn’t discovered The Key) and my patient and I were getting nowhere towards ridding him of the panic attacks. Finally, in desperation, I asked him how long the panic attacks lasted. He said about 20 minutes usually. Then I asked how often he had them. He answered once or twice a week. When I realized that he was out of work and in a psychiatric hospital because of his fear of what he experienced 40 minutes a week, I was shocked. “Do you mean to say,” I asked, “that your whole life, 24 hours a day, 7 days a week has been messed up because of your feelings about what you go through for 40 minutes a week?!!” He agreed that this was so. “Well,” I said. “We do not seem to be getting anywhere about changing those forty minutes, but what if you changed all the rest of the minutes? What if you went back home and back to work with the conclusion that we had failed? That you were going to go through forty horrible minutes each week and nothing was going to change that. But you could at least have the rest of the time each week to live your life?”
Well, this made sense to him so we agreed that he would try it: He would expect the forty minutes of panic attacks each week but would try to not let it affect the rest of his week any more than necessary. And he was able to do it pretty well. I did not know him long enough to hear whether this reduced his panic attacks. From what I know now, I think it probably did. But the last I did hear, he was back enjoying the most of his life and feeling good about it.
I never forgot the moral
to this story: sometimes a person’s reaction to a problem is a
bigger problem than the original problem, itself. (We frequently see
this same phenomenon in physical medicine – for example, that’s
what is happening in severe allergic reactions.) Later, when I
Displacement (Transferring Feelings From What They Are About To Something Else)
The way being trapped in our lives becomes fear of being trapped in places such as the grocery store is the process of "displacement." It is a psychological phenomenon that has long been recognized. In fact, Freud first described it. Here's how it works:
We believe that there is nothing we can do about the Life Trap so we stop thinking about it. But it's as though there is somebody within us trying to give us signals that something is very wrong. The signals are the panic attacks in trapped situations in daily life. That not-so-little voice (of the panic attack) is constantly saying: "No traps!" The big trap, which we feel we can do nothing about, gets experienced as all these little Day-to-Day Traps. In other words, the feelings of fear have been displaced (moved from one place to another) from the big trap to the little ones.
Perhaps you remember some of the old cartoons in which the character gets hit on the head causing a bump to arise. He pushes it down only to have another bump come up some place else. I am often reminded of this when thinking of displacement because we try to ignore the feelings of one trap only to have them come out about another one.
As we already noted, there can be some benefit to this. Being unable to go to the grocery store by yourself may result in your husband doing more of his fair share of the shopping. Or, accompanying you to the store may give him a way to be caring which he didn’t have before.
Primary and Secondary
Gain For those who are interested, this after-the-fact benefit of panic attacks is what has been called "secondary gain." In other words, it is a secondary benefit from the way of adapting that we call "panic attacks."
When I first started working with Agoraphobia, there were very few professionals who recognized what it was. The poor agoraphobics of those days got all sorts of wrong diagnoses and treatments (like my guy with the following fog who had admitted himself to a hospital). Frequently, agoraphobics were considered to be highly dependent people because they relied upon others to either help them go places or to go places for them. Some counselors got the idea that maybe this reliance upon others was the purpose of developing Agoraphobia in the first place. In other words, agoraphobics were simply getting others to do for them.
Wrong! Anything good that comes out of agoraphobics’ reliance upon others is simply a side effect. Or, "secondary gain". The primary “gain” is that it is the mind’s way of dealing with seemingly impossible circumstances -- namely, traps. Agoraphobics cannot get out of their traps or (often) even afford to experience them as such. So instead, the fear is displaced onto the little Day-to-Day traps that can be successfully dealt with by avoiding them. That is the primary gain (or reason) for the avoidance pattern of Agoraphobia.
Can you see why, towards the end of treatment, many agoraphobics come to realize that home -- which had been considered the only "safe place", was really the only unsafe place? When this happens, the displacement has been undone. And the person is experiencing her Life Trap for what it really is. Then it can be dealt with -- no matter how hard that may be. Also, ceasing to project her anger gives her the assertiveness to stand up for her right to an untrapped life. (Huh? Don’t worry. Read on.)
This is the phenomenon of believing that someone else has feelings or thoughts that are actually feelings you are having but of which you are not aware. (Whew! That was complicated.) But projection is really quite simple. It is thinking the other person has your feelings. Instead of knowing you have them.
Here’s an example: I perceive you as being mad at me. You, in fact, are not mad at me. Where did I get the mistaken idea? From myself. Where else could it have originated? There are only the two of us here.
So, the idea of being angry came from me and I put it on you. Did I know I was doing this? Of course not! If I had known the anger was in me, not in you, I would not have perceived you as angry. I could only have made this mistake if I didn’t know it was a mistake. In other words, the projection of anger onto you was an unconscious process. It happens without our knowing it. And projection always is unconscious. As soon as we become aware that we are projecting, we aren’t doing it anymore.
Also, we are projecting all the time. In fact, it is how we see the whole world. Sometimes our projections are true. Sometimes they are not. And sometimes, we will never know.
You say: “This is great chocolate!” And I say: “I know what you mean.” I am projecting. In actual fact, I will never know if the chocolate tastes the same to you as it does to me. All I can do is project onto you how it tastes to me and imagine that that is what you are experiencing. I assume the projection is accurate. But there is no way to know because I cannot get inside you to know what it is like to get the chocolate sensations from your taste buds.
Lots of times, it is clear that our projections are untrue. He says: “Isn’t that a beautiful green?” She says: “I think it’s awful!” He thought she would see it as beautiful. His projection onto her of how the green looks to him was wrong. It does not look that way to her.
Freud realized that the processes of projection and displacement are how a phobia gets born. The famous “Little Hans” case illustrated this. Here’s the case, in brief: Little Hans was a small child who had a phobia of horses. Freud figured out that this fear came about because Little Hans was angry with his father. Here’s why: You cannot want to overthrow the king for very long before you begin to believe that the king might not like this and has it in for you in return. In other words, you project your anger onto him. (The fact of the matter could be that the king doesn’t even know you exist off in your remote corner of the kingdom.)
So Little Hans projected his anger onto his father, perceiving that it was not he who was angry with his father but that it was his father who was angry with him.
Living in a house with a big adult who you think is angry with you was too scary for Little Hans to deal with. So Little Hans’ mind solved the problem for him (of course, without Little Hans knowing about it) by displacing the fear from his father onto horses (which were the common means of transportation at the time). Now, Little Hans had a fear he could deal with. As long as he ran away and hid whenever a horse came down the street, Little Hans felt safe. And voila – a phobia was born.
It all starts with projection – thinking that someone else has evil designs towards you when it is really you who has the evil designs towards them.
This may all seem to be an unnecessary complication - something for psychoanalysts to worry about, not regular people. And it’s true that you don’t have to understand it to overcome your Agoraphobia. But it gets right back to the world of “regular people” if you happen to realize that an unfelt anger at someone is sometimes what started one of your fears.
Where does Sylvia’s fear come from? Not from Darrell’s threats or even his abuse. She is used to those. They do not frighten her, they just hurt. But they make her mad! And like Little Hans, there is nothing she can do about her anger. So, she projects it and then displaces it onto the grocery store situation. If Sylvia realized how angry she is at Darrell and at her father, her fears would largely vanish! Just like that. Anger felt equals fear not felt.
Depression and Agoraphobia
The prevalence of depression is greater than 50% at one time or another in the agoraphobic’s lifetime. This makes perfect sense since depression is so closely linked to anger. You have probably heard the old saw that “depression is anger turned inward.” Well, that is rather an oversimplification but it does contain the truth that depression often results from how the individual deals with anger. When anger is not acceptable to you and you cannot allow yourself to feel angry, then a phobia can result just as we saw with Little Hans. Or depression can result.
Here’s how I came to understand this: I noticed that many situations that cause anxiety for other people were like the exams I faced in college causing anxiety for me. The catastrophic thoughts I had about failing included the ideas that I would be a failure, that I could not face my friends or parents if I flunked out of school and that I would end up in some kind of humiliating job. In other words, it was as though I had constructed a kind of paper mache model of myself that I constantly kept an eye on to make sure that it was good enough. The anxiety over possibly failing the exam was the fear that my image would be permanently disfigured. I would look at it and see that it (meaning “I”) was bad (a failure, humiliating job, etc.)
Furthermore, I noticed that if enough time went by, my anxiety would turn into depression. After struggling and struggling to master all the material and finding that it was impossible, I would stop fearing that I would fail the exam and, instead, conclude that failure was inevitable. I gave up. There was no longer any anxiety because failure had really already happened. I just had yet to go through the exam and finally get my grade. But the fact that it was going to be an ‘F’ was already settled. So my paper mache image became an image of a bad me and there was nothing I could do about it. In other words, anxiety was the fear that I would have to conclude that I was no good, and depression was having already concluded it.
After noticing this (many years later, unfortunately), I began looking at other situations in which people felt anxious to see if this was generally the case. I found that it often was. For instance, the fear of having a panic attack and being judged as crazy by others is nothing more than the fear that your image of yourself will be: “a person who others think is crazy.” So once again, it is your opinion of that image that is damaged.
Try it yourself: Think of your catastrophic thoughts. See if the catastrophes are not really about your image becoming something you feel badly about. Then, think about your depressed thoughts. Again, are they not about the conclusion that some bad image you feared seeing as you has already happened – that you are that image?
So it becomes obvious what will occur if you feel angry and, at the same time, feel that it is bad to be angry or to be seen as angry. You will have anxiety that the anger will come out or be perceived by others. This would turn that image into a bad one. (“She’s an angry person.”) Eventually, you will conclude that you are that bad image anyway; because the anger doesn’t go away – it just stays showing that you are that angry (bad) person. At this point, your anxiety turns into depression.
Lastly, it is worth noting that anxiety and depression seem to be alternatives. If you become depressed, your anxiety goes down. This makes sense. If anxiety is the fear that you will conclude you are bad and depression is having concluded it, then of course you will only have one or the other. You will not fear something happening if you have concluded that it has already happened. Just like when I became depressed about the hopelessness of passing the exam – instantly, I was no longer anxious about taking it. (Ugh! What a lot of stress that was for nothing!)
So now you know what goes on in your body and your mind to make panic attacks. We’ll be spending our time in future articles on the subject of the ways there are to overcome these.
Until next month, I wish you peace and progress,
Mark Eisenstadt, M.D. You can now find the seventh article Here
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