300.22 - Agoraphobia Without History of Panic Disorder

DSM-IV-TR Criteria for Agoraphobia:

A) anxiety about being in places or situations from which escape might be difficult (or embarrassing) or in which help may not be available in the event of having an unexpected or situationally predisposed Panic Attack or panic-like symptoms. Agoraphobic fears typically involve characteristic clusters of situations that include being outside the home alone; being in a crowd, or standing in a line; being on a bridge; and traveling in a bus, train, or automobile.

Note: Consider the diagnosis of Specific Phobia (if the avoidance is limited to one or only a few specific situations, or Social Phobia if the avoidance is limited to social situations.

B) The situations are avoided (e.g., travel is restricted) or else are endured with marked distress or with anxiety about having a Panic Attack or panic-like symptoms, or require the presence of a companion.

C) The anxiety or phobic avoidance is not better accounted for by another mental disorder, such as Social Phobia (e.g., avoidance limited to social situations because of fear of embarrassment), Specific Phobia (e.g., avoidance limited to a single situation like elevators), Obsessive-Compulsive Disorder (e.g., avoidance of dirt in someone with an obsession about contamination), Posttraumatic Stress Disorder (e.g., avoidance of stimuli associated with a severe stressor), or Separation Anxiety Disorder (e.g., avoidance of leaving home or relatives).

I have never been diagnosed with Agoraphobia. I have very often found it easier to let others assume that I am agoraphobic than to try to explain my situation in detail, although I usually have felt like I was copping out or being dishonest when resorting to that option. I have not met the criteria for Panic Attacks, although in adolescence I did experience some symptoms of anxiety, such as sweating, shaking (this was usually related to feeling cold, as the sweating resulted in wet clothes) and stomach pains.

It was not as simple as symptoms developing predictably upon exposure to a known stressor, e.g., attending school. It was like I experienced a fluctuating level of symptom severity throughout the day, and over time I learned how to spot the signs of anxiety developing such that I could make efforts to relax somewhat. If I skipped school, it was usually because certain clothes were too tight (and I was at a point in my fluctuating weight cycle where I did not have any that were looser), and I dreaded the idea of facing a 10 hour day in such clothes, realizing that I was most likely to experience sweating and stomach pain in those circumstances.

Stomach pain was likely the result of a combination of digestion issues (due to my disordered eating patterns) and tensing my abdominal muscles, both voluntarily (in order to enhance my appearance by showing an attribute - flat stomach - to advantage), and involutarily (due to anxiety). This would be exacerbated by tight clothes.

In Major Depressive Disorder, the individual may avoid leaving home because of apathy, lack of energy, and anhedonia. Through the years, I think depression, including loss of major ties to life, was the primary factor when it came to my apparently 'agoraphobic' lifestyle. I did not have a history of actual panic attacks, and I did not fear having panic attacks in public, or of being caught some place from which I could not escape.

I was once taken to the hospital for extreme stomach pain. I did at that time think I was dying, as the pain was extremely intense. However, I think it was related to my digestion issues, combined with the fact that I had extremely strong abdominals, and had been holding in my stomach while visiting neighbours.

Anxiety did play a role in my life, but I think the underlying reasons for the anxiety - related to food and body image issues and an overall identity crisis, were the most relevant factors.

Posttraumatic Stress (1982) might have contributed to the development of a somewhat agoraphobic response, but at the same time, there were situational factors which did not require me to leave the home. I was 'playing housewife' in a way, cooking and cleaning for my siblings after our mother died suddenly, while taking a year of high school through correspondence courses. It's true that I quit attending school because of the incident which led to the PTS, but before that time I was not actually doing well in school. I had run away from home, and was far from my family. I was completely stressed, I was not adjusting or catching up for the month I initially missed, and I was basically a time bomb. This had less to do with anxiety itself than with an inability to process all that had happened in a relatively short period of time (1982).

Posttraumatic Stress may also have triggered body dysmorphic disorder. Up until that time, I may have always had certain insecurities related to my appearance, but afterward they may have crossed the line over to unmanageable. This would have been a difficult thing to diagnose, as my upbringing had instilled in me the belief that it was wrong or vain to be concerned with one's appearance to the extent that you stopped participating in life or refused to go out. I realized it was unjustifiable, because it is important to make the most of what you have rather than complain about what it is you don't like.

I actually do remember what it was like to 'accept' my place in life and just continue to do my best. When I stopped attending school, that was harder to do, since I had always derived some sense of identity through my ability to excel in school despite moves, changes and upheavals.

Although it may be accurate to include agoraphobia as part of my diagnosis, it should be with conditions, and with the understanding that it is not the primary diagnosis, but a symptom of major depression, body dysmorphic disorder or bulimia nervosa, and that originally it may have manifested as a symptom of posttraumatic stress which went unrecognized and unresolved.

One important point to consider is that I do not answer the phone. I don't experience panic in relation to phones. On the phone, it can't be an appearance issue, and if it is not an anxiety issue, it may be a self-esteem issue related to major depression, or may represent a profound loss of ties and connections to 'normal' life.

I have never once received a visitor or personal phone call in the 10 years I have lived in GK's house. If anyone comes to the door or phones, it will be someone who wants to sell something, who wants a charitable donation or who is calling for GK.

If I was forced to go out in public, I don't think I would have a panic attack. I would feel a kind of resignation, and despair, and I would feel bad about my personal appearance. It takes a lot of energy to face a world in which you have no status or don't fit anywhere. Mainly, facing the world results in me feeling drained, and like there is no possibility of connection. I try not to face that unless I have first made efforts to build myself up. I think it's somehow connected to feeling overburdened by responsibilities, or crushed by them. I have never in all these years managed to get my head above water, and as a result even relatively minor things can seem insurmountable. I have tried to do some unusual things, and I have put a lot of energy into certain projects, but those things are usually self-chosen, and not about what I can't control in life.

Fear of having panic attacks or of being without help in the event of a panic attack does not keep me in. I also don't fear being trapped in public with no escape route. I sometimes fear being trapped if someone comes to the house and there is nowhere for me to hide.

In 1999, GK asked me to visit him in Australia. In more than 2.5 years, I had only left my apartment a few times. Somehow I managed to get a passport, and to cope with a 24 hr flight. I did experience anxiety, but to me the situation was so unusual that I was willing to deal with the anxiety. I did experience excruciating stomach pain for a while during the flight, my period came early, and an outbreak began. But GK and I had been corresponding for 4.5 months, and he was not unprepared regarding my issues. We were surprisingly comfortable with each other considering the circumstances.

It is true that sometimes if I have been in a situation in which I have been expected to go somewhere, and I don't want to but can't see a valid explanation, rather than drag things out, I will simply say that I am not going. I accept whatever consequences there are. If it relates to a relationship of some kind, I may accept that the person will be offended and/or that it is time to withdraw. In such situations, it may seem too silly to me to say 'I can't do it', and I won't want to say that. I don't like it if someone says on my behalf that I 'can't' do it.

It is hard to be specific, but if it's a situation in which a more 'normal' person has expectations about my response - e.g., they are asking something perfectly reasonable in the circumstances, and it doesn't seem like there could be a rational reason for me to say no, it is necessary for me to say no, and not make up a false excuse. I also do not want to confuse things with emotional complication, especially if I can figure out that the person involved has no patience for dithering. I think it may be partly a kind of 'pride' - I realize my position is not justifiable, and rather than dwell on it, it seems to make sense to just say no and accept whatever consequences there are. This sort of response might be common in agoraphobics, and may interfere with seeking therapy or treatment.

Medication to relieve stress or depression would not create ties to life. If I go out now, I am more likely to feel comfortable in unfamiliar surroundings than familiar, and I am able and very often prefer to go on my own. I have travelled around the world by myself. Familiar surroundings, and the associated repetition of behaviours make me feel depressed, such that I really don't want to do them, e.g., grocery shopping in suburbia. I may handle these things well at first, or occasionally, but over time my motivation to deal with the repetitive realities of life wanes. There is more of a 'reward' for me in attempting the challenge of facing something new. What I think this represents is that I have experienced a long-term understimulation in my environment (which also hindered my further development).

The above is more reminiscent of social anxiety, in which sufferers do not necessarily mind going out alone, since the presence of another could be a source of stress in itself. At times for me, it has been true that there is less pressure to live up to an image in front of strangers than in front of my family. With my family, once I was no longer academically successful, and there were many years of not going outside, resulting in a loss of social contacts and ties to the community, the only area in which I could potentially have some respect related to physical fitness, as that was something that every member of my family was predisposed to respect.

I think the following is potentially relevant:

It must be remembered that some agoraphobics experience little anxiety because they are consistently able to avoid their phobic situations. The presence of other symptoms such as depression, depersonalization, obsessional symptoms, and social phobias does not invalidate the diagnosis, provided that these symptoms do not dominate the clinical picture. However, if the patient was already significantly depressed when the phobic symptoms first appeared, depressive episode may be a more appropriate main diagnosis; this is more common in late-onset cases.

Wikipedia

It is true that my life is structured (or over a very long period of time I have structured it) such that I am consistently able to avoid situations I find unpleasant. However, I think this is key here: if the person had pre-existing depression or some other issue, agoraphobia might not be the correct diagnosis.

It's difficult to explain that reasons for not going out might include depression, an eating disorder or body dysmorphic disorder, or a combination of all. It seems a lot more simple to allow people to think you are agoraphobic according to the popular view of what agoraphobia is, because it is the easiest thing for people to accept without the necessity for elaboration.

When I did go out from ages 18-21 and 22-23, the most consistent occasions were always related to holidays and birthdays, and I find it at least somewhat interesting that I became more reluctant to deal with those occasions as time went on. It was like as long as I put in the effort to be social and appear normal on those occasions, there would be no pressure from relatives, and the shameful secret of my everyday functioning could not taint anyone in my immediate family. It became my responsibility to remain 'convenient' in that way. But every family occasion resulted in a breakdown for me. I would dutifully pretend to be as normal and positive as possible, and then when the event was over I again would 'break down' - which would usually include intense binge/purge behaviour which I found very difficult to get under control.

When I stopped attending family gatherings, I think the others grew resentful of this abandonment of my responsibility, and might have even taken it as a sign of my lack of humanness. At that point, my attempts to go out in the world became much more frequently undertaken on my own initiative than on account of the requests or invitations of family members. It became essential for me to make that distinction: to go out on my own initiative and approach life on my own terms rather than to go out and put on a brave face for my family.

Early recognition and appropriate management are imperative in order to enhance the quality of life of individuals with anxiety disorders. Proper recognition and management also help to prevent common secondary disorders, such as depression and abuse of drugs and alcohol.

Wikipedia

I am guessing that at the age of 44 my prognosis would be poor or worse. However, some of my attempts to manage my anxiety over the years seem at least somewhat creative and/or brave.