Agoraphobia Recovery

A laymen's guide

Note – This is an early draft and will be a continual work in progress.

Intro

Agoraphobia has been the main thing in my life. I don’t mean the main problem, I mean the most consistent, salient thing. Jobs, relationships, health, school, money, whatever - everything else is a side note. That’s what it seems like at least.

It didn’t have to be like this. I got bad advice, and I didn’t trust the good advice. The good advice sounded like they just didn’t get it.

Turns out, I was the one who didn’t get it. Well, now I do get it. I see why I got so bad & I understand how I got better. If I met my 20 year old self, I could’ve gotten him out of this in a few weeks. I started writing whatever this is with him in mind.

If I get this right, it’ll have everything my 20 year old self would have needed to get over this.

I hope this gets to someone else in that same spot.

The Cure

The Only Winning Move Is Not To Play

The way out isn’t easy, but it’s not a mystery. I think the simplicity makes it harder to trust. This section alone won’t be enough to convince you, but it’s important to keep in mind what the cure actually is & not overcomplicate it. It’s the hardest thing I’ve ever dealt with—so don’t interpret this as me saying “just get over it, bro.” I’m with you, but we’ll get there.

First, Drop the Shame

This isn’t your fault. Your brain wiring combined with your experiences brought you here. You didn’t choose those things. You’re not weak-willed, you’re not a coward. This can be hard to understand from the outside. The people giving you shit about being a shut-in care about you; they want you healthy and happy. They just can’t understand why you’re so scared of going out with a tummy ache or whatever. The advice here will sound annoyingly similar to shit these people have been saying for years. Keep an open mind.

Panic attacks are uncomfortable, but not dangerous.

Agoraphobia hijacks the fight/flight response—there is no way to experience panic without believing you’re in danger, by definition. That doesn’t mean there actually is danger; that’s just how this works. You will not panic yourself into a heart attack, psychosis, fainting, losing control of the car, etc. The feelings will appear, intensify, peak, and wash away.

No, yours are not different. I know, I know—trust me, they’re not.

Trying to make the feelings go away makes them worse. This is avoidance. Stop all attempts to feel less anxious. No breathing exercises, ice water, meditation—nada. There’s a time and place for all that, but it’s not while you’re in the habit of avoidance.

Test it. See what the feelings can actually do if you don’t avoid them. Puking is probably the worst of it. So what? Swish some water and change your shirt. The part of your brain that creates these feelings is deaf to thoughts; it only learns through experience. Show it there’s no threat by acting as if there’s no threat. Changing your behavior is the cure. The feelings will dissipate, but it’ll take longer than you think, and praying for that day to come is avoidance. The good news is that even the worst panic attacks aren’t that bad when you don’t resist. This is a skill, and it takes practice.

Why Should I Listen to You? If you’re gonna say it’s that easy, you obviously don’t understand what this is like.

Good question.

First of all, I never used the word easy, I said simple. You’re trying to override the the impulse that evolved to keep you safe by any means necessary. Ignoring that might be the most counter-intuitive thing a person can do. What you’re feeling when you go outside is the same thing people feel with a gun to their head. What I’m telling you to do is simple, possible, and effective. But definitely not easy.

This isn’t about me, but my credibility is in my experience, so I’ll do a quick overview of my history with all this.

Timeline

Things I Tried (That Didn’t Work)

My symptoms

A Few Lowlights

A few times I Was Sure It Wasn’t Anxiety

So we’re talking 20 years of crippling agoraphobia, 7 years on benzos. And now I’m 100% fine.

No, I’m not a therapist. I’m not the best writer. I have no aspirations to be some sort of coach or authority figure. There are plenty of reasons not to listen to me. But me not getting it is not one of those reasons.

How do you know nothing’s wrong when it feels like something’s wrong? Food poisoning and panic attacks feel the exact same to me. Or when my throat feels like it’s closing, it literally feels like it’s closing. I never know what it is until way later. You expect me to just go out feeling like that? Just ignore it?

Ignore might not be the right word, but yeah. Sorta.

When you’re panicking, there’s no way to know with 100% certainty that what you’re feeling is just anxiety. Certainty doesn’t exist. But you’re mixing up two different things:

Tolerance of discomfort vs. A sense of actual danger

Let’s start with danger.

Panic attacks can mimic almost any medical condition. Chest pain, nausea, dizziness, numbness, throat closing—whatever. If you’re having a new or alarming symptom, go to the doctor. Maybe even go to the ER. I’ve had multiple EKGs, and I don’t regret any of them—even when it turned out to be nothing.

That’s the right move: get checked out. Get tests done. Rule out the big stuff.

Tell the doctor what’s going on. If they blow you off, insist. If you’re not convinced, get a second opinion. But once you’ve ruled out the big stuff, you have to stop treating every symptom like it’s life-threatening.

That’s the trap. That’s how you teach your brain to freak out at every twitch, every tight breath, every stomach gurgle.

The more inappropriate medical reassurance you seek, the worse your symptoms will get. Every time you go looking for proof that you’re safe, you’re training yourself to believe that you’re not.

Let’s say you rule out the throat closing issue. You’ve done the allergy tests, you’re not gonna go into anaphylactic shock. Your tonsils are fine. What are you supposed to do the next time you get that feeling?

Accept and allow. Ok, my throat feels like it’s closing. There is no good reason this would ever happen, and you know panic can cause this.

Attention amplifies sensation.

You ever done a bodyscan meditation? In a bodyscan, you work your way around your body, paying attention to every part, one at a time. The crown of the head, forehead, ears, eyes, nose, feeling of breathing through your nostrils, cheeks, neck, and so on.

Try this right now: Sit still and place all of your attention on your left thumb. What’s the temperature? Is there a breeze hitting your thumb? Do you feel any pressure? Is it resting on your index finger? Do you feel the weight of it? Close your eyes and place your attention like a spotlight on your thumb for 10 slow breaths.

When I do that, it feels cold. It almost throbs, I can feel my blood pumping through my thumb with each heartbeat. It feels swollen, like I dropped something on it a few minutes ago.

That would drive me up a fucking wall if I kept my attention there for long enough. You turn the knob up on the sensations the more you pay attention to them.

There’s nothing going on with your thumb.

When you panic over a new sensation, you’re throwing rocket-fueled attention on it. One of the main functions of adrenaline is to focus our attention intensely on one thing - usually a threat - so we can respond accordingly.

So combine the sensations caused by adrenaline, with the rocket-fueled attention on that sensation, PLUS cognitive worries over what this sensation could be, and you end up with an incredibly good illusion of a serious issue.

So you’re telling me just to get my mind off of it. How? I can’t just stop thinking about it when I feel something like that.

Don’t picture a pink elephant.

No, that doesn’t work. You can’t remove thoughts. You can kinda replace them by deliberately paying attention to other things, this is where grounding exercises can help. A common one is to look around and name 5 things you can see, 3 things you can hear, and 2 things you can feel or something like that. That kinda works as a grounding exercise, but there’s a fine line between grounding and distraction(avoidance).

The solution is to accept and allow. To steal a mantra from Barry Mcdonagh - “I accept and allow these anxious feelings, I accept and allow these anxious thoughts”.

If your throat’s gonna close, let it close. You already know you don’t have any medical issue that would cause that to happen. This is the adrenaline-attention-sensation spiral. This sensation in particular is so common, it has it’s own name - Globus Hystericus.

Ok fine, that might work for things like chest pains and dizziness, but I literally throw up from anxiety sometimes. I feel sick to my stomach. I need to rush to the bathroom or I might shit myself. How could all these stomach issues just be in my head when they’re physically happening?

Very good question. First of all, what’s so bad about throwing up? Aim for a bag, clean yourself off, move along. Yeah it kinda sucks, but living a normal life where you puke at inconvenient times is far better than living in fear of the possibility of that happening. This is part of acceptance. Life can be uncomfortable. Later we’ll talk about re-defining recovery and getting a better understanding of what it actually feels like to be normal. Normal is by no means comfortable.

Something psychological being “just in your head” is a lazy misnomer. The mind and body are one system and emotions manifest physically. Anxiety is mostly a physical state. Psychogenic is the better term, which just means the origin is psychological.

How the adrenaline-attention-sensation spiral affecst the gut is known as visceral hypersensitivity..

In normal digestion, your intestines stretch (distention) when food is pushed along. Somtimes, the distention is big enough to trigger pain and an urge to shit, even when the rectum is empty. Think of when you’re about to get in the car but sprint to the bathroom one last time in an emergency, then sit down only for nothing to come out. Then you go back out to the car and get hit with the urge again.

People with IBS (very common diagnosis with agoraphobes) have a lower distention threshold than people without. So low in fact, that the nerves send a pain and “uh oh gotta shit now” signal to the brain, even when distention is in the normal range of normal digestion.

They figured this out by shoving balloons up peoples asses and inflating them to different degrees. People with IBS report pain at way lower inflation levels than people without it.

When you’re anxious and your mind is on your gut, these nerves get hyper sensitized. Adrenaline also speeds up the food transit by increasing muscle contractions in the intestines, which can lead to diarrhea. It also pulls blood away from your core and into your limbs, which can fuck up your digestion and make you puke if your stomach is full.

This is all normal, safe, well understood physiology.

So all the stomach issues you’re plagued with are not signs that you have food poisoning and need to cancel the trip. It’ll come and pass in waves.

That makes sense to me now, while I’m calm sitting at home.
But as soon as I try to go do something, I’m gonna panic and forget all of this.
I can’t just ignore the sensations—they’re overwhelming.

Yeah, of course. Understanding what’s happening is just the prerequisite to the cure, it’s not the cure. Bridging the gap between knowing and doing starts with a concept called defusion.

Defusion (In Two Senses)

“Defusion” is kind of a double entendre here.

In Acceptance and Commitment Therapy (ACT), cognitive fusion is when you’re completely wrapped up in your thoughts.
You’re fused with them. There’s no space between you and what you’re thinking.
You can’t step back or intervene.

Cognitive defusion means creating some mental distance.
Widening your view. Stepping back. Detaching. Watching the thought instead of being the thought.

In the DARE response method, D stands for Defuse in a different way—like defusing a bomb. Defuse the threat by saying “ok…and?” to every fear.

Your throat feels like it’s closing?
Nope. It just feels like that. That’s a specific medical condition you don’t have. It feels a little tight, ok and?

You think you’re gonna pass out while driving?
Nope. Anxiety raises blood pressure, fainting is caused by a drop in blood pressure.

You feel like you’re gonna puke?
You might. So what? Puking is a safe, normal bodily process. Unpleasant? Sure. Dangerous? Nope.

To get better, you need to defuse in both senses of the word.

You create space from the thoughts and feelings by observing them, and you disarm the threat by calling it’s bluff.

That’s how you bring your rational understanding of safety into a moment of panic.

“You’re just telling me to calm down in different words. How is this supposed to be helpful? The waves don’t come and go. I’m in a constant state of terror & sick to my stomach until I get back home. Even when I rationally know I’m safe and it’s just anxiety, the feelings are overwhelming. This would not work. ”

We think of the key, each in his prison, thinking of the key, each confirms a prison.”

Now we’re onto tolerance of discomfort.

Panic does come and go in waves, but the fear of the next wave coming can keep you in panic mode. It’s like a chinese finger trap. Pull out as hard as you can, you won’t get out. Push in, and the grip loosens, allowing you to easily slide your finger out.

Story time: I tried to follow this approach for years and thought I was doing it right. I saw progress, I was doing more shit, but it was still kind of a nightmare. Stomach all fucked up, irritable, was completely wiped out for the rest of the day.

My first glimpse into real acceptance happened on accident.

My girlfriend at the time dumped me, the anxiety was probably the main reason it wasn’t working. I was wrecked. I booked a flight both to get my mind off the break up and to confront the anxiety.

After take off I got hit with a level 10 mega panic attack. I couldn’t catch my breath, spinning, dryheaving. There was crazy turbulence, I got this cracking sensation in my chest. After the crack, an ice cold liquid felt like it was spreading throughout my body. I was sure it was internal bleeding and I was about to die. I was still so depressed, I didn’t really care.

Not to say I lost my will to live or was suicidal or anything like that - but I thought fuck it, guess this is it. Oh well.

The cold liquid turned warm. The panic washed away and was replaced by a sense of relief so strong it was almost euphoric. It was like I popped a molly or something. I was giddy, giggling like a fucking psycho next to strangers.

When I returned to baseline, I thought “ooooohhhhhhhhh woooooooaaaah that’s what acceptance is.”

What I had been doing before was white knuckling and seeking comfort.

Acceptance has to be experienced to be understood. You have to kinda get a feel for it, but then you can’t unsee it.

Ok, good for you. I’ve tried to accept the feelings, they don’t just go away like that. My panic attacks are different. They’re completely overwhelming, and sometimes can be traumatizing. I’m worried that I’ll get on a plane or something and have a panic attack so bad that I have a major setback and get even more scared of going outside.

We’re back to the illusion of danger. Except now it’s not about the physical symptoms, it’s about losing your mind. It’s still the same exact process. Hate to break it to you, this is still run-of-the-mill panic attacks. Which means the answer is still accept and allow. We can play whack-a-mole with every symptom and every delusion you want.

Panic attacks are not dangerous physically, or psychologically. Let’s talk about the word “traumatizing” though, because you do have a point.

Trauma is a big word that’s been thrown around a lot. But all trauma means is an experience so distressing that it leads to lasting changes in our thoughts, emotions, and/or behavior.

The first major panic attack in the start of panic disorder probably qualifies as a traumatic event by definition.

Neuroplasticity is another big word thrown around, all it means is that your brain adapts. Adaptations aren’t necessarily good or bad, they’re just a change.

The more emotionally significant(traumatic) a situation is, the less repetitions it takes to lead to lasting change. The higher the stakes (real or perceived), the more adaption takes place.

So, when you’re in a panic attack, the behavior that follows is very strongly imprinted and becomes a lasting change. Whether that behavior is avoidance or acceptance, it’ll leave a mark.

This is why exposure is so effective, and all non-exposure exercises are not. Well, not on their own at least.

A setback comes from avoidance during high stakes. Growth comes from going through it. Eveything you do is habit forming. You vote for the person you’ll be and the behaviors you instill with every single thing you do. This is partially why cross-culturally, religions have the idea that “God is always watching and judging, then rewarding or punishing”. Divorce that concept from the control and political games many religious insitutions push, and think about it symbolically.

Your behavior matters, it’s one link in an infinite chain of events. Things beget more of the same.

Ok back to pragmatic, rational land:

The traumatic power of a panic attack is just because it’s fertile ground for neuroplasticity. Run away, you’ll want to run more. Face it, you’ll be able to face it more.

A setback is not set in stone, you can undo it with one successful bout of exposure.

So look at the “traumatizing” nature of your panic attacks as an opportunity to quickly make lasting change.

“But I can’t handle all the feelings. I will run away if it gets bad enough. So I’m right in thinking that it could be harmful for me to be in a situation I’m not ready for. How am I supposed to act like this is harmless if backing out during a panic attack is harmful?”

This is the reason gradual exposure tends to be more effective than flooding.

Gradual exposure works by starting low and working your way up in manageable steps. Flooding is goin fuck it yolo and chucking yourself into a situation you’re genuinely not ready for.

If you haven’t left your house in months, don’t get on an international flight. You could spaz out and think “I WILL NEVER GO OUTSIDE AGAIN FUUUUCCCKKK THIS”.

Gradual exposure helps you build up the confidence.