Dear Ann Landers,
am writ-ing in the hope of reaching "House-bound" and others who are afraid of crowds, other people, and have a host of fears that can't be described. My life was good. I had every human comfort. There was no logical reason for me to have attacks of panic. But for a long time I was afraid to go anywhere for fear I'd faint or be hurt by some unknown force. It is impossi-ble to describe the tortures I suffered because none of it makes sense. I went to two psychiatrists. They didn't help me. I joined another church. It made no difference. Then a neighbor suggested Recovery, Inc. I thought, "What do I have to lose?" So I went to a meeting. It was like a mira-cle. Suddenly I knew I was going to make it. For the first time someone got inside my head and said, "You are not the only one with this problem," and told me what to do about it. Because of Recovery, Inc., I realized I had "agoraphobia." At last my fear had a name and I knew what I was fighting. Today I am able to go anywhere. I love life. I'm free of fear. I'm a new person. Please, Ann, I know you've mentioned this grand organization in your column before, but do it again. It- SAVED ME

DEAR SAVED,
Thank you for re-minding me to recommend, once again, Recovery, Inc. There are hun-dreds of chapters all over the United States, 70 in Canada, and eight in Puerto Rico. It costs nothing. Look in the phone book. Recovery, Inc. is for men and women who feel they need help with emotional problems of all types. Their record of success is fabu-lous. What more can I say? This piece was written especially for the Encyclopedia by Dr. Claire Weekes, M.D., D.Sc., F.R.A.C.P. Dr. Weekes is the world's foremost authority on agoraphobia. She has written three books, Peace from Nervous Suffering, Hope and Help for the Nerves and Agoraphobia. When I recommended the first two books in my column, I was inundated with letters of appreciation from readers. A woman from Oregon wrote, "This is the first thing I have ever read about my illness. It has kept me in the house for years. I had no idea the problem was so widespread. God bless Dr. Weekes." Another reader, from Lansing, Michigan, wrote, "I have read both of Dr. Weekes' books and they have given me a new lease on life. I can't thank you enough for recommending them." Agoraphobia is sometimes referred to as the fear of open spaces. It could more accurately be defined as a condition in which a person suffers incapac-itating fear when away from the safety of home, particularly in crowded or isolated places where he cannot make a quick escape or get help immediately should his fears grow beyond him. This includes fear of traveling in a vehicle, especially one he cannot stop at will. In crowded places, such as a restaurant, church, school, or at a sports event he sits always near the exit "just in case." The term "agoraphobia" comes from the Greek word agora meaning a place of assembly (for example, the market place), the term "phobia" from the Greek phobos meaning flight or panic. The word "agoraphobia" was first used by C. Westphal in 1871. Agoraphobia is more common than one would suppose. It is estimated that approximately one million people suffer from it in the United States. More women than men are agoraphobic. In a survey I made in 1973 on 528 agoraphobic men and women in Great Britain and Canada, only 9 percent were men. Agoraphobia develops more naturally in women because their work at home provides the opportunity of shelter. The majority of agoraphobic women (approximately 78 percent in the survey) are housewives. Men working away from home must make the effort to leave the house daily, and therefore do not easily develop agoraphobia. If they do, they often express it as a city-bound executive syndrome; that is, they avoid traveling to other cities and some even refuse promotion if it means leaving their home town, even occasionally. Agoraphobics complain of a variety of fears: fear of a panic attack, of collapsing, fainting, having a weak spell, of being "paralyzed" in the street, fear of entering a shop, of standing in a line at a check-out counter, feelings of unreality, loss of confidence, of harming others (especially a child) and depression. Some complain of general (free-floating) anxiety without specific cause. Agoraphobia has no known single cause. Sometimes it follows a distressing or dramatic event. Example: The woman as a child tended to wander away from her mother. Once, when she was eight, she wandered away from her family at the beach. To teach her a lesson, the parents disappeared. Her panic started her agorapho-bia. Later her father had to take her to and from high school. Married, with two children, she was dependent on her husband to take her everywhere. Precipitating causes of agoraphobia, given in order of frequency, in the 1973 survey were: physical illness following a surgical operation, difficult confinement, tuberculosis, infection, arthritis, domestic stress, loss of a loved one, difficulty or pressure at work, dominating parent or parents, strain of looking after an elderly parent, an alcoholic parent, a sudden occurrence of frightening symptoms while moving about socially (panic, giddiness, weak-ness, palpitations and so on). A few agoraphobics could give no cause for their illness. Of the 528 people in the survey, only 5 (not even 1 percent) mentioned sex as a problem. In other phobias, extreme anxiety may occur in specific situations, but agoraphobics are subject to spontaneous panic even in the home. One patient described an attack this way: "I was sitting at home, enjoying TV and really feeling good. All of a sud-den I had an attack. I was sweating; my heart was palpitating; I felt as if I were going to die." During the last ten years, agoraphobia has been much discussed on radio, television and in newspapers and magazines. Ten years ago, doctors were pessimistic about a cure. However, since using the practical approach of tak-ing the agoraphobic into the places he fears and teaching him how to cope with them, cure is now frequent, especially since the introduction of treat-ment by remote direction: LP recordings, cassette tapes that can be played while the sufferer is trying to venture out alone. In my experience, the great majority of people who become agoraphobic are first in an anxiety state. Their agoraphobia arises from this. So, to under-stand agoraphobia, one must understand the anxiety state. Most anxiety states are of two kinds. One is relatively straightforward and the sufferer is mainly concerned with his symptoms, the way he feels. He has minor problems only, such as inability, because of his illness, to cope with re-sponsibilities. He may be happy at home and at work (even happy in his sex lifel). The second is caused by some serious conflict-sorrow, guilt or disgrace. The continuous tension of prolonged anxious introspection sensitizes nerves, just as a sentry on guard becomes sensitized to the slightest noise. Indeed, our subject may eventually be more concerned with the upsetting symptoms -the state he is in-than with his original difficulty. Three main pitfalls can lead to an anxiety state and then into agoraphobia. They are sensitization, bewilderment and fear. By sensitization I mean a state in which nervous and emotional responses to stress are greatly exagger-ated and may come with alarming swiftness. In a severely sensitized person, nervous reactions to stress can be so sudden, the sufferer may think they come unbidden, as if (in the words of some patients) some "thing" was doing this to him. There is no mystery about sensitization. Most of us have felt mildly sensi-tized at the end of a day of tension when our nerves are on edge and little things upset us. It's not pleasant but we don't take it very seriously. However, severe sensitization (such as the nervously ill person experiences) can be much more distressing. A severely sensitized individual may feel the symp-toms of stress so intensely that an ordinary spasm of fear may seem like a whipping, almost like an electric flash of panic. This can be terrifying because panic can flash in response to the slightest shock-simply tripping in the dark -or it may flash for no apparent reason, "out of the blue." To understand agoraphobia one must appreciate the severity and swiftness of the panic that sensitization brings and also understand how, reinforced by bewilderment and fear, the original sensitization may increase so that one flash of panic may follow the other, each flash mounting in intensity. This is why an agoraphobic is reluctant to go where he thinks panic may strike; why he sits at the back of the hall or church, always near the exit. In this article, I will use the term "sensitization" to mean the exaggerated sensations and intense emotional responses found in people in an anxiety state as opposed to the ordinary mild sensitization that most people under stress experience from time to time. The sensitized (and by now I mean the severely sensitized person) may complain of any or all of the following symp-toms: "thumping" heart, "missed" heartbeats, pain around the heart, con-stantly, quickly beating heart, attacks of heart palpitation, giddiness, "lump" in the throat, difficulty in expanding the chest to take in a deep breath, hyperventilation, blurred vision, aching muscles, churning stomach, intes-tinal discomfort. Above all, he may suffer from flashes of intense panic and, if away from the safety of home, have an almost overwhelming desire to re-turn as quickly as possible. To these symptoms of acute stress, the symptoms of chronic stress may be gradually added: fatigue (physical and mental), loss of appetite, headaches, sleeplessness, depression. It is important that the doctor and patient recognize that an anxiety state may be not so much the mere presence of the symptoms of stress as their ex-aggeration in a sensitized body. Usually people become sensitized either suddenly, as a result of a sudden shock to their nerves (as mentioned earlier, a surgical operation, accident, heavy hemorrhage, difficult confinement and so on), or more gradually, from prolonged stress (debilitating illness, too strenuous dieting, living or working with a stressful life-situation and so on). A woman debilitated after an exhausting surgical operation may find minor shocks, such as the slight impact of a tray against the end of her bed, shoot through her "like a knife." The strain of simply waiting for visitors to arrive (or leave) may seem unendurable, as if her nerves are stretched like rubber bands. She may be so upset by such experiences that she will worry about them constantly. The added strain of apprehension about coping with house-work or a job, should she feel this way when she returns home, may further sensitize her nerves until the spasm of fear becomes a flash of panic. She is caught in the cycle of sensitization-bewilderment and fear-more sensitiza-tion. The state is now set for the development of agoraphobia. In my experience with hundreds of agoraphobic patients, the feeling of panic is the symptom above all others that keeps the sufferer a prisoner in his own home. If the sufferer is a woman with no necessity to leave the house, she may so consistently avoid going out that she may gradually become too afraid to go as far as the clothesline to hang out the laundry. She may be to-tally dependent on others, even a child, to do her shopping. Some women will venture out if they push a baby carriage to support themselves or they will wear dark glasses even if it is raining. Somehow they feel the glasses protect them against people who want to come "too close." Reluctance to leave the house may be further established if, on plucking up the courage and going out alone, her apprehension about panicking, her struggle not to panic, brings the stress that invites the very panic she fears. She usually returns home quickly and, from then on, becomes adept at mak-ing excuses to avoid leaving the house. As one woman said, "We become wonderful liars!" I have known women to cling to home for years, twenty or more, and so well have they hidden their fears, their family has been only vaguely aware of their disability. Far from being dependent types, as agoraphobics have been sometimes de-scribed, many show remarkable courage and independence, fighting their fears, often with little help from their families and, unfortunately, sometimes without adequate understanding or explanation from their doctors. Treatment lies essentially in explaining sensitization and teaching an agoraphobic person, indeed most nervously ill people, that his symptoms are those of stress exaggerated and are kept alive by his fear of them. To put it simply, by being afraid of the symptoms of fear, he puts himself in a cycle of fear-symptoms-more fear. He must understand this and be taught how to cope with his symptoms until he is no longer afraid of them, especially of panic. It is not enough to tranquilize symptoms away. The little tablet be-comes the crutch and the patient remains bewildered and basically afraid. The only way to permanent recovery is to teach the sufferer how to cope with panic and all the other symptoms-indecision, suggestibility, loss of confidence, feelings of unreality, possibly obsession and depression-so that he loses his fear of them. The agoraphobic should also be taught to expect and cope with setbacks, because setbacks, particularly in recovery from agoraphobia, are so common. He should understand that he learns as much, if not more, in coming through a setback as when in a good spell. So much depends on a therapist's ability to explain the nuances of this strange illness: for example, to explain why, when the sufferer is feeling bet-ter, setbacks can come for no apparent reason and yet be so devastating, as if no progress had been made at all; to explain why symptoms thought forgot-ten can return acutely after months, or years, of absence; why all the symp-toms can so quickly appear; why such demoralizing exhaustion can so rap-idly follow the return of symptoms; why, despite the right attitude, sen-sitization may sometimes linger. Some people recover when they get no more than a good explanation of their symptoms. It is a revelation to learn that the symptoms they thought were unique to them are no more than the symptoms of stress exaggerated by sensitization, and kept alive by their fear of them; that fighting their symp-toms and not accepting them has been creating the tension and kept them ill. One woman said, "I did not know it could be so simple! I feel like I have been let out of prison!" credit: Dr. Claire Weekes, M.D., D.Sc., F.R.A.C.P., Consultant Physician, Rachel Forster Hospital, Sydney, Australia. Alcoholism SHARING TODAY