Carol Watkins is a board-certified psychiatrist. She has written numerous articles on the treatment of anxiety disorders in children and adults, and maintains a website on anxiety issues.

David Roberts: HealthyPlace.com moderator.

The people in blue are audience members.

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David: Good evening everyone. I'm David Roberts. I'm the moderator for tonight's conference. I want to welcome everyone to HealthyPlace.com. Our topic tonight is "Anxiety and OCD Medications." Our guest is psychiatrist, Carol Watkins, who is board certified in adult and child psychiatry. She is a clinical assistant professor of psychiatry at the University of Maryland and maintains a private practice in Baltimore, Maryland. She is the author of many published psychiatric papers and a frequent lecturer at workshops and seminars. Dr. Watkins has also written numerous articles on the treatment of anxiety disorders in children and adults, and maintains an active online resource site dealing with anxiety, that you can locate here.

Good evening, Dr. Watkins and welcome to HealthyPlace.com. We appreciate you being our guest tonight. We get a lot of email that goes something like this: "I've tried 3-5 different medications for my anxiety or OCD and nothing seems to work." Why is it that psychiatric medications work for some but not for others?

Dr. Watkins: Each person is different, both in personality and in their individual biochemistry. Some people have different rates of metabolism based on differences in their liver metabolism. On the personality side, people have different attitudes and expectations of medication.

David: What is a reasonable expectation when it comes to the performance of an anti-anxiety medication?

Dr. Watkins: A certain percentage of individuals of each ethnic group may have different enzymes that metabolize a particular medication. It depends on the subtype of anxiety. For OCD, you might expect a 50-70% positive response with medication. Higher, if combined with the appropriate psychotherapy.

David: And for an anxiety disorder or panic attacks, what can one expect?

Dr. Watkins: For panic attacks, I would expect a similar response rate. I often start with smaller medication doses for panic than for Obsessive-Compulsive Disorder. For generalized anxiety, I expect a lower medication response and emphasize therapy in addition to the medication.

David: If you are suffering from an anxiety disorder, would you recommend medications as a first line of treatment, or would you say to the patient, try therapy first and if that doesn't work, then we'll talk about anti-anxiety medications?

Dr. Watkins: It depends on the situation. For adults, I discuss both options. If the symptoms are mild, I am more likely to go with therapy first. If severe, I often recommend starting with medication and therapy simultaneously. For children, I am more likely to recommend a course of therapy first. However, in some cases, if the anxiety symptoms are pervasive, or if the child refuses therapy, I might start medication right away.

David: I know you are a psychiatrist, but I'm wondering what your thoughts are about a person going to see their family doctor and having that doctor dispense medications for their anxiety disorder versus seeing a psychiatrist to be treated?

Dr. Watkins: In some cases, there are primary care physicians who know the patient well, maybe for decades. The physician might know and treat the family too. If the doctor has the time and expertise, then it is OK. If the doctor is busy and can only allot a few minutes, it is better to refer. If the person does not respond well to the first treatment, then a referral is also a good idea. I deal with some primary care physicians who know me and have a good sense of when to refer on to a psychiatrist.

David: We have a lot of questions, Dr. Watkins, and then we'll continue with our conversation.

Sharon1: How do you feel about Serzone as a treatment for panic disorder?

Dr. Watkins: I prefer to start with an SSRI, such as Zoloft (Sertraline) or Luvox (Fluvoxamine) and reserve Serzone if the person has side effects on an SSRI.

sadsurfer: What do you think of alternative medicine, such as acupuncture or massage therapy alone to reduce anxiety if one wishes to come off medication?

Dr. Watkins: Some people get good results with acupuncture. One should also realize that many people get good results with cognitive behavioral therapy or hypnosis without using medications at all.

David: So are you saying that hypnosis and acupuncture are legitimate treatments for anxiety disorders?

Dr. Watkins: I believe that hypnosis, cognitive behavioral therapy and some other forms of therapy are legitimate. I am not an acupuncturist, but I have seen some good results. I do get concerned when some acupuncturists go on to prescribe herbal preparations without checking with me to make sure that they are not interacting with my medications. This can be dangerous.

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auburn53: Can hypnosis work by using tapes or do you think you need to have it done in an office?

Dr. Watkins: Some people get good results with the tapes. I prefer to do it in my office to see what technique works best and then make the person a custom tape. It is best though if the person can do self-hypnosis without a tape. More portable.

ninas: Hi David. Is there any way to wean off Clonazepam? Why are my panic attacks cyclical?

Dr. Watkins: If you go off the Clonazepam (Klonopin), do it gradually and with medical supervision. It may take a few months if you are on a large dose. Substitute something else like another class of medication or a form of psychotherapy to get you through.

David: What side effects can one expect if they suddenly decide to withdraw from some of these medications?

Dr. Watkins: Don't suddenly go off a Benzodiazepine (Klonopin (Clonazepam), Valium (Diazepam), Xanax (Alprazolam), Ativan (Lorazepam) etc.). You could get seizures or maybe just feel jittery and anxious. A slow taper is a good idea especially if you have medical conditions or are on other medications.

LISA R: I've been given Topamax for Panic Disorder; however, I've yet to find anyone taking this medication for Panic Disorder. Is this a commonly prescribed medication?

Dr. Watkins: I have never used it for Panic. I have heard of it as an adjunct for Bipolar Disorder.

GreenYellow4Ever: What benefit do you see in making a combo of anti-depressant and anti-anxiety medication?

Dr. Watkins: I prefer to use an SSRI medication such as Zoloft or a medication such as Effexor XR (Venlafaxine). If the person needs something immediate, I will start a Benzodiazepine until the SSRI kicks in. I may also add a benzodiazepine (Klonopin, Xanax etc.) in cases where the first-line drugs do not work completely.

madi: I just had my Prozac dosage raised and it seems like I am going through side-effects again. Is that possible? It seems like the OCD symptoms are worse because I feel so hyper.

Dr. Watkins: Some people can get a restless feeling, called Akathesia from SSRI medications such as Prozac. I have seen it more in Prozac because it is a little more stimulating than some of the other medications in its class. You might talk to your doctor about a switch to another SSRI medication, or you might back off the dose. Sometimes a low dose of a beta blocker (Propranolol, Atenolol) can block the jittery feeling.

Kerri20: What happens when someone can not take medication due to bad side-effects or even allergic reactions, but therapy is just not enough?

Dr. Watkins: Sometimes, you might start back on medication at a very low dose. I see a lot of people who are sensitive to medications. I use a lot of liquid SSRI medications. Then I go up slowly. I once tasted several of them for the benefit of my pediatric patients. Taste matters to that group. Liquid Paxil tastes best. I haven't tried liquid Zoloft yet. If the jitters bother you, a beta blocker, or a Benzodiazepine might help.

vcarmody:Q: Please speak to significance of Clomipramine at 25mg on a twelve year old child. How significant a dose in suggesting severity of OCD?

Dr. Watkins: I don't always see a correlation between dosage requirements and severity of the disorder. I measure it based on improvement and side effects. Often that would be a low dose, but I don't know if the child is a slow metabolizer.

flowerchild: What is a good medication for panic disorder for someone who is sensitive to meds?

Dr. Watkins: It would depend on the nature of the sensitivity. I sometimes use Zoloft in low doses for adults. In children, I often start with Luvox.

ponder8n: I've read that Benzos can become addictive very quickly. Any comments?

Dr. Watkins: Not always. I am probably more stingy with Benzodiazepines than some of my colleagues. If a person has a tendency toward addiction, I am more cautious of the Benzos. However, I have some people on them who do not display the psychological characteristics of addictions. It depends on how and why you prescribe the Benzodiazepines. If you use them cautiously and do not continuously bump up the dose, they can work well.

David: Some of the medications, like Prozac, that are being mentioned are for depression. And some members of our audience would like you to talk about the connection between anxiety, OCD and depression.

Dr. Watkins: Medications like Prozac and the other SSRIs do help with depression and anxiety and OCD. These disorders are separate entities and may be inherited separately. However, anxious individuals are more likely to get depressed and vice-versa. Often people who have had an anxiety disorder (especially untreated) for a long time, go on to develop depression. In children, I sometimes see anxiety earlier than depression but not always.

Dugan: Dr. Watkins, I am currently taking Celexa, Buspar and am coming off of Paxil because of weight gain. Does this combination of medications have a good success rate for Obsessive-Compulsive Disorder?

Dr. Watkins: Yes, they can work well for OCD symptoms, but you can get weight gain on Celexa (Citalopram) too. Exercise helps with the weight and improves anxiety symptoms too.

madi: Do vitamins have any effects when mixed with OCD medications such as Prozac?

Dr. Watkins: I have not seen any controlled studies (compared to placebo with carefully selected subjects) that show a consistent effect. A balanced diet, at least three meals a day and regular exercise do help.

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hobster: If you were treating a patient who is housebound, with some form of OCD with an eating problem, would you recommend medication, cognitive behavioral therapy, or would you recommend Seroxat?

Dr. Watkins: I do not know what Seroxat is. I would recommend CBT and an SSRI. I might also start a Behzodiazepine. Housebound patients may need a couple of home visits from the doctor or a treatment outreach person until they can get into the clinic. For treatment-resistant anxiety I may augment an SSRI with Lithium, Depakote, or I may use a beta blocker such as Propranolol. MAO Inhibitors such as Parnate and Nardil can be quite effective, but you need to be on a special diet and they can lead to weight gain. They are probably underused. I don't combine the MAOI with other medications in most cases.

David: Just to clarify hobster's question before, Seroxat is the UK name for Paxil.

Kerri20: I did cognitive behavioral therapy and exposure therapy for about three weeks and I found it was working great. I noticed I went down hill after stopping therapy. I guess I want to know what is the average length of time that someone would be in therapy to get the best out of it, or to keep it up, so to speak.

Dr. Watkins: You can have relapses after stopping either therapy or medication. The time frame varies. I usually recommend follow up therapy sessions as "boosters." When I stop the active phase of treatment, I have the patient and often a significant other write down the early warning symptoms. We make plans for what we will do if it starts to come back (anxiety disorder relapses). We write these down and everyone has a copy. Same process for coming off medications.

Cortny9: I am nine years old and I take Zoloft. It has helped me a lot. But my mom and I would like to know if there are long term side-effects?

Dr. Watkins: Paxil is a good SSRI to use for a patient with OCD. We don't have a lot of long term data on Paxil in children. However, physicians are supposed to send in reports of problems with medications. I haven't seen severe long-term side-effect reports.

Brin: Should a nine-year-old be on Zoloft?

Dr. Watkins: Zoloft can be used in children that age with OCD. Each case is individual. I look at a variety of treatment options in a child with OCD. There is a great book, "Blink, Blink, Clop Clop, Why Do We Do Things We Can't Stop?" that explains OCD to children.

David: You can visit the HealthyPlace.com psychiatric medications area, if you are looking for information on a particular medication.

tracy565: Do people with panic disorder need to be on medication all their lives?

Dr. Watkins: Not necessarily. Some people learn techniques to deal with the symptoms. I will taper it in some people and have them step up their therapy while we do the taper.

sgroove63: I've been on Serzone for anxiety and anorexia and bulimia for about a month (up to 200mg). I have had strange side effects. I'm dizzy, spacey, silly, and have a lack of coordination. How serious are these? My psychiatrist also started me on a small dose of Celexa a week ago, I think in anticipation that the Serzone won't work for me. What do you think?

Dr. Watkins: I have had several people who have had those types of symptoms on Serzone. Often, they are the same people who have trouble on Prozac. Celexa might be a good substitute for the Serzone. Ask your doctor if she is planning a substitution or if she intends to keep you on both. You need to use caution if you combine the two.

David: Why, what can happen?

Dr. Watkins: Sometimes, when you use two different medications that act on Serotonin, you can get a buildup of the Serotonin. This can occasionally lead to Serotonin Syndrome, one might get a bit disoriented.

Dr. Watkins: St. Johns Wort, combined with some medications can cause serotonin syndrome too.

Jitterbug: I have recently found that I have severe OCD and I don't like medication. However, I took the advice of my therapist and went on Zoloft. I then heard about Luvox and I was wondering which medication is better for OCD. I am having the hardest time functioning everyday. I'm feeling depressed and need something to help.

Dr. Watkins: Is your therapist also your psychiatrist? I am not keen on non-medical therapists recommending medication, unless the therapist is in very close contact with your psychiatrist. One is not necessarily better than the other. Luvox can interact with some other medications, so I tend to use it more by itself. I like it with children. Celexa may be less likely to interact if you are on a lot of different medications.

btlbaily: I have been on Zoloft for about six months. If I decide to get pregnant, is it recommended to discontinue the medication? And, if so, how long does it take to "wean" yourself off the medication?

Dr. Watkins: Some women do take Zoloft and Prozac during pregnancy, without problems. You need to discuss this with both your psychiatrist and your OB/GYN prior to conception. You should have your medications prescribed by a psychiatrist who is familiar with this sort of thing and who is willing to keep in touch with your OB. You need to go over the risks and benefits of taking the medication and the risks and benefits of going off medication.

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pavanne: What is your opinion of using Buspar instead of Zanax and the like?

Dr. Watkins: BuSpar is less likely to be addictive. However, it takes longer to kick in. If I need something to work really fast, I would go with a Benzodiazepine. However, I like to consider SSRI medications first.

David: Roughly, how long does it take for a medication to be effective?

Dr. Watkins: A Benzodiazepine can be effective in a matter of minutes or hours. An SSRI such as Zoloft or Prozac may take longer (a week to six weeks). BuSpar takes several weeks. A beta blocker may take effect fast, but mostly just covers the external manifestations of anxiety, such as tremor and palpitations. People with stage fright sometimes take a small dose of a beta blocker before a performance to block the tremulousness. If they can control that external part, they may be able to manage the internal feelings.

murkyangel: I've tried over ten medications: Serezone, Welbutrin, Effexor, Trazadone, Buspar, Remeron, Depakote, Zanax, and am currently on 450mg Welbutrin (again), 1mg Risperdal, and usually 10mg valium a day. It's better than no meds, but not really taking away the anxiety during the day (I take the valium at night). Anyway, what else do you suggest? And yes, I've tried therapy and groups and all that other stuff). I'm at my end in all of this and I don't know what to try next. I've tried many combinations of those medications that I listed.

Dr. Watkins: It is difficult to say. It would depend on the subtype of anxiety. It would also be useful to find out what relatives have taken and what helped them. A MAOI such as Parnate or Nardil might be a consideration. You would need to discuss this with your psychiatrist and get counseling about the MAOI diet. No beer, aged cheese and several other things.

terrjohn: Does a person have to be weaned off of Paxil? My doctor just changed my meds.

Dr. Watkins: Some people who stop Paxil suddenly, feel like they have the flu. It feels uncomfortable for some people. Same for Effexor.

terrjohn: How well does Wellbutrin work compared to Paxil for panic and anxiety disorder?

Dr. Watkins: I think that Paxil would generally be a better choice. Wellbutrin is a great medication for some depression and can also help ADHD, but is not as good for panic. I have occasionally seen it make panic worse. I might add Wellbutrin to an SSRI if the person's anxiety was better, but he or she was still depressed and lethargic. I might also add it to help with sexual dysfunction associated with an SSRI.

Veralyn: I am on Paxil and I was on Prozac a few years ago. I have both depression and anxiety with it. What is the difference between Paxil and Prozac?

Dr. Watkins: They are both selective serotonin reuptake inhibitors. (SSRIs). They have the effect of increasing the availability of serotonin between nerve synapses. Prozac tends to be more stimulating and lasts longer. Paxil is likely to be more sedating and wears off quicker. When you stop Prozac, it stays in your system for weeks or more and gradually goes out. Paxil goes out faster. That is why you may need to taper Paxil but not Prozac. A few people get sleepy on Prozac and are more alert on Paxil but they are in the minority.

David: Thank you, Dr. Watkins, for being our guest tonight and for sharing this information with us. We will see you tomorrow night to talk about "Bipolar and Depression Medications". Dr. Watkin's website is here.

And to those in the audience, thank you for coming and participating. I hope you found it helpful. We have very large Anxiety and OCD communities here at HealthyPlace.com. Also, if you found our site beneficial, I hope you'll pass our URL around to your friends, mail list buddies, and others, http://www.healthyplace.com.

Here's the link to the HealthyPlace.com Anxiety Community. Thank you for coming tonight.

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Disclaimer:We are not recommending or endorsing any of the suggestions of our guest. In fact, we strongly encourage you to talk over any therapies, remedies or suggestions with your doctor BEFORE you implement them or make any changes in your treatment.

Samantha Schutz, our guest, is the author of I Don't Want To Be Crazy" a poetry memoir documenting her personal battle with an anxiety disorder and the incapacitating panic attacks that first struck during college.

Natalie is the HealthyPlace.com moderator

The people in blue are audience members

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Natalie: Good evening. I'm Natalie, your moderator for tonight's Anxiety Disorders chat conference. I want to welcome everyone to the HealthyPlace.com website. Tonight's conference topic is "An Inside Look At Anxiety." Our guest is Samantha Schutz.

Ms. Schutz is an editor of children's books. She is also the author of a recently released book: "I Don't Want To Be Crazy" a poetry memoir documenting her personal battle with an anxiety disorder and the incapacitating panic attacks that first struck during college.

Samantha, thank you for joining us tonight. You are now 28 years old and this book is based on your experiences with anxiety and panic during your college days; starting about 10 years ago. Before I get into those details, how are you doing today?

Samantha Schutz: I'm feeling pretty good. I haven't had a panic attack in a long time - months, really. Of course, I still get anxious and get flutters of panic, but they usually don't last very long. I'm also starting a new job in a few days. I'm a little nervous about it, but nervous in a normal way. In other words, it's not giving me panic attacks.

Natalie: Your book, "I Don't Want To Be Crazy" provides real insight into not only what it's like living with anxiety and panic, but also the personal struggle most people face in trying to get the right treatment for an anxiety disorder. The book is specially written for teens, 14 and up, along with their parents, but it's an excellent read no matter what your age. Samantha, why did you target this group?

Samantha Schutz: There were no books for teens about anxiety disorder. (There are of course, many self-help-type books on the subject, but they weren't engaging reads and they didn't make me feel any less alone.)

There are books for teens about drug abuse, depression, rape, suicide, OCD, cutting, learning disabilities, eating disorders...but there were no books about generalized anxiety disorder or panic disorder--ironic since anxiety often plays a major role in other disorders. In short, I wanted representation.

There was also a big part of me that was writing the book because I wished that I had had a book to comfort me and make me feel less alone.

Natalie: What were the first symptoms of anxiety that you experienced and what was going on in your life at that time?

Samantha Schutz: The first panic attack I ever had was after I smoked pot for the first time in high school. I really freaked out. I was pretty sure I was going to die. Or at least have to go to the hospital. I swore I would never smoke pot again . . . but eventually, I did. Sometimes when I would smoke, I would freak out. Sometimes I wouldn't. It never occurred to me that anything besides the pot was responsible for the anxiety.

The first panic attack I had when I wasn't high was right before I left for college. I was shopping for school supplies with my dad and all of a sudden I felt really strange. The ground felt soft. I felt really spacey and confused. It was like everything was moving too fast and too slow at once.

Natalie: As time went on, how did the symptoms progress?

Samantha Schutz: During my freshman year, my first panic attacks were scattered and seemingly without pattern. Although, I did have A LOT in class. But it wasn't long before the attacks picked up speed and I was having several a day. I often felt nervous, not in control of my body, and convinced that I was going to die. As their frequency increased, it became difficult to do normal things like go to class, the dining hall, or parties.

Natalie: What impact did the anxiety and panic attacks have on you?

Samantha Schutz: This is a really hard question. At the time it kept me a bit withdrawn. Not terribly so, but enough to hold me back socially. Luckily, by that time I already had a few very good friends. Academically, I was doing ok. My grades first semester were actually quite good. But mostly I attribute that to the fact that I purposely picked classes that I knew I would like. I knew that the transition from high school to college would be hard (for anyone) and I thought that it wouldn't be the best time to have to deal with hardcore requirements like math. Now, if you want to know what impact panic disorder has had on my life in the overall sense, well..... that's an even harder question. One that I am not even sure I can answer. Would I be the same person I am today? I doubt it. But what would I have been? These are HUGE questions.

Natalie: Your book is called "I Don't Want To Be Crazy". Did you think you were going crazy? Did it come to that?

Samantha Schutz: There was a very short amount of time where I thought that. It was freshman year right before I went into therapy and went on medication. I had no idea what was happening to me and the only explanation I could come up with was that I had gone crazy. At the time I had never even heard of anxiety disorder. No, I never thought that I actually went "crazy". But it was something I was very fearful of. I guess I envisioned "crazy" as something I would or could enter into and never come out of.

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Natalie: And how did your friends, others on campus and family members react to your behavior and illness?

Samantha Schutz: My friends were very supportive. They did what they could, but for the most part they had to just follow my lead. If I needed to leave wherever I was because I was having a panic attack, then we left. If I needed water, then someone got it for me. If I needed to stay up and talk, then there was someone who would stay up and talk to me. I had one friend in particular who was wonderful. She was always there for me. There was also another friend who was diagnosed with an anxiety disorder. Our relationship was interesting. We were really able to help each other, but there is some irony in that. She could calm me down, but not herself. And vice versa. I told a few teachers that I was having problems. The classes were really small and I was worried that they would notice how I was always leaving. I lied and said that I was claustrophobic. Any teacher I told was really understanding and sympathetic.

Natalie: Samantha, many people with psychological disorders, whether it's bipolar disorder, anxiety, depression, OCD or some other disorder, feel as if they are the only one on earth with this problem. Did you feel that way?

Samantha Schutz: Yes and no. Yes, because I couldn't imagine that someone knew the depths of what I was feeling. For me, the anxiety was in my head. No one could see it or hear it. It was mine alone to deal with. That added to it being a solitary experience. But I also knew I wasn't the only one. I had a friend who was going through the same thing.

Natalie: And, at what point did it become apparent that you weren't alone?

Samantha Schutz: I think when I realized that other people I knew were having the same types of problems.

Natalie: I can imagine that it was difficult for you - especially at a time when most kids are trying to figure out who they are and wanting to fit in and here you are standing out. What about depression? Did that set in too? And how bad did it get?

Samantha Schutz: I think once I went into therapy and on medication, some of those feelings went away. But for the most part, I don't think I was very depressed. But then again, this wouldn't be the first time that I appeared one way to outsiders and perceived myself as being another way.

Natalie: After I graduated from college I was REALLY depressed. I was having so many panic attacks and I felt broken and hopeless. I had no idea what I was doing with myself. I was back living in my parents' house. I hadn't found a job yet. Things felt very shaky.

Samantha Schutz: My anxiety and depression were at the worst they had probably ever been. I cut myself off from my friends and almost never went out at night on the weekends. I remember having very serious talks with my parents about going to the hospital. I didn't know what to do with myself. And neither did they. We decided not to . . . but my parents played a big part in getting me out of the house and then back to therapy. I was really grateful for that. I really needed someone to swoop in and take charge.

Natalie: So now we have a sense of how anxiety, panic and depression had a grip on you. I want to address diagnosis and treatment. How long did you suffer with the symptoms before seeking help? And was there any turning point where you said "I really need to deal with this?"

Samantha Schutz: I was in therapy and on medication within two months or so after getting to school my freshman year. The moment when I went for help was almost comical . . . at least it seems that way now. I was in Health Services (I went there a lot in college) and there was a poster on the wall that said something like "Having Panic Attacks?" I know that seems strange, but it's the truth. I can't even be sure I had even heard the phrase "panic attacks" before, but when I saw that poster, things made sense. That same day I made an appointment with the Counseling Center.

After my initial appointments with a therapist I was asked to make an appointment with the staff psychiatrist. It was easy. There was a path. And giving over a bit of control over to my therapist and psychiatrist was comforting after feeling so out of control with anxiety.

Natalie: How difficult was it to find help?

Samantha Schutz: As I said above, it really wasn't. But I don't think that that's the average response. I think people sit with things longer and let them fester. I am thankful that I possess two qualities: being forthcoming about my feelings and being proactive about my health. I believe that these qualities are a big part of the reason that I was able to ask for help.

Natalie: Did you have the support of your family? If so, in what way did they help? And was that important to you?

Samantha Schutz: Being forthcoming about my feelings and being proactive about my health. I believe that these qualities are a big part of the reason that I was able to ask for help. I told my parents about my anxiety disorder around Thanksgiving of my freshman year. I think finding out was a big shock for them. They probably thought I was off having the time of my life at school and when I told them what was really going on I think it really shocked them. They also didn't get to see my panic in action until I was home after my junior year. I think that not seeing me in the middle of "it" might have made it harder for them to understand what I was going through. But when I was having a hard time after my junior year and then again after I graduated my parents were there for me. They were very supportive and tried to get me whatever help they could. It was great having their support.

Natalie: So talk about the road back. Was recovering from panic disorder and depression easy, hard, extremely difficult? On the scale of difficulty, where did it lie for you? And what made it that way?

Samantha Schutz: I think recovery is a great way to describe what I have gone through in the last few years.

For the last few years, whenever I tried to talk about my experience with anxiety disorder, I ran into the same problem. I couldn't describe myself as having an anxiety disorder because I'd gone months without having a panic attack. And I couldn't say I had an anxiety disorder because I still felt its effects. Trying to find the right verb was more than just semantics.

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For many years, having an anxiety disorder shaped nearly every bit of my life- where I went, who I went with, how long I stayed. I do not believe that anxiety disorder can be flipped off like a switch, and accordingly, simply using past or present tense did not accurately reflect how I was feeling. The body has an unbelievable capacity to remember pain, and my body was not ready to forget what I had been through. It was only about a year ago that I settled on saying, "I am in recovery from anxiety disorder."

As far as recovery goes, my life is VERY different than it was when I was diagnosed with panic disorder ten years ago. Since that fall, I have seen more than a half dozen therapists and taken as many different medications. I've had two episodes where I nearly checked myself into a hospital. I have been to yoga and meditation classes, swung tennis rackets at pillows, practiced the art of breathing, tried hypnosis, and taken herbal remedies. I've done things that once seemed impossible- like going to crowded concerts or sitting with relative ease in a packed lecture hall. I've also gone many months at a time without panic attacks or medication. I don't know how to quantify how hard it was. . . but it sure wasn't easy. It was what it was. I dealt with things as they came.

Sometimes times things were good and I didn't have many panic attacks. Sometimes things were bad and I had several panic attacks a day. I just had to always remember that panic attacks always end and that bad days and bad weeks always end too.

Natalie: You tried different treatments, different medications. At some point, did you just want to give up? What motivated you to continue on with seeking treatment?

Samantha Schutz: I don't think I ever wanted to give up. There were sometimes when things looked pretty bleak . . . but I kept trying new meds and new therapists because I wanted to get better. That even though things are pretty bad, there is something they are getting out of feeling bad. There have been a few times that I have felt really depressed and I wanted to feel depressed. It was comforting. I think that at some point I decided I really wanted to get better and that was a sort of turning point for me and I started making more progress.

Natalie: One last question before we turn to some audience questions: You mentioned at the beginning that you are stable and better able to live your life. Are you ever afraid that the anxiety and panic attacks and depression will return? And how do you deal with them?

Samantha Schutz: Sure I do. I am still on medication and I wonder what will happen when I go off it. Have I learned tools to deal with my anxiety? Have I passed through that stage of my life? I don't know. I am really hopeful though.

At the end of my book there is a poem that says a lot about how I felt on this subject. Keep in mind that this poem reflects how I felt several years ago. I am in a house. I am in one room and my anxiety is in another. It's close. I can feel it. I can go to it. But I won't. It still felt like the anxiety was there. That it was close, but that all of the work I was doing (the meds, the therapy) was helping to keep it at bay. I don't feel like it's as close now. I don't feel like I could fall back into it as easily as I once did.

Natalie: Here's the first question from the audience

terrier7: Was there a line of demarcation that kind of separates who you were before the panic attacks/anxiety and afterward or was it a lot more gradual than that?

Samantha Schutz: There is no hard line. I can only wonder how things would have been. It's not like I was very outgoing before and then really shy afterward. I think it could take me a lifetime to figure out how things are different, but even then, is it important to know? And really... I will never know for sure what is different about me. I was diagnosed at such a critical time. I was 17. A lot was changing about me and developing anyway.

Natalie: Thanks Samantha, here are some more questions from the audience.

trish3455: I experienced many different symptoms of anxiety and I worry that maybe it's something serious and not anxiety. I have read many books and it seems I experience symptoms that are not common. Did you experience this?

Samantha Schutz: I know I thought that a lot too. There were times I thought I had some weird illness. There are so many different symptoms and so many different ways that people feel. The important thing is to NOT diagnose yourself. Let a doctor do that.

Debi2848: Does the panic/anxiety attacks embarrass you and you have to leave a family gathering for no reason and can't go back for fear of having a bad attack in front of people?

Samantha Schutz: I think that for a long time I just left where ever I was if I was having a panic attack. So I wasn't there long enough for many people to see what was going on for me. I don't think I felt very embarrassed by my anxiety. I did feel bad that I was putting my friends out and that they left all sorts of places because of me.

sthriving: I have had anxiety and panic attacks for about 7 years now. Things like driving, socializing, etc. I can now do without any hesitation, but I am still on Xanax. Do you think there is anything wrong with having to take medication to enjoy doing things?

Samantha Schutz: Hard question. I remember when I was first thinking about going on medication I was hesitant. The psychiatrist asked me if I would have trouble taking medication if I was diabetic. I said of course not. There have been times when I didn't want to go on meds. Others where I could not swallow the pill fast enough. It depended on how I was feeling. I am sort of in the same boat now. I have been on meds for a long time and am wondering if I should go off. I wonder if I need it? But then part of me wonders if I should stay on. If I am feeling good, why mess with it. But again, I am not a doctor.

It's different for everyone and of course your doctor should have some input into this decision. This does not sound like one decision you should or can make alone.

support2u: I have had anxiety all of my life and recently started having what I would call panic attacks and I start hyperventilating and breath holder. How would someone like me cope with this and how did you?

Samantha Schutz: There is a type of therapy called CBT: Cognitive Behavioral Therapy This therapy is all about teaching you specific ways to deal with specific problems. In CBT a patient might do a lot of breath work on learning how to breathe in a way that will help you calm down. I hope you are seeing a doctor. I know I sound like a broken record. But I can only speak from my own personal experience.

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Neeceey: Did you develop any specific phobias? I have a medication phobia among many others (bridges, crowds, elevators, etc.)

Natalie: Sort of. The thought of passing out scares me a lot! There were also a lot of places I avoided and things that I hated doing because I would have panic attacks. Having a medication phobia is rough. especially when medication is something that can help you.

3caramel: How did you manage to overcome your fears, I am unable to go to restaurants or go on trips and I don't know how to overcome that?

Samantha Schutz: I mentioned CBT before. That might be helpful. There is also something called Aversion Therapy. These therapies give you strategies to deal with your fears.

How did I get over mine? Some of them faded. Some of them are still there. I think what was most helpful was trying to go to places that freaked me out. If I went to a club (a place where I had had many attacks) and didn't have a panic attack, then that was a success. Then, the next time I would be nervous about going to a club, I would remember that I was ok the last time. I would try to build on that.

Natalie: Okay Samantha, the next questions are about your book. How long did it take to write your book?

Samantha Schutz: It took about 2 years from the time I decided to write it to the time I gave it to my editor. But I had many years worth of journals to use for inspiration.

Natalie: Here's the last question. Has your life changed after writing your book?

Samantha Schutz: In some ways it has. I get fan mail from adults and teens telling me how much they love my book and how much of an impact I have had on their lives. I've had people give my book to their kids or parents as a way of explaining what they are going through. It is amazing to know that I am having an impact on people. I also think that writing this book gave me a lot of distance from my experiences and a way to look back on it and make sense of it. I don't think it could be considered closure, but it has definitely helped.

Natalie: I am sorry but we've run out of time.

Samantha Schutz: Thanks for having me!

Natalie: Samantha, do you have any final words for us?

Samantha Schutz: The only thing I can say with certainty is that my commitment to therapy and my willingness to try new medications has made the most difference. I know that it seems hard and it is awful to have to go on and off meds trying to find the right one... but it is worth it. It is also worth it to try new therapists.... it's like a good friendship. Not everyone is the right fit. I am really lucky I am seeing an amazing therapist now and it makes all the difference.

Natalie: Thank you very much for being our guest tonight Samantha.

Samantha Schutz: My pleasure!

Natalie: Thank you everybody for coming. I hope you found the chat interesting and helpful.

Good night everyone.

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Disclaimer:We are not recommending or endorsing any of the suggestions of our guest. In fact, we strongly encourage you to talk over any therapies, remedies or suggestions with your doctor BEFORE you implement them or make any changes in your treatment.

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Ken Strong: is our guest tonight, Ken has not only suffered from panic attacks, agoraphobia, depression, and OCD, but he's also been a caregiver to a good friend who suffered from panic attacks, and agoraphobia.

David Roberts: HealthyPlace.com moderator.

The people in blue are audience members.

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David: Good evening everyone. I'm David Roberts. I'm the moderator for tonight's conference. I want to welcome everyone to HealthyPlace.com. Our topic tonight is "Anxiety Caregivers." Our guest is Ken Strong. Ken has not only suffered from panic attacks, agoraphobia, depression, and OCD (Obsessive-Compulsive Disorder), but he's also been a caregiver to a good friend who suffered from panic attacks and agoraphobia. Ken has written a book on the subject directed towards support people, family and friends.

Good evening, Ken and welcome to HealthyPlace.com. We appreciate you being our guest tonight. You have been on both sides of the fence as sufferer and caregiver. What is the most difficult part of caring for someone who suffers from an anxiety disorder?

KenS: Watching the mental pain they are in is very difficult.

David: Can you elaborate on that for us?

KenS: Seeing them lose their self-confidence, knowing it is really all in their heads and feeling they have lost control of who is running the brain. Also seeing them suffer with panic attacks.

David: What is the responsibility of the caregiver?

KenS: For themselves, or for the person with the disorder?

David: First, to the person with the anxiety disorder?

KenS: Remember, they are probably the primary caregiver and the person with the anxiety disorder needs a solid post to lean on. Especially, one they can trust. Also, they should try and understand the disorder and show empathy where they can. During a particularly bad time, the caregiver may be the only person that the sick one may be able to turn to for support, love, understanding, and assurances that they are not insane and that they are not going to die.

David: For lack of a better term, what are the job duties? What are the things that the primary caregiver does, or can do, to help the anxiety sufferer?

KenS: The most important "duty" is to give needed emotional support, however, there are a number of other things as well. For instance, they should see that the person is getting out as much as possible and help them all they can.

David: Could you be more precise when you say "help them all they can?" A lot of people who come to our anxiety chats want to know exactly what can they do to help?

KenS: There are a number of things which a caregiver can do depending upon the circumstances. However, first, I want to say, that the caregiver must not let the anxiety disorder affect his or her life to the point that they lose their friends, become depressed themselves, etc. To be more specific, they should set ground rules with the person as to how much help they can give. Once that is established, they can help in a number of specific ways.

The caregiver also needs to plan ahead. An anxious person does not need surprises, or last minute changes. If the caregiver is going to the store with the person, then they should just go to the store and not make any side trips. The caregiver should always stick to the plan and remember that the person they are on an outing with, calls the shots. If they have to retreat, then retreat. The caregiver should not make a fuss. As the person learns to become calm again over time, then the caregiver can start making changes.

I could go on all night, but unless there is something specific, the audience can find a lot on my anxiety caregiver site. There, you will find suggestions for many different types of events, etc.

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David: Ken, I imagine it's pretty tough being a caregiver. After awhile, I am sure that the stress of dealing with someone who has a severe panic disorder, can get to you. What are your suggestions for dealing with that?

KenS: Here are some general tips:

1. The anxiety caregiver must remember to look after themselves, because having two people sick will not help.
2. The caregiver must make sure that they are aware that they can only help the person so much. They need to realize that the healing has to come from within.
3. Also, being a very close and available person, the caregiver may get yelled at a lot. They need to realize that this is a way for the person to get rid of stress and anger. However, they don't have to be a doormat or a servant. In other words, they just need to have a thick skin. If the person is overstepping their bounds, the caregiver needs to tell them so, firmly but nicely. It may even be necessary for them to leave the area for awhile.
4. The caregiver needs to make sure that they continue to carry on their life as best as they can. They should keep up the social side, such as finding new activities, or even going out by themselves. Not being able to go out, or staying at a party, meeting, etc., can put a dent into their social life in a hurry. For example, if the anxiety caregiver can invite and have people in, then they should. However, they should be sure to tell their guests that their wife may have to go bed etc., due to her disorder.
5. The caregiver should find other people to be temporary support people such as; friends, neighbors, church groups, etc. Any of these "support people" can help come in, or take the person to appointments. The caregiver should not feel they have to do everything, because they are the only person that the person in need feels comfortable with. The caregiver may even be blamed for being the cause and that could hurt. The caregiver must remember that unless they have a particularly tumultuous relationship with the person in need, they aren't the cause. The roots of anxiety can be genes, and/or go back many years. They might even say they feel worse coming home, so it must be the caregivers fault. This is probably not the case. It is because they have come to associate the home with anxiety because that is where they spent most of their time.
6. The caregiver should not feel there is something that they must do in order to be able to help them recover. There isn't in the short run, because recovery is 3 baby steps forward and 1 back, or 2 back, or 3 back.

People frequently ask, "What can I do for my wife during a panic attack." Basically, very little. Someone in a full blown attack:

• may wish to be left alone
• may not want to be held
• may want to be reminded that they are not going to die
• may use relaxation breathing techniques
• may find that a certain type of music calms them

David: Ken, for those of us who haven't experienced it before, can you please describe what it is like having a panic attack?

KenS: That may be difficult, but let's try this. The body comes complete with a mechanism to protect itself in times of danger. This is when adrenalin is released as the body prepares to fight, or run away. This causes a number of things to happen: breathing increases, blood flow changes, and eyesight becomes more acute, as do the other senses. If your body is busy running or fighting, you don't notice this. However, if you are just hit with a sudden flow of adrenalin, without any discernable cause, you are fully aware of all the changes. There is list of panic attack symptoms on my site and the changes that take place in the body and their effects.

To get an idea of what it feels like, imagine the feelings of a six year old child who has been chased into a narrow rock crevice by a vicious wild dog. The boy can squeeze back just far enough to get out of the way of the snapping jaws, however, the claws keep trying to reach him but never quite do. His anxiety level is ready for battle, which is a very high level characterized by much adrenalin flowing. He is trapped, but the brain is screaming danger. He can't move, he can't do anything. He is freaking out and is really at panic station. When he is finally rescued, he probably wants nothing more than to be in the arms of his mother (his safe person) and at a safe place (his home).

A person with a panic attack goes through all that, but since they can't even find a cause for it, they can't do much about it. To take it a step further, if every time that boy went outside he found that dog was waiting for him, he would not want to go outside. The same thing happens with a person with agoraphobia. They are afraid and can't do anything and they don't know why. What has happened during a panic attack and subsequent agoraphobia, is that a natural protective response the body is instilled with, is occurring on its own without any discernable cause. I hope that helps.

David: We have some audience questions, Ken:

ashen: I take care of my forty-five year old wife. Her agoraphobia has been going on for the last six years, and it's about all I can stand to even come home anymore. I love her, but I'm about ready to give up. She won't even go out so we can see a therapist. What else can I do?

KenS: Since she won't see a therapist, I don't think there is much you can do. You need to take care of yourself and she should get help too. Also, make sure you have someone you can talk to about it. Do not carry the load alone. Why won't she seek help?

ashen: The doctor says that she has to come to his office. He won't come to the home and she won't leave our house.

KenS: Well, that can be "catch twenty-two" situation. Does she go out at all?

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ashen: She won't leave the house.

KenS: As you may know I live in Canada, but most of the people I am in contact with are in the US. In the U.S., many have had success in phoning their county mental health agency for advice and help.

David: Here's a similar comment, Ken:

thaiphoon: I feel like a hostage in my own home. My husband never lets me go anywhere, and on the rare occasion he does, I have to take a cell phone with me so he can call me if he has a panic attack. I feel like a dog on a leash. I'm getting angry and resentful. He too, due to his horrible panic attacks, will not leave the house to seek help. What can I do?

KenS: That is a common problem. Your husband is not going to die from panic attacks. Try taking short trips, or have someone come in with him while you are out. My friend wanted me to get a cell phone or a pager. I refused and took control by saying I will phone you two or three times while I am out. While at work, she would phone many times but I had alerted the secretary about what the problem was. I usually got around to phoning later, and by then the severe anxiety had passed. Have you spoken to any counselors, clergy, etc, about this? You must find a way to talk to someone and let off some steam.

David: Here's a comment from an audience member:

Debbles: Do what they did to me. They picked me up and took me to the doctor! That was the best thing that ever happened to me.

KenS: Thanks, Debbles. Nice to see you. Good idea. That would bring it to head in a hurry.

Debbles: I don't recommend it for all situations, just for getting that first initial help, if you feel you can't get out at all. The reason is, if you stay home you will never get better. There are therapists out there who will come to your home and work with you to get to the office. I have had one like that and she was very helpful, but you too can also do it by taking baby steps by getting them to go out a little at a time. Also, anti-anxiety medications are a big help with this disorder, finding the right one to work for you is the hard part.

KenS: Thanks , Debbles. Would you include Ativan (Lorazepam) in there? That is very useful for that.

David: What do you think about that, Ken? And I know you're not a doctor or therapist. But is it right to forcefully take someone outside of their safety zone?

KenS: I really would not want to force a person outside their safety zone, unless it were an emergency. However, I do see what Debbles is saying. It worked with her panic attacks. What works for one may not work for all.

thaiphoon: I also feel like a servant and not a wife. Marital relations have stopped, and I can no longer work due to his constant calling at my job. I'd love to have someone stay with him, but he won't let anyone else into the house. It's the only place he feels safe and he doesn't want anyone in his space. Since my husband can't work, and he won't let me get another job, we have no money for counseling. I wish I could.

KenS: You were fired for it?

thaiphoon: Yes, fired for repeated personal calls.

KenS: Thaiphoon, I am sorry that happened. I have helped some people find help when they could not afford it by getting them to contact their local mental health unit or university psychology department.

David: Here's a question, Ken...keeping in mind that many people with anxiety disorders deal with dual diagnosis; they turn to drugs and alcohol to quiet their anxiety symptoms:

KenS: Yes, they do. Anxiety and alcohol go hand-in-hand. Men, particularly, turn to alcohol for "help." It is not unusual to find alcoholics in the families of those with anxiety.

Alohio: What about someone who has a mate that also drinks?

KenS: I have helped some family members by directing them to go to places like Alanon, etc. Well, one of you is going to have to take control and get help.

David: Anxiety, Panic Attacks, and Agorophobia: Information for Support People, Family and Friends is the name of Ken Strong's book. I encourage you to pick up a copy. There's a lot of useful information in it.

KenS: Thanks.

CHRIS26: I'm wondering how long I have to be a caregiver? Does panic ever come to an end?

KenS: Well, some get over it in a few months. Others go on for years, but people do get over it eventually. You have to work at getting yourself in a balance between what you can do and time. There is nothing wrong whatsoever in saying you need a break etc.

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yahooemt: What do you do if your mate can come up with any excuse in the world for why they can't seek help?

KenS: Are they afraid to get help?

yahooemt: I'm assuming so. I also think they are afraid of change.

KenS: Yes, I think you put your finger on it. I would make a list of all the possible help available. Then I would tell them to pick one, because you are not going to devote your life to someone who will not help back.

yahooemt: I've made a list of all the help available, and I still am unable to encourage my mate to seek help. What now? How can I help? When I get frustrated due to his lack of helping himself, he gets frustrated with me. I'm at a loss.

KenS: Then look after yourself. Speak to counselors, or anyone else who can help. You can go to your county mental health agency too. They might be able to give you ideas of how to approach it. You may have said for "better or for worse" but you did not include "even if it kills me." Yahooemt, in some situations you can't do anything, that is why I suggest for you to get help for yourself.

David: I'm letting Thaiphoon ask two questions because I think a lot of people are concerned about this topic, but may be afraid to bring it up.

thaiphoon: Is it normal for people suffering from panic attacks to lose all interest in making love? I realize the intimacy question may prove uncomfortable to answer, but I need to find out if this is a panic attack related problem, or another. It's hard enough being a caregiver 24/7 under the best of circumstances, but without that needed marital contact, it's really miserable.

KenS: That is a common question. Depression, as well as psychiatric medications, can cause a loss of sex drive. Furthermore, even coming close to an orgasm is something that some feel they are losing control of their body with. ( I taught Sex Education for years to grades eighth through twelfth, so ask what you like. I am not uncomfortable.)

David: Thank you, Ken, for being our guest tonight and for sharing this information with us. And to those in the audience, thank you for coming and participating. I hope you found it helpful. You'll find a lot of helpful information there. If you found our site beneficial, I hope you'll pass our URL around to your friends, mail list buddies, and others: http://www.healthyplace.com.

Thank you again, Ken.

KenS: Thank you for inviting me. Good night.

David: Good night everyone and I hope you have a pleasant weekend.

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Disclaimer:We are not recommending or endorsing any of the suggestions of our guest. In fact, we strongly encourage you to talk over any therapies, remedies or suggestions with your doctor BEFORE you implement them or make any changes in your treatment.

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Our guest, Paul Foxman, Ph.D., talks about the definition of agoraphobia, the three ingredients in most cases of agoraphobia, and treatment for agoraphobia (anxiety control skills, exposure therapy, visualization, anti-anxiety medications). We also discussed the different levels of fear that agoraphobics experience, from a moderate pattern of avoidance, like avoiding air travel, to a housebound agoraphobic with a severe case of anxiety and an extreme need to be in control.

Audience members shared their agoraphobic experiences and had questions about anxiety disorder relapses, anxiety and depression, how to overcome anxiety, facing phobic situations, and anxiety associated with a medical condition. Some also expressed concern that they had tried various treatment methods to no avail and were worried that they might never recover from agoraphobia.

David Roberts: HealthyPlace.com moderator.

The people in blue are audience members.

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David: Good Evening. I'm David Roberts. I'm the moderator for tonight's conference. I want to welcome everyone to HealthyPlace.com. Our topic tonight is "Help For Agoraphobia." Our guest is Paul Foxman, Ph.D., Director of the "Center for Anxiety" in Vermont. He is a psychologist, in practice for 19 years, who specializes in the treatment of anxiety disorders and trains other therapists on how to treat anxiety disorders. Dr. Foxman is also the author of "Dancing with Fear," a popular book which offers help for anxiety.

Just so everyone knows, Agoraphobia means a fear of open spaces. Here is a more detailed definition of Agoraphobia.

Good evening, Dr. Foxman, and welcome to HealthyPlace.com. Many agoraphobics are afraid to even step out of their homes. They want help. They call the doctor and the doctor says "you need to come to my office." If that's the case, how is the individual supposed to get treatment for agoraphobia?

Dr. Foxman: First, I would like to clarify my definition of agoraphobia. The condition to me means a pattern of avoidant behavior designed to protect oneself from experiencing anxiety. There are many situations people avoid, including, of course, going out into the public. In those cases, getting to a health care professional can be a problem but there are some alternatives. I use a home-based self-help program called "CHAANGE" for those who are truly housebound, with telephone consultations. If we have time, I would be happy to say more about the CHAANGE program.

David: You mentioned those agoraphobics who are housebound. Are their different levels of fear when it comes to agoraphobia?

Dr. Foxman: In my opinion, the housebound agoraphobic is usually a severe case of anxiety because a pattern of avoidance has developed and the person's life is severely limited.

David: So what would be some other "less severe" instances of agoraphobia? What would that look like?

Dr. Foxman: Many "agoraphobics" function in what appears to be a normal way, such as ability to work outside the home, hold responsible positions at work, etc. However, internally, they are anxious and uncomfortable. Typically, there is a still a pattern of avoidance of some kind, such as meetings, travel, etc. There is also a need to be in control, and anxiety is highest when control is not feasible.

David: How does a person develop agoraphobia?

Dr. Foxman: In my view, agoraphobia is a learned condition that develops over time, usually resulting from having an anxiety experience in a particular situation. Thereafter, that and similar situations are associated with anxiety and avoided.

There are three ingredients in most cases of agoraphobia. First is "biological sensitivity": a tendency to react strongly to stimuli outside as well as body sensations. Second is a particular personality type that I discuss in my book. Third is stress overload. It is usually stress overload that determines when a person becomes symptomatic.

David: You mentioned "personality type" as being one of the precursors. Can you explain that in more detail, please?

Dr. Foxman: Yes. The "anxiety personality," as I call it, consists of personality traits, such as perfectionism, difficulty relaxing, desire to please others and obtain approval, frequent worry, and high need to be in control. These traits are both assets and liabilities, depending on whether you are in control of those traits or whether they are controlling you.

The anxiety personality sets a person up for increased stress and anxiety symptoms.

David: We have a lot of audience questions, Dr. Foxman. Let's get to a few of those and then I want to address treatment issues. Here's the first question:

Zoey42: But what causes that first inital anxiety attack for no apparent reason?

Dr. Foxman: Although it seems that the first anxiety attack occurs "out of the blue," it is usually preceded by a period of high stress when other coping mechanisms are strained. Take a look at the 6-12 month period preceding the first attack and see if your stress level and other changes occurred.

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David: So, are you saying that first anxiety attack is a way to "blow off" the high level anxiety?

Dr. Foxman: It would be better to think of the first attack as a warning signal that your stress level is high and earlier signals have been ignored or not attended to. Prior signals include muscle tension, GI symptoms, headaches, etc.

David: Here are a few places that are troubling to some of our audience members with agoraphobia:

Rosemarie: I have problems with airplanes and also crowded areas, such as Malls.

AnxiousOne: Yes, I avoid air travel and crowded places.

jjjamms: To be in large supermarkets, malls, large bookstores, etc., upsets me quite easily but very small stores do not. Why is this?

Dr. Foxman: In my opinion, all these places have something in common. They are places where people anticipate experiencing anxiety. It is, therefore, not truly the place or situation that people fear but the anxiety and loss of control that is anticipated in those situations. This is an important point to understand, as it pertains to treatment approaches.

Danaia: Is it true that Panic Disorder goes hand-in-hand with Agoraphobia? Also, what if there is no reason for agoraphobia? I have spent many hours in counseling for this problem, but I cannot figure out why it has happened to me.

Dr. Foxman: Panic disorder frequently occurs in conjuction with agoraphobia. Before 1994, the American Psychiatric Association would diagnose Agoraphobia, with or without panic attacks. Now, it's Panic Disorder, with or without Agoraphobia.

As for why anxiety or agoraphobia develops, it is helpful to understand the history leading up to it but that, in itself, will not lead to recovery. Recovery requires practice of new skills and behaviors, which we can discuss in more detail.

David: What is the first line of treatment for agoraphobia?

Dr. Foxman: Agorophobics typically "scare" themselves with anticipatory worry. That needs to be replaced with anxiety control skills that are practiced before entering the phobic situation and then the person must learn to face the situation and try those new skills. One needs to face the phobic situation in order to overcome it, but equipped with the appropriate skills.

David: I think what you are referring to is "exposure therapy." Am I right?

Dr. Foxman: Exposure therapy works best when the person has first practiced anxiety control skills, such as the ability to calm oneself at the first sign of anxiety. Only when equipped with such skills can the person hope to have a positive outcome when "exposed" to the feared situation. In addition, exposure should be gradual.

David: Over what period of time?

Dr. Foxman: The time period depends on how entrenched the avoidant pattern is. It is a good idea to make a list of all the avoided or feared situations, and then rank order them in order of difficulty. Then, using "visualization," imagine yourself going through the situation while relaxed. Continue until you can do the whole situation without anxiety. Then try in real life, using small steps. This could take weeks or months.

David: Here's an audience question:

checker: How does one "calm oneself" at the first sign of anxiety?

Dr. Foxman: First, practice relaxation daily when you are not anxious. Think of it as a "skill:" the more you practice it the better you get at it, just as in learning to play a musical instrument or keyboarding on a computer. Then, when you feel anxious, you are more likely to be successful in using this self-calming technique. A good analogy is childbirth preparation class, where you learn how to breathe through contractions. In other words, you practice relaxation in advance so when you need it, it is more likely to work for you.

Our instinct is to tense up when we anticipate something bad happening, such as feeling anxiety in a feared situation. It is important to have the ability to relax so that you can face the situation and counteract the anxiety. The idea is to replace the anxiety reaction with relaxation.

David: A few site notes and then we'll continue:

Here's the link to the HealthyPlace.com Anxiety-Panic Community. You can click on this link, sign up for the newsletter on the side of the page so you can keep up with events like this.

Here's the next audience question:

Tash21567: I have made progress in the past, only to have setbacks (anxiety disorder relapses). Why do we have these?

Dr. Foxman: We have setbacks due to the power of habits. Agoraphobia involves habitual ways of protecting ourselves-usually by avoidance-and we revert to these habits when anxiety is up or stress is high or when we are tired. Try to think of setbacks as "practice opportunities." But be sure you have some appropriate skills to practice when you have a setback. It is also important not to get upset with yourself for having a setback. It is to be expected, just as when you are learning anything new. There are good days and not-so-good days when it doesn't "flow."

David: By the way, I forgot to mention Dr. Foxman's website: http://www.drfoxman.com

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MaryJ: Dr. Foxman, I am most interested in your CHAANGE program. I have been housebound three years and have no help. I don't know where or how to begin. I can't take much more of this and I am depressed all the time.

Dr. Foxman: Mary, you raise a few important points. One is the relationship between anxiety and depression. It is natural to become depressed when your life is so restricted, and when you are not in control of the anxiety. However, there is hope. The CHAANGE program is a 16-week course in learning how to overcome anxiety. The success rate is quite high, about 80% based on patient self-ratings at the beginning, middle, and end of the program. You can learn more about the program from my book, Dancing with Fear.

David: And that brings up another important point, and I know you are not a psychiatrist or medical doctor, but generally speaking, are anti-anxiety medications effective here in relieving the high level of anxiety and depression that many agoraphobics experience?

Dr. Foxman: My position on medications is that they can be helpful in the short run for controlling symptoms and enabling some anxiety sufferers to focus more effectively on learning the necessary new skills. However, medications have many pitfalls, such as adjusting the dosage to get a therapeutic effect, side effects, etc. I do not think medication is a good long term solution to anxiety. Even when they work, some people are fearful that their anxiety will return when they stop medications. I have had some patients come in with the presenting problem being fear of stopping medication.

David: We have some audience questions on whether a medical problem could have resulted in developing panic disorder. Here's an example, Dr. Foxman:

violetfairy: I have a personal question I hope you'll answer. I was a housebound agoraphobic for 3 1/2 years, then recovered (yay!). However, I still experienced major disorientation often. (That was always what set off my panic attacks.) I found out I have a giant cyst in my sinuses and I'm going for surgery next week. It seems to me that this could cause a lot of disorientation (I am particularly disoriented whenever there are barometric pressure changes-- right before it rains). Can you tell me if it's possible that the cyst is what caused the panic disorder?

Dr. Foxman: Yes, a medical condition can trigger panic disorder. However, it is usually the anxiety associated with the medical condition that the person fears. In your case, it is the disorientation that was so distressing, and it sounds like you have developed a fear of disorientation which is a precursor to the panic feelings.

Tess777: I was in my 40's when I had my first anxiety attack, which was after I witnessed my husband having a gran mal seizure. Is it possible that could have caused it?

Dr. Foxman: Yes, you witnessed a "traumatic" event and that may have "scared" you. Once you had the "scary" feelings, you developed a fear of that happening again. Everyone should keep in mind that it is the anxiety that is feared in agoraphobia and panic disorder.

Dlmfan821: I have a terrible problem with feeling guilty. It used to be I was the one everyone could turn to. I have four children, all grown now, thank God, and now I have to depend on them and my husband. My husband was in the military for many years and we moved from one end of the country to another and since my husband was gone a lot, I took care of everything without a problem. Now, when it is supposed to be time for my husband and I to vacation, maybe go on a cruise, etc., I've ruined everything.

Dr. Foxman: I can understand your feelings of guilt and letting your family down. What may have happened is that you worked so hard taking care of your family that your stress level went into overload and you became symptomatic. It is not a permanent condition.

David: I'm sure that many agoraphobics and those with panic disorder, because of their self-imposed restrictions, are unable to go places and family members get very upset. 1) How would you suggest handling the guilt the agoraphobic feels and 2) then how do you deal with friends and family members?

Dr. Foxman: It is always important to maintain balance. When we go out of balance, we become symptomatic. Take it as a learning experience and focus on resuming balance by taking care of yourself. This means addressing your health needs: diet, proper rest, exercise. These are the basics of health and energy. If you are in a deficit due to being out of balance, it may take some time to restore your balance. Just work at it everyday and it will come in due time.

zeena: Can fear of driving be a type of agoraphobia?

Dr. Foxman: Yes, absolutely. Fear of driving is a common form of agoraphobia. However, it is not the car or driving that one fears. It is the anxiety that might occur in the car or while driving that one fears. It usually develops from having an anxiety experience while driving. Many of my anxiety patients say, "I don't get it it. I used to love driving, now I am afraid to drive or I avoid it." The issue, again, is fear of anticipated anxiety, not of cars or driving. The same can be said of other feared situations, such as travel, airplanes, malls, or even being alone. It is all about the fear of anxiety. ga

David: This is from Jean, who has severe agoraphobia. She says she has no family or friends. She is housebound, feeling desparate and developing physical problems. Is it possible to recover from agoraphobia on your own, through self-help?

Dr. Foxman: Yes, it is possible. But as I have been stressing tonight, it is important to have some guidance in learning the approrpriate new ways of thinking and behaving. Some people can learn on their own, using a guidebook or program such as CHAANGE. But most people benefit most from contact with a trained professional who knows what skills are important. Some anxiety therapists are willing to provide telephone counseling to the homebound agoraphobic. That could be a viable option.

David: I'm getting some questions about what if you can't afford therapy?

Dr. Foxman: Naturally, cost can be a factor. Consider using a structured guidebook, such as the Anxiety and Phobia Workbook, or my book, Dancing with Fear. Also, group therapy is an effective form of treatment for anxiety, and usually it costs less than half the fee for individual counseling. I run two anxiety therapy groups per week and find it powerful and gratifying.

The self-help strategies I mentioned earlier are low-cost steps that can make a significant difference. Also, consider a relaxation tape, daily yoga or another form of relaxation, and then use imagery desensitization to prepare for facing phobic situations.

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sandee ane: Were you saying earlier, we fear the anxiety that we once felt due to a traumatic event? A doc told me that my problem is my feelings about my mother's death when I was 5. He said that I should have had help at age 5 and 9. What do I do about those feelings now? I am 53. I witnessed her death in bed at night.

Dr. Foxman: It is not simply the traumatic event that causes anxiety. It is the painful feelings that were so overwhelming. In other words, it is the internal reaction to the trauma that we must deal with. You can deal with the feelings now by discussing them and realizing that they are not life-threatening. What you probably missed was help in dealing with strong feelings. Some skills for that are described in my book in a chapter called, "Feeling Safe with Feelings."

Tash21567: Is it true the longer you live with panic, the harder it is to conquer?

Dr. Foxman: In a sense, yes, because the patterns and habits that develop to cope with panic are so entrenched. But that simply means it may take longer to recover due to the power of habits. It should not mean being discouraged. The keys to success are motivation to change combined with a proper program for recovery. The three factors determining treatment success are motivation, chronicity, and current stress level.

neofairy: Do you think that many agoraphobics have been abused at some point in their lives?

Dr. Foxman: Unfortunately, a history of abuse is common in people who develop anxiety disorders. In such cases, the abuse is the "trauma" that we have been discussing. If you read my book, you will find in "My Anxiety Story," that I was a victim of childhood abuse. Related to abuse is a pattern of low self-esteem in many people with anxiety disorders, including agoraphobia.

David: Here are two similar questions:

Zoey42: In my case, the first anxiety attack was the beginning of the end. Slowly starting avoidance and some good years. Then, when it would hit again, it would come back worse then it was. Then slowly for the next 24 years, continuing on and off, but always coming back. Is this common?

Danaia: What if the situation is not a "typical" situation? I have a strange fear of vomiting in public. How can I desensitize myself from that? I've tried everything from drugs to hypnosis and nothing so far has worked. It gets better for me, and then it gets bad again. Am I stuck with this forever? My fear is, what if this is as good as it gets?

Dr. Foxman: Without knowing what treatment efforts you have made, it is difficult to offer a definitive answer. Generally, however, I am optimistic that people can overcome anxiety with proper guidance. Many therapists deal with anxiety but are not truly specialists and do not understand the condition from personal experience. I have worked with many people who have suffered for years, and have had prior therapy. I usually use the CHAANGE program in such cases because it focuses on new skills rather than on talk therapy. The structure is important, as is knowing that other people with similar conditions have been successful. Never give up hope.

As for the fear of vomiting in public, that is another form of fear of losing control and publicly embarrassing oneself. When you learn to be in control of yourself, you can handle the situation.

David: Thank you, Dr. Foxman, for being our guest tonight and for sharing this information with us. And to those in the audience, thank you for coming and participating. I hope you found it helpful. We have a very large and active community here at HealthyPlace.com. Also, if you found our site beneficial, I hope you'll pass our URL around to your friends, mail list buddies, and others. http://www.healthyplace.com

Thank you again, Dr. Foxman, for coming and staying late to answer everyone's questions.

Dr. Foxman: Thanks for the opportunity to share on this important topic.

David: Good night, everyone.

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Disclaimer:We are not recommending or endorsing any of the suggestions of our guest. In fact, we strongly encourage you to talk over any therapies, remedies or suggestions with your doctor BEFORE you implement them or make any changes in your treatment.

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ANXIETY DISORDERS

As an educator, Kenneth Strong is noted for his ability to turn the complex into clear, concise and interesting information. He also has the almost uncanny ability to asses accurately if a project will meet the intended goals. Throughout his teaching career both governments and large industries frequently consulted him for help in developing materials. Ken had panic attacks and agoraphobia for awhile. Upon his recovery he turned his attention to helping those with them. In 1995 he began searching the net for caregiver information; finding none he used the resources of the NET to contact hundreds of those with the disorder as well as their support people. Using constant feedback from these people Ken developed these pages for the internet and continues to update them. As an author with several titles to his name it is not surprising he was asked to publish additional information for caregivers. Again using various formats and feedback a book was developed in the format which most said was well received. Ken has turned down offers from large publishers to do larger texts as he does feel the information will serve its purpose. "The larger books," he says, "will not be well received by caregivers. That is, they won't read them." We are sure you will find this material understandable and useful just as have the hundreds of thousands of other who previously visited his site.

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The material presented here was gathered from panic and anxiety sufferers as well as mental health professionals. This information is intended for educational purposes only and the general site disclaimer applies. For the purpose of clarity, the use of she has been adopted to include both he and she.

What employer wouldn't want an employee with these qualities?

• Shows extraordinary job commitment

• Pays strong attention to details

• Exhibits a high degree of selflessness

Yet many mental health professionals agree that it is often people with these same perfectionist traits that have a tendency to suffer from panic and anxiety disorder (PAD). PAD manifests itself in sudden attacks of anxiety and may include such symptoms as trembling, difficulty breathing, rapid heartbeat, sweating, numbness and nausea. During an attack, the employee may fear she's having a heart attack or becomes so overwhelmed by panic that she feels compelled to escape to a place where she feels safe.

Workplace stress can initiate or heighten anxiety, but even tension outside the job sphere may harm the employee's performance. Ashamed of and isolated by the disorder, she is constantly terrorized by thoughts of having an attack at in the presence of a boss or co-workers.

So what can an employer do to retain a valuable employee and reduce the possibility of a workman's compensation or disability claim? According to mental health professionals, both employers and employees stand the best chance of surmounting problems arising from panic disorder if they educate themselves about the condition and communicate in good faith. Lack of candor on either side can be quite damaging in a business relationship. A worker who inflates what she's realistically capable of handling at the present time for fear of "letting the company down" may sabotage the relationship as much as the boss who agrees to lessen workplace tension and then continues to impose rigid deadlines.

"Part of the problem is distrust," says a former panic sufferer who works with others with the disorder. "For instance, a person with panic and anxiety went back to his job and was welcomed with open arms. Then he accidentally discovered they were keeping a file on him in preparation of firing him. That shattered him enough to put him back on sick leave and in a worse state than before."

With a variety of methods, including relaxation techniques, behavioral therapy and medicine, PAD is highly treatable. Therefore, the chances for a positive work outcome are high if both parties are willing to be honest, flexible and realistic. "I found what helped me most at work was the complete acceptance of my disorder," says an anxiety sufferer. "My co-workers asked me to explain it and what they should do if I started to feel uncomfortable. If I needed to leave the room in a hurry, they were very accepting. It only took a couple of weeks working in this atmosphere before I was very at ease at work and didn't have any problems."

Considerations for the Workplace Environment

1. Warm fluorescent lights seem to help in place of cold. The worker with Panic-Anxiety Disorder (PAD) may benefit even if these lights are installed over just the one work station.
2. Move an anxious employee's desk away from high-traffic and noisy locations.
3. Save a seat near a doorway in a meeting so the worker may exit the room quickly and unobtrusively if need be.
4. Music (classical, New Age, etc.) played at low volume can soothe frayed nerves. Allow the worker a place to keep and play a cassette deck if relaxation tapes are helpful.
5. Provide, if possible, a quiet, relatively private place where a worker can practice relaxation and breathing skills. A crowded "staff room" or public restroom are not appropriate settings.

Suggestions for Employers

If you manage an employee who suffers from Panic-Anxiety Disorders, here are some suggestions on how you can have a positive impact:

1. Encourage the person with Panic-Anxiety Disorder (PAD) to seek medical treatment first to rule out any underlying medical condition. If possible, put her in touch with the company's Human Resource Director or Employee Assistance Program.
2. Assure the PAD sufferer that it is fine to enlist a couple of co-workers with whom she feels comfortable to act as support givers in the event of distress. If she is dizzy or having trouble catching her breath, she may fear being alone.
3. Help her combat catastrophic thoughts by replacing them with positive ones. For instance, encourage her to change a thought like: "I'm going to collapse" to "I've never collapsed before, so there is no precedent that I'm going to collapse now."
4. Try to design assignments to maximize the PAD sufferer's effectiveness without adding additional stress. If there are jobs she can complete at home and that is where she feels safe, perhaps in time of distress she may be allowed to work at home.
5. Don't insist that a worker with a "social-situation phobia" attend lunch meetings in restaurants or staff parties that will increase her anxiety.
6. Discuss assignments with the affected worker before imposing them. Involve her in setting expectations.
7. Don't underestimate the healing power of compassion and compassionate humor. One employee with PAD says she and her co-workers laugh together each morning when they gather around the coffeemaker and she is given only 1/2 cup of decaffeinated because they don't want to have to take her to the Dizzy Clinic. "For me," she says, "a serious approach with a touch of humor make my work environment a delightful place to be."
8. Understand that a worker with PAD may need to be excused from work-related travel or find someone to drive her to and from work or therapy appointments. PAD sufferers often avoid confined places such as automobiles, trains, busses, subways and airplanes. She fears being "trapped" in a location or setting from which "escape" may be difficult. She's also anxious about what other people will think of her if they witness her having an attack.
9. Invite an employee afflicted with PAD to make up her own First Aid Kit: a list of potential workplace remedies that can be realistically and readily adopted.
10. Don't treat the worker as if she's a child or her complaints are "made up" or "all in her head." PAD is a real disorder and it is estimated it affects some 15 million North Americans alone. Although a child can suffer from PAD, your worker is not one and deserves to be treated with dignity, the same as you would treat a worker with a chronic illness such as diabetes.

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Do you know what a marmot is? A marmot is an animal very much like a gopher and for our story we could choose a gopher, a mouse, an elephant or even a camel. It doesn't matter -- they all respond the same. I chose a marmot because I like them.

On a sunny afternoon, Martin, the marmot, was out for a stroll when the shadow of an eagle passed overhead. Martin didn't have to stop to think that an eagle looking for a meal was bad news because through years of evolution, Martin's brain was preprogrammed to respond immediately to the threat. Martin didn't give any conscious thought to what was going on around him. His body automatically prepared Martin for the danger and he was out of there at top speed to find a safe place. As long as that eagle was out there, there was no way that Martin would feel comfortable coming out of his hole.

If Martin could have looked inside himself, he would have noticed adrenalin was being released; more blood was being diverted to the muscles; respiration rate increased; heart rate increased; the pupils of the eyes had opened wide to let more light in and to give him more acute vision, etc.

Martin knew he was all hyped up and he knew the reason why. That was enough for him. He was just staying put until the danger passed. When the danger was gone his body would again return to a more relaxed mode and Martin could get on with his sunny afternoon stroll. The automatic reaction had saved Martin. That was its purpose -- to prepare him to run or fight so he could live to run or fight another day.

And a very useful purpose it is too.

A very long distance away in a place completely unknown to Martin was a woman named Terri. Terri didn't know anything about Martin either. But that didn't matter; even though Terri knew nothing of Martin she had a great deal in common with him. She had a heart, lungs, legs and a mouth -just to name a few things. In fact, well over 75% of Terri's genes were the same as those which made Martin into what he was. They had much in common and, yes, she even had almost identical genes to those in Martin which made him act as he did when the eagle flew over his head.

Terri was just getting out of her car when a big barking dog started running toward her. The dog didn't look friendly and those very same genes that were in Martin, took over in Terri. Her heart started to beat faster, she began to breathe more rapidly and the blood was rerouted so that most of it went to her muscles so she could run or fight. Terri bolted back into her safe place -- her car --and slammed the door shut. Soon the owner came and took the dog away.

The thinking part of Terri's brain now took over and as she realized the danger was past her body started returning to normal. With the dog safely gone, Terri could now get out of her car with no problems. The danger was past and she felt quite safe.

Just a few blocks away from Terri and the dog was a man named Luke. Luke was just leaving his office. Luke didn't know anything about Martin or Terri; he had never heard of them. That didn't matter. But Luke still had those same genes including the ones that made Martin and Terri go to battle stations. What were not there were the dog and the eagle. In fact, there was nothing there that should have told Luke it was run or fight time.

As Luke stepped out of his office he began to feel strange. He started to breathe faster, he could feel his heart pumping in his chest. The lights bothered him and the walls seemed to be folding in on him. "This isn't right", said the thinking part of his brain. "There is nothing here that should be causing this."

Knowing this made Luke feel even worse. Luke became very afraid there was something seriously wrong with him. So serious that he was afraid he was going to die. Things didn't get any better for Luke. Pains developed in his arms and chest, his hands and lips felt all prickly and his legs began to feel very strange and wobbly. On his rubbery legs Luke returned to his office chair, sat down, didn't feel much better. By now he was starting to sweat, feeling like he was not really there and becoming even more afraid.

Luke was so afraid he had someone call an ambulance for him which took him to a hospital. After many tests Luke found he had just had his first panic attack --and a real whopper it was too.

What Martin, Terri and Luke had in common was a normal body chemistry reaction to a frightening situation. The difference was, of course, there was no outside reason for Luke to suddenly go to "battle stations".

Many professionals feel that a panic attack is a normal response to a very dangerous situation but without there being anything dangerous to trigger it. The body has just gone into to panic mode on its own and the person has no more control over it than had either Martin or Terri.

I have come to believe, to some extent, that if a person can think through what is happening to them during a panic attack, they can break the cycle of becoming more afraid thus causing even more panic. That doesn't work for everyone but, as a support person, it will be useful for you to know what is behind the strange feelings.

In the table below, I listed the symptom and gave the major cause. Of course, they are all interrelated but I just wanted to keep it simple.

Hope this information helps.

Ken

SYMPTOMS	CAUSES
Heart Pounding	Heart speeding up to move blood and oxygen faster.
Breathing faster	Obtaining more oxygen for the muscles
Chest pain	Muscles tightening.
Rubbery legs	Blood supply building up in the legs/decreased oxygen to the brain
Feeling of Dissociation	Less blood going to the brain and/or some think a trance state is almost reached.
Bright lights are disturbing	Pupils have opened for more acute vision
Walls are bending inwards	An effect of the pupils opening wide
Sweating	The body is harder to hold onto in a fight
Numbness in hands	Due to the diversion of blood to the muscles
Tingling in mouth	A result of hyperventilating
Choking sensation	Due to muscle tension
Shaking	Due to muscle tension

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As you have read under General Description of Anxiety and Panic Attacks, being a support person is something which you cannot take lightly. The ill person has turned to you to be his or her life-line in returning to a "normal" world. Love and sincerity play an essential role, but in addition, you must understand what you are doing and why. If, therefore, you have not yet read the descriptions of a panic attack and agoraphobia found on this site, do so soon.

Remember, there are various schools of thought on being a support person. I am giving you what I have heard and found to be most helpful to the people with whom I have worked among on being a support person.

To help you understand why I like this approach, I am going to give you a brief true story of a person I will call Anne.

Anne developed panic attacks about 12 years ago, before panic attacks were more widely known and a variety of treatments became available.

For several years, she looked for a diagnosis and effective help. Eventually both were forthcoming but in the interim she developed severe depression and agoraphobia to the point where she could not leave the house without tranquilizers and a caregiver. Even then, there were times she had to come home without accomplishing her goal, and the failure led to greater depression and more anxiety.

About three years ago, came a change in her thought patterns. Anne realized that by setting a specific location or a specific accomplishment as a goal, she was constantly setting herself up for possible failure. There is a world of difference between "I am going for a walk" and "I am going to try to go to the store."

In the first, the goal is to go for a walk. It may be to the property line or 12 blocks and back; Anne does as much as she feels comfortable doing. In the second case, Anne has to make it to the store or she will have failed. The same is true of any such project. Why make a big thing out of trying to drive to the store when you can be more relaxed just going for a drive and doing whatever you feel comfortable doing? Turn right. Turn left. Come home. Keep going. It doesn't matter. Allowing yourself freedom of choice without feeling pressured or guilty is the key.

After a few weeks, Anne found she was driving greater distances and eventually could set off for a specific location, knowing she had been there before while on her no-pressure drives. She can now drive virtually anywhere. Stoplights and inner lanes are still a bit of a problem, but not enough to force her to use alternate routes.

A number of authors have come to see the effectiveness of this strategy and have referred to it as "giving yourself permission."

Before getting into specific suggestions, there are few points to keep in mind:

1. At all times, be supportive but not condescending.
2. Remember, you are not responsible for your companion's recovery. You are doing what you can but the majority of the healing must come from within.
3. Don't blame yourself if the person has a panic attack or is unable to complete the outing. It's not your fault.
4. Don't feel there is something you must be able to do help the person get over a panic attack. There is little you can do. If at home, the person may want to be held or just left alone. If you are out, he or she may want to just sit for a few minutes or return home.
5. The person you are with is in charge; he or she calls the shots. If she or he wants to abort the outing, abort; to go somewhere other than where you planned, go there. That person, not you, knows what feels most comfortable.
6. After a few outings, try to have someone else come along so that the person you are supporting can begin to feel comfortable with the other person. Eventually, you don't have to be present all the time.
7. Don't wear yourself out. For your own health, there may be times you have to say "no" to a request.
8. You may not understand panic attacks, but never tell the person that it's all in her or his head, that he or she could go out if she or he really wanted to. PA's and anxiety don't work that way.
9. Don't call outings "practices"; "practice" seems not to expect less than success. Since there is no specific goal, how can one fail? Every outing is successful if looked at correctly.
10. As part of your support role you may have to remind the person that backsliding is normal, assure them that they are sane and that they are not having a heart attack or other physical trauma.
11. Don't be upset if you get snapped at occasionally. The person may be very up-tight.

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Practical guidelines for going out together:

1. Don't make a big deal of it. The person is probably anxious, and to plan as though you were preparing an invasion will make him or her more anxious. How much planning and structure is required varies from person-to-person and will probably change over time.
2. If you are not familiar with the place you plan to go to, go ahead of time to case it out. See which areas will seem confined, find the exits, ask about times when it is not too crowded. Know where the stairs are located in case escalators or elevators are a problem. Being able to tell the person you know the area may make her or him feel less anxious.
3. If the person wants you to stay with them do so--like glue. It's not his or her job to keep an eye on you. It's your job to keep your eye on her or him.
4. If your companion wants to hold your hand or suggests you stay a few feet back from them, do what she or he requests.
5. Always have an agreed upon central place picked out at which to meet in case you accidentally become separated. Once it is obvious you have lost the person go directly to that spot. Do not waste more time looking. He or she will feel more comfortable if she or he knows you will be there.
6. If the person wants to leave you for a while, set a definite time and place where you will meet. Don't be late. It is better to be early in case he or she arrives early.
7. The only responsibility with which to charge your companion is to let you know if she or he feels overly anxious or panicky. Frequently you can't tell from just looking at him or her.
8. If the person indicates that she or he is becoming anxious ask them what they would like to do--take a few deep breaths? sit down? go to a restaurant? leave the building? return to the car? A break may be all that is needed for his or her anxiety to diminish. She or he may want to go home or return to the place you have left. That is up to him or her. Ask the question but don't push.
9. If your companion has an unmanageable panic attack lead her or him from the area to a place where he or she feels safer. Don't forget to see that there are not inadvertently unpaid for items in her or his hands. They probably won't be thinking of them.
10. Don't add stress by giving the impression that there is something YOU must absolutely accomplish before returning home. The free permission to return home at any time is now gone.

Going out alone:

Driving is a problem for many. Again, remember that there is no need for failure if no specific goal is set. The person should just follow what that little voice inside says it is O.K. to do. Here's a method many have found helpful--there is no set time. It may take days or months or longer to work through the sequence. There is no time limit.

1. Go with the person; either of you driving. He or she may want you help locate turn-around points or pull-off places. Your companion just needs to know he or she is not trapped on the road.
2. When the person is ready he or she can drive alone with you following close behind. Make certain she or he can see you in the rear-view mirror at all times.
3. When the person is ready he or she drives down the road with you following, but just out of sight.
4. If the person wants to drive on her or his own try to borrow a cellular phone so that he or she can be in contact with you. The person may ask for you to come and lead them home or just to give them some reassurance. If you are using a phone keep the line clear. The person needs to know she or he can reach you at any moment.

Other Situations:

The ill person may need you when visiting doctors or dentists. Understanding medical people usually don't object, especially when they realise they may have to deal with a panic attack if you aren't there. Your sense of humor may help in unusual situations and you may be able to joke your companions along; or the person may feel more comfortable just telling you to shut up.

Some techniques I have used: making certain we took the right cassettes to the dentist for the person to listen too while having work done; suggesting to the dentist that a rubber dam may not be the best idea; holding hands while your companion is in the dentist's chair; making certain that everything the doctor or dentist does is explained as it is being done; holding hands with your companion during a biopsy under a local anaesthetic; discreetly looking the other way while holding a hand during a mammogram; climbing inside the far end of a CAT scanner to describe the tunnel to the person before he or she is moved in; sitting in post-op so your companion has a familiar face to wake up to. You never know what is next. I have learned a great deal just by watching what's going on and the person's reactions.

Finally, don't let yourself start to suffer. If you find the stress of looking after a loved one is wearing you down, get medical advice. Also, being able to be a support person is not for everyone. There is no shame, nor lack of caring, in not being able to do it. You have your own health to consider as well.

Here are examples of letters I have received. They speak for themselves.

I received this letter from a support person awhile ago and eventually posted it (with permission) to a professional Anxiety news list on the internet. Because of the intense nature of the letter, I had no intention of posting it on our own Anxiety news list. I felt many may be upset by it and some fail to recognize it was an extreme case. I was wrong! I eventually had to post it. It was so full of mental anguish I called it "A Cry From the Heart." It was very well received. Several wrote to me saying how much it relieved their minds to know their experiences were not isolated. I have included one representative response.

P.S. He has now received the support as well as the professional help he needed and is much better. His wife has also improved and they have both grown closer together as a result of the experiences they shared.

A Cry From the Heart

It's 5:45 am. There is a whimpering coming from the person beside you and the bed is shaking. She is having another panic attack -- the third tonight. She has tried hard to be still and not wake you but now she knows you are awake her arms go around you and the whimpers become full sobs. You hold her tight and tell her it is all alright. Everything will settle down in a few minutes. One part of you is trying to get back to sleep while the other is staying awake because you know that to her the bed is rolling, the walls falling inwards, her heart is pounding and her hands feel like they are swelling up to the size of beach balls.

Today is your day off which means she will able to come out of the bedroom and be with you. Since the agoraphobia set in she has not been able to leave the bedroom unless you are home. She has awakened some time ago but is afraid tell her body it is time to get up and cause that initial surge of adrenalin as it will bring on another attack. Because it is a special day with you home she does get up then slowly, hanging on the railing, makes her way into the kitchen. She walks like a drunkard but you know that is because her legs are rubber, the floor is seething and the lights overhead seem to be falling on her.

The next day is a work day. About 11 am comes a phone call from her crying for help. She has been fighting an attack since 9 but can't seem to remember her exercises to bring herself back down. The secretary is very good at putting her calls through immediately. You excuse yourself from the group and take the phone to take on the process of bringing her down. You are worn out from it but your voice, somehow, assumes a calm tone and you gently tell her what to do. It was so much easier when there were other people to help but friends gradually drifted away due to the frequent last minute broken engagements, a fear of mental illness (which this is not) and the relatives have all found reasons not to be involved. Who else does she have? No one.

You arrive home much earlier than usual. In the bedroom she is sitting on the bed and trying to hide the bottle of narcotics she has been staring at for time. You gently take the bottle; kiss away her tears of shame and tell her it is alright you love her just as much as when you were married and will always be with her. You talk about the time she will be better ..and hope there will be one. Everyone does get over it eventually - so you are told. You fully understand why the divorce rate is over 80% - but the echo of "in sickness and in health" keeps running around in your head. And the suicidal thoughts do not surprise you as she still has all her mental faculties but she can't control what is going on inside her body. The suicide rate is extremely high. Sometimes you walk in the door not knowing if you will find a living person or a body - maybe she was asleep when you phoned or just didn't hear it, or maybe.....

It's November and she has her heart set on buying you a Christmas present all by herself. There is no hope of it being a surprise as you have to stay within a few feet of her at all times or the waves of a panic attack start flowing in her. Several times she tries to go into the store but you end up back at her safe place in the car. Finally she makes it into the store, grabs almost the first thing she sees and pretends you are not with her. Come Christmas Day you will both act as if you had no idea of what you were getting. But that will be Christmas Day. In the immediate future you know she will sleep most of the next few days from the energy exerted in doing the best she could for you.

The time has come for her to try to start driving again. Hopefully this will take some of the pressure off you. You have both spent weeks going out together with her driving sometimes and you driving when she found she could not continue. She has a cellular phone. You can stay at home and relax. Not likely, you have to sit by the phone to ensure the line is free if she needs it. You are just as much on watch as if you were with her. When she does phone you have to gently talk her back to the house or to one of the "safe places" she has identified so she can wait until you can reach her.

It has been a good week. No panic attacks and the agoraphobia seems to be lessening. She can get out a bit by herself. She is even starting to be able to make SOME decisions again. Unfortunately the lack of control she had with the panic attacks has left her with little to no confidence in the decisions she has made. They are constantly being re-examined and there a fear there which makes it almost impossible to take a definite step. On top of this she has become so fear driven that every small event is catastrophes. Do you leave her to work it out herself or again assume that calm voice and talk rationally to her about it? God. We have come to assume a frightened child/parent relationship. Where is the person I married? Where is the relief for you. You don't even have the sex to help remove the tension as the last thing a depressed person is thinking of is sex. Also, who wants sex when the adrenalin flow will bring on another panic attack? That part of your life was denied you years ago.

You know there is a build up in tension in her because she is starting to yell at you again and taking everything the wrong way. Dealing with her is like walking on eggs. You are almost wishing for her to have an attack to get it over with. She will sleep for some time afterwards which is the only peace you get.

---

A VERY MOVING RESPONSE

Dear Ken:

Thank-you for posting this. The story comes as no surprise as my husband and I have gone thru it, though a little less extreme. The tears are running down my face, as I think what has been going on in my wonderful husband's mind. I thank GOD daily for your book, as it has given us the strength to keep working at our marriage. Now that my depression has lifted, I think that if I had not become ill with depression, and Panic disorder, I wouldn't have met all my good friends-Ken you are one, and become a fuller , more compassionate person. It has also done this for my husband who before living with me, wouldn't have understood or cared about people with our disorder.

Thank-you Ken.

Shelley

This letter was written in response to another letter in which the support person was having difficulties.

Hey Doug...

Wow... If you have a clone somewhere, it would have to be me! I have the same problems just as you described yours, with a few exceptions. Let me lay them out for you.

I live in a very small community in the western US, and I don't live "in town". I live several miles from town, up a mountain and through the woods. We both work at a small hospital in town. Very political organization (which causes MUCH stress all by itself). I moved here a few years ago in my mid 30's and very single. I met my wife and what can I say... I just popped and fell head over heals in love with this wonderful, caring, beautiful, sexy, smart, sensitive woman that just does it for me (apparently she must have felt the same cuz she married me, thank God).

When we first met, she was seeing a counselor and taking medication for this panic/anxiety thing. At the time, I never noticed any strange (to me) behavior or anything out of the ordinary except that she was mildly co-dependant and was afraid to drive on the highway. No problem, I thought. I love to drive and when the blizzards come in, we shouldn't be on the road anyway.

About 2 years ago, we purchased a "mini" ranch and decided to live our dreams. We got horses and chickens and dogs and all of the standard ranch stuff. We live kind of remote, and a very basic lifestyle, without many of the frills and benefits that most of you take for granted, but we didn't care. We love to look out the front window and see the elk grazing, and the foxes that come in to steal our chickens and not seeing any neighbors or cars or honking or yelling. Its quiet except for the sounds of nature. Very relaxing when you get off work.

After we bought our dream we decided that because we were rapidly approaching the big "40's" and we wanted to have a child, everything was right with our world and we had better get started. First, she had to get off the Xanax because of possible birth defects. No problem, we took it slow and before long it was over. No more Xanax and it didn't seem to bother her to get off them and I didn't notice any real personality or emotional problems.

She got pregnant in July and carried our child through the worst winter ever recorded in our area with blizzard-after-blizzard and times when it was 40 below for weeks at a time. Nobody plows our road and sometimes there were drifts of snow that were 20 and 30 feet high. We mostly went around them and for months we made our own roads to get in and out, depending on which way the wind was blowing. Many people that lived near us just moved out because it was too much, but we stayed and I got a book on home birth/delivery just in case (by the way, on the humorous side, I asked our OB doc where I could find a good book on home birth and she said "in the trash").

Well the time came and I cranked up the Dodge during a horrible blizzard and the snow was over the hood of our already "monstorized" (high off the ground) ram charger and we made it in and the baby was born in our little hospital in march. The delivery was incredible and very simple (even my wife said so) and we took our new BEAUTIFUL son home. Life was, and still is, good and we were blessed and still are.

When our son was about six months old, something happened and our son started having a focal seizures. I remember the first time when my wife called me at work and was out of control. She was holding him and he went into a seizure and then went limp and she thought that he stopped breathing and was turning blue. She dropped the phone and jumped into the jeep to fly down the hill to our hospital, and I jumped into the truck and met her halfway and we flew to the hospital and he was admitted.

Turns out that the limp and color was due to the seizure and he was just sleeping after the seizure because they are so draining. He seemed fine after he woke up and had a blast at the hospital and got tons of attention. We work with all of the hospital people everyday, so he got extra fun grabbing glasses and pulling earrings off of the nurses that were constantly holding him. Smiles the whole time.

---

By the 2nd day, still no more seizures and no apparent cause for the first. The doc comes in and says if there are no more that we can go home that evening. No more and I am holding him playing with his feet waiting for the doc to discharge us that evening. The doc is on his way down the hall and wham he starts having another seizure while I am holding him. I will tell you it is quite a shock seeing your perfect little boy jerking all over. I handled it ok and the doc came in at the tail end of it and I held him to the side so that he would not choke and then it was over.

Doc said that I did fine and he was just going to sleep it off. I put him in the crib and left the room to find my wife who had run out of the room when it started. On the way, I started thinking about things and everything started to hit me and I just lost it. I cried and fell to my knees in the hallway and just couldn't stop crying. Being a computer guy for the last 20 years kind of made me have a logical thought process and seeing him, and realizing that this just wasn't some "General Protection Fault" fluke, I became very emotional.

It was serious and something was very wrong. I tried to pull myself together and went back to the room and the nurses were putting an I.V. in his little arm and the doc was telling me that they need to get him to another hospital in Billings. Working at this hospital, I know that when we transfer somebody to "Billings," it means that the patient often dies. I lost it again, just couldn't seem to get it together, but my wife, Mrs. Anxiety, was like a rock and helped me pull things together for the long trip to Billings. She rode in the ambulance and I drove the truck behind them. It was a long drive to Billings even at 80 mph. I can't tell you how alone I felt during that drive by myself. I alternated between crying and praying and offering myself to the Lord so that he wouldn't take my son. I remember asking the Lord to just crash this truck if it meant that my son might live. I was ready to die right then if the Lord would agree to take me, instead of my son.

Well, needless to say, I got to Billings in one piece thanks to the only radio station I could seem to receive. It was a Christian station (which I don't usually listen to Christian radio). I was looking for any C&W station that I could get, but the Christian station was it. I started listening and I know that God was talking to me through it. I found all sorts of messages that seemed to be meant for me alone and opened my mind to them and found comfort. All of this from me? Mr. Atheist!

Anyway back to the subject. We got to Billings and he never had another seizure and some doc told us after a week of tests that it seemed to be a liver thing that seemed to be healing and we went home, Happily. We had made it back from the dreaded Billings with our son. That is when things started to go wrong with me and my wife.

My normally happy, smiling wife had started having these anxiety attacks where I was the bad guy instead of the husband/partner. It got violent for awhile, where she was very abusive, verbally saying things like we never should have gotten married and f**k you, and I don't love you, and I never loved you bla bla bla.

The attacks would last for days at a time where I was some sort of enemy and was constantly under attack form my sweet loving wife. She would get violently angry with me if she had to stay home alone with our son, or if she might have to drive somewhere by herself. She would say things like "you don't have any idea what I am going through, or you don't even know who I am or how I feel," and then would be mean or would not even look at me for days. It was like I was alone in our house with people in it. There were times that she would not even acknowledge my being there for days at a time.

I started to realize that it wasn't me, but that the thing with our son kinda triggered this anxiety thing again. I started looking for help. It helped working at a hospital and pretty soon I found out from medical people that had known her for 15 years that this had happened many times before. They asked me if she was taking any medication or being seen by anybody and I told them no. They said that I needed to get her in to see her old doc again.

So home I went with the idea that I would ask her as tactfully as possible to consider getting checked out by doc so-and-so. Boy was that a huge thing. She was in total denial and would not go back. I didn't give in though because I wanted my sweet wife back. I took all of the abuse and anger (which was really fear) that she could dish and continued to take care of our son and did my best to keep my attitude together. I treated each day as a new chance to get things on the track towards treatment. I kind of treated the problem like a huge snow drift. If you can't drive through it, find a way around it. I kept telling myself that there is a way, even if I have to move the drift one snowflake at a time.

It would take love and courage and patience, but every snowflake that I managed to move meant one less to deal with. There were times that the entire drift fell in on me and I had to start over, but I didn't give up and eventually I was able to make a path through to her and get her back to treatment. Now she is on a different med (Paxil) and some counseling and a whole lot of love from me, and things are getting slowly back to normal (what is normal?).

I can't tell you how wonderful it is to see that loving smile again or that incredible feeling when we become one in bed. We are becoming totally emotionally/physically/spiritually connected again. Life is good and we are a family again. We still have bad days, and I believe that we always will, but now there seems to be some sort of balance. I would take many bad days for one smile, or touch, or sparkle from her eyes.

I think that you need to decide in your heart (not the logical brain) that you WILL or WILL NOT deal with whatever her troubles are and take things one day at a time. I have come to believe that there is no total "cure" for this thing, just understanding. Its kind of like a cold, we can only treat the symptoms, we cant cure the cold. There were, and are, many times that I say to myself "f**k this. I have had it, there are lots of fish out there, I don't need this kind of crap, nobody can treat me this way." I think of leaving and sometimes I just want to slap the woman (not that I would). Then, when I calm down, I realize how much this woman means to me and I convince myself that the larger the mountain you climb, the sweeter the victory's are. Don't quit man. Be the rock that you promised when you took your vows.

---

Its okay to run sometimes, just make sure that you come back. There always seems to be an easy way out of our troubles, but the easy way isn't always the best way. "That's what makes us men," my father used to say.

So try a little research on the problem. It will help you to understand the problem. Its okay to push her, I think, but make to sure to push the love also. It will make things easier for her to swallow. Make sure that she knows that you are her rock no matter what. Also kind of make it a game for yourself to "save" her when the car breaks down. Remember that she is calling her knight in shining armor and maybe there might be a reward for saving your damsel in distress. Sometimes a call for help can turn into an intimate encounter that you wont forget, but you can't tell the kids about.

Most of all though, try to loose the logic thing when dealing with the wife. I have that problem and it is hard for me to turn off sometimes. Remember that if you are dealing with an emotional wife, be an emotional man, and when she is being a logical wife, be a logical man. If you adjust to her, she will adjust to you also. Maybe not overnight-- but she will.

Most important though, take time for yourself to get away from the situation for a day sometimes. In order for you to be strong for her, be strong for yourself. Everybody needs a little healing/quiet/whatever time for themselves. You have to be true to yourself before you can be true to others.

Anyway, enough rambling. Good luck

Shaw

Hi Ken, I have been online (and offline) for a few years now and never knew about your website. I think this is fantastic!

My husband suffers from "Chronic Panic Disorder with Agoraphobia." He was termed disabled 6 yrs. ago but has suffered must of his 31-year old life. We have been married almost 10 yrs. and most of our life together was haunted by panic. It is a very hard thing to watch your spouse go through.

We lived in a very small town and no one knew what panic was. 8 yrs. ago was when it was the worse.11 doctors and a year of testing etc. and him becoming housebound until they finally diagnosed him. Then a year of fighting with agencies to get him some financial support. We still have not found a doctor who could help him, so we have done it ourselves!!!

Success story, here we are! 8-years ago Tom was housebound...actually stuck in 2 rooms (the bathroom and the living room). I was his "safe" person and was stuck w/ him. When I cooked or went into our children's room, he would stand at the door and watch me, very anxious. When I took a shower, he was in the bathroom w/ me. I never left the small 4 room apt for about 6 mos. My family and friends had to do our shopping, our errands, even take our newborn and 2 yr old to the doctor. We could not afford to have a phone. We sold everything but our children's beds and clothes to keep food in their mouths. It was rough time!!!!

Slowly, after those 6 mos., I got Tom to take a step outside the door. The next day 2 steps and so on. It was a very slow process, but over a long period of time, I got him back to a doctor and on his way to recovery. I did so much research because all the docs did not have a clue and he could not travel outside our town. We forced the docs to keep trying new meds while Tom and I worked on behavior modification. Tom would only do so much though before the fear took over.

Well to make a long story short, one day, in fact the 4th of July 1999 (HIS DAY OF INDEPENDENCE!!), he decided that his family and his life was worth more than the panic and he did it--he drove to Buffalo, NY which was a hour away from home. He had tried and tried in the past, but could never make it even half-way. The next day we did it again and then 2 days later we drove 750 miles to my parents in TN!!!! He was finally free! We laughed and cried and went through lots of panic and anxiety but we did it. We have made several trips back and forth. In fact, the end of July, we moved to TN!!

And now after 8 yrs., Tom is working a full time job, a half-hour away from our new home and away from me!! He has learned how to accept panic as part of his life and how to cope w/ it. We have found each other and ourselves again. And yes, I still cry everyday but out of joy instead of frustration now!!!

Please share this w/ panic sufferers and their families to give them hope. There is life w/ panic! And if anyone needs some support, please send them my way. Thanks for listening!

Love and Prayers. DTILRY

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The Caregiver

"Nine, Ten , Do it Again." A book for those with OCD and their families.

We're constantly searching the world for excellent books which may not be readily available through your usual outlets. We're very pleased to present Kathryn I'Anson's most recent book on Obsessive-Compulsive Disorder (OCD).

Rather than describing the book, the author has allowed us to place the chapter on caregiving those with OCD on our site. I'm sure you'll agree it is written in the clear and straightforward style of a person familiar with OCD who does not have to constantly fall back on technical terms to provide the help and understanding the book offers.

This book is now available through Amazon. Click on the title to order.

Highly Recommended: Nine, Ten , Do it Again: A Guide to Obsessive Compulsive Disorder: An excellent clearly written book for both those with OCD and the families of those living with it.
Kathryn I'Anson. $12.00

Table of Contents

• Introduction
• What is Obsessive Compulsive Disorder?
• 'Life Begins at 47! A Sufferer's Story
• What Causes OCD?
• Assessment of OCD
• Treatment of OCD
• Self-Help Strategies
• For Families and Carers
• Other Books Which Will Help

The following section is based on extracts from: Nine, Ten , Do it Again: A Guide to Obsessive Compulsive Disorder 2nd edition, 1997. 91 pages

From the Cover: The author, Kathryn I'Anson is the Director of the Obsessive Compulsive & Anxiety Disorders Foundations of Victoria (Australia) . The material has been reproduced by kind permission of the author. The British and Australian term for "support person" is "carer".

This is one of the most informative and easy to read books I have come across on OCD. The author's style is such that you feel she is talking to you on a one to one basis explaining OCD both from the feelings of the sufferer and from those of the caregiver.

Extract from the Chapter for the Family and other Support People

Helping the Carer

If you are a spouse, sibling, mother, father, child or friend of a person who has OCD, then it is quite possible that you have been suffering too. Carers of people with OCD have to deal with many emotions that arise as a consequence of living with and caring for a sufferer. You are likely to feel worried, frustrated and confused, and sometimes despairing. These difficult feelings arise from the impact of the OCD on your relationship and environment and because it is so hard to see someone close to you either battling or in despair over thoughts and behaviours that seem to make to sense. Maybe insidious guilt thoughts creep into your mind. "Is it my fault?", "What have I done wrong?", Should I have loved and cared for him/her more?" Maybe you feel angry and confused - simply can't understand how it is possible that this person, who seems quite rations in all other respects, just can't stop these ridiculous behaviours. Have you secretly wondered, "Is it attention seeking, laziness, naughtiness?'" On top of all these conflicting feelings, there is the feeling of helplessness you just don't know what to do.

The Following ideas and strategies may help:

Do not condemn yourself for having negative feelings. They are natural reactions to a difficult and confusing illness. You cannot be expected to understand behaviours and emotions which you have not experienced yourself - at least initially. You will develop greater understanding if you spend time reading relevant material and listening to your family member and other sufferers at support groups. However, negative feelings will continue to arise - occasionally or often, and self-condemnation and guilt over these feelings will only make them more difficult to let go. Accept your feelings, and actively find a way of releasing them on a daily basis - for example, talk them through with a friend, cry, go for a long walk or drive, do an activity such as gardening, painting or craft which enables the creative expression of feeling.

Obtain support and care for yourself.

Maybe you have a great circle of family and friends who provide an empathic listening ear and practical help when you need it. If not, you might consider joining your local OCD Support Group where you will find some people to care for you, and you can talk to and learn from other carers who have been in similar situations. If your own state of mental and emotional health is suffering, it may be helpful for you to see a therapist. This will be a positive act of affirmation that your health and needs are important, and will put you in a better position to help the sufferer effectively.

---

 

Obtain and read information and books about OCD so that the disorder can put into a proper perspective.

As you learn more, you will be able to make some new choices about your feeling and reactions to the OCD. For example, you will learn that your family member's strange and excessive behaviours are not caused by a lack of willpower, and that pleading, threatening or cajoling them to stop will not help. You will learn to accept that the OCD impulsive urge, anxiety and intrusive thoughts are the compelling force behind the repetitive behaviours, the slowness, the constant questions or requests for reassurance. You will also learn that you didn't cause it. You will recognize the important part you can play in your family member's recovery and discover many ways that you can help. The recovery journey will not e easy and you will still feel frustrated and despairing sometimes. However, now you know why you are feeling this way, and that your feelings are a reaction to the OCD, not the sufferer.

Take Some Time Our for Yourself

Every week - or every day if possible, spend some time doing something that you really enjoy and where you cannot be interrupted. We all need some time to ourselves, and we all need time to relax, have fun, and to pursue those goals that interest us. If you are able to look after you own mental and emotional well-being, you will cope better with the stresses that the OCD brings into you life.

Helping The Sufferer

If you have been living with a family member who has had severe OCD for along period of time, it is likely that the disorder has caused significant disruption and distress to your home life, relationships and social life. Possibly you have been involved in the sufferer's rituals or avoidance behaviours, trying to ease her distress, or just to keep the peace.

Avoidance Behaviours:

People with OCD avoid many situations or objects that trigger their compulsions. Your involvement in avoidance behaviours may take many forms - for example, you may do all the shopping because the sufferer's compulsions are triggered by contamination and decision making fears involved with buying food, or you may always have to cook the meals, clean the house, or answer the home telephone or the front door because of similar triggers of compulsions and the sufferer becomes too distressed if pressed to to these things. There are several things that you can do to help ease the daily stresses as is the sufferer in their recovery.

Share your knowledge and new understanding of the disorder with the sufferer.

The isolation that four family member has been feeling has been an enormous burden, and she has been feeling distressed and guilty about the affect of the disorder on you. Now, hopefully, you will both be able to talk about the disorder, and express your feelings about it, openly and honestly. This will be a great beginning to the healing process for both of you, and any other family members of friends that are involved.

Encourage the sufferer to talk to you about her disorder.

This will help you to understand exactly how her obsessions and compulsions, have been interwoven into the daily fabric of her life, an yours. This may be very difficult for as it is often very embarrassing and to explain, so ask, but don't push and let her tell you in her own time. When your family member does decide to confide in you, listen attentively, encourage her to get it all out , and thank her for trusting you. Return this trust by accepting what she tells you as an hones and accurate account of what she feels and experiences. Ask questions, if you need to, to clarify what the anxiety or compulsion or obsession in and when it occurs, but don't start trying to engage the sufferer in discussion about the logic of her behaviours. The sufferer will immediately catch on to the fact that you do not understand, and it may be a long time before she will confide in you again.

Encourage the sufferer to obtain professional help.

Your role here will be to provide support and encouragement, and if she agrees, to offer some practical help in locating an experienced therapist. If the sufferer decided to try behaviour therapy, and if you have been extensively involved in the rituals or avoidance behaviours, it will be important that you join in the therapy at some stage. The sufferer will need your help as she begins doing the work with exposure and response prevention, and so you will need to know what to do, what not to do, and the best ways to support her. If you and other members of the family are involved in the sufferer's rituals or avoidance behaviours it is important that you begin to reduce your involvement and find ways of normalising the family routines. Firstly, discuss this with the sufferer - don't just abruptly stop your involvement as this may cause her a great deal of agonising distress. Tell her that you want to reduce your part in the rituals or avoidance behaviours to help her get better, and decide with her which ones you and other family members will no longer participate in. Set some realistic goals together, and make sure that the whole family agrees to abide by the plan. Once you begin to work cooperatively together in this way, your situation will gradually change and the sufferer will no longer take your involvement for granted. When the sufferer undertakes behaviour therapy or a self-help programme, the work you have done together will give her a great head start. Once therapy begins - whether pharmacotherapy" [medication] " or behaviour therapy, your involvement in the sufferer's rituals and avoidance behaviours should be reduced to zero - if at all possible. The doctor or therapist will need to be informed if y our involvement continues, so that they can work on this aspect with the sufferer.

---

Create a Supportive Home Environment:

The home is often the primary setting of compulsions, and is also generally the 'haven of avoidance' for the anxiety sufferer. The less tension that in 'in the air' the better. If there are significant conflicts in some the family relationships, it would be very helpful to the sufferer if these conflicts are worked through and resolved - including those conflicts that include the sufferer.

Ask your family member to tell you when she is having a particularly hard day.

Your family member's symptoms may flare up when her anxiety is high, she is depress, or when she is stressed about something. Offer what support you can, and be flexible in terms of what you are expecting from the sufferer on that day.

If you notice improvements, however small, acknowledge them, and encourage the sufferer to reward themselves for the progress. Fro example cutting down a hand washing routine by 5 minutes, or reducing a checking ritual from 50 checks to 40 checks may seem insignificant, but represents a great step forward by the sufferer. Your recognition and praise will encourage her to keep trying.

Try to maintain a non-judgemental and accepting attitude toward the sufferer. A non-judgemental attitude from you and all the family, to sufferer, and avoidance or personal criticism, will enable the sufferer to focus her efforts at coping and getting well, rather than expending her efforts in dealing with anger and resentment.

Laugher is good medicine.

When the sufferer is doing well, and having a good day, a bit of humour and laughter - offered with sensitivity, is great balm to soothe away some of the painful feelings and thought which arise.

Be patient.

None of the treatments or self-help programmes that are available for sufferers provide quick 'cures' - or even immediate relief. Recovery is a slow and gradual process. Be prepared to support the sufferer on a long-term recovery programme, and don't make day-to-day comparisons. Recovery always includes slips and set-backs - the important thing is that the set-back isn't interpreted as failure. The guilt and stress that will arise from thoughts and feeling of failure could make the set-back much more difficult to overcome, than if it is viewed as an opportunity to learn.

There can be no simple, straight-forward plan that will smooth away every rock on the road to recovery. Every person who has OCD, and every family who has a sufferer as a member, has a different set of symptoms and circumstances to deal with, different relationships, different personalities and a whole complex array of different influences, Try these ideas and strategies, and draw upon all the resources and support that you have. Slowly, but surely, you and sufferer will discover the treatments and self-help strategies and ideas that will work for you."

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