A Case Presentation: Hyperventilation & Agoraphobia

    Tami, a 26-year-old woman, suffered from hyperventilation a few times a day, and from agoraphobia. Tami could not go out of her apartment by herself. The fast breathing made her feel dizzy, lightheaded and tingling. She claimed that all her symptoms had started about two months earlier, and that she did not have the slightest idea what caused it. During our first meeting, I gathered information about her personality and the onset of the symptoms.

    Tami was born in Chicago to Israeli parents. When she was 16, the family emigrated to Israel. She described a happy childhood. After serving in the Israeli army as a secretary, she worked in a civilian office, apparently enjoying her employment. She was married about two months previously, and her symptoms started during her honeymoon. She described her husband as a wonderful person, who loves and cares for her very much. From the way she described her life, up to the onset of her symptoms, I could not find any clue to explain why she felt suddenly so anxious. I asked her to describe her honeymoon. Since she was born in the USA and had not returned there since she left for Israel, she decided to spend her honeymoon there, and to visit Chicago where her grandparents live, and also briefly tour New York city. The trip to Chicago indeed turned out to be very exciting. She enjoyed meeting her grandparents and showed her husband her old home and school, and they met some of her old friends. Their plan was to spend a week in NYC before returning home. While the plane from Chicago was descending toward the JFK airport, she suddenly started breathing very fast and felt heart palpitations. She feared she might faint. The couple took a cab to a hotel near the airport, proceeding immediately to go to the emergency room of the nearest hospital. A physician diagnosed her symptoms as a panic attack and prescribed medications. All night long, Tami walked in her room, from wall to wall and did not stop crying. In the morning, the couple flew back home. An Israeli physician changed her medications, and recommended psychotherapy. The following day she tried to go out for food shopping, but she returned immediately since she felt very strong heart palpitations and she feared she might faint. Since then, she was staying most of the time in their apartment, feeling very anxious. She claimed that the medications hardly helped her.

    During our second meeting, we focused on trying to understand what had triggered Tami's anxiety attack. I suggested her to close her eyes and visualize her honeymoon, as if she was watching a movie, and to describe it to me. She re-experienced the positive feelings she had while visiting her grandparents in Chicago and their preparation for the trip to NYC. I asked her if she had visited NYC while living in the States as a child. She answered in a very tense voice:
- "No, my parents did not allow me to go to NYC. They said that it is too dangerous."
- "Tel me more about it."
- "It was during summer vacation, just before we emigrated to Israel. I planned a week's trip from Chicago to NYC with my girl friend. We discussed the possibility of staying with her relatives. However, my parents refused to let me go, stating that NYC is too dangerous for two 16 years old girls to walk there by themselves. They were sure that we would be robed, raped or even murdered on the first night there."

    As Tami told her story, her breath accelerated and her entire body was very tight. On the other hand, I felt relaxed. Her story gave me a hint on what had triggered her symptoms, and I started planning ways to help her. My first step was to re-label her symptoms. Instead of relating to her as a neurotic woman, who suffers from agoraphobia and hyperventilation, I would describe it as an exaggerated reaction of a normal instinct.

"You should be proud of yourself, Tami" I started in a supportive voice. Your hyperventilation and your accelerating heartbeat started as your plane was descending toward the JFK airport. Such symptoms indicate that your body and your mind were prepared to cope with a dangerous situation. It seems that part of you agreed with your parent's view of NYC and was afraid of being hurt there."

    Tami opened her eyes and gave me a bewildered look. I explained myself. "Yes, you were ready to face people who might attack you or to flee from them." I want on to explain the evolutionary theory of "Fight or Flight" and the fact that hyperventilation must have been a useful tool that helped our ancestors to survive, but that this reaction seems to interferes with coping in modern times. (For more information, read the appropriate chapters in the site). It appeared that the evolutionary explanations helped Tami to feel somewhat better about herself. I suggested her to share the theory with her husband and to ask him to join us in the next meeting.

    During our third meeting, I instructed the couple with a variety of relaxation techniques and Mental Imaginary exercises. I suggested to Tami to practice relaxation by listening to a Relaxation CD twice a day, once in the afternoon, and once while going to sleep (For more information, read the appropriate chapters in the site). I suggested to Tami's husband to practice with her going out of their apartment. Every afternoon, when he comes back form work, they should go out together. He should walk a few steps behind her without talking. Tami should feel as if she is walking alone but feels secure because he his right behind her. When she feels somewhat more comfortable to walk like that, he should walk even farther away behind her. I suggested to Tami to focus on stimuli around her, such as looking at cars, at houses, at trees or at flowers whenever she feels frightened. At the end of the session, I applied a Paradoxical technique.
"I hope until our next session you would have at list five and a half hyperventilation attacks." I said with a smile.
"Why do you wish me to have such attacks? I pay you to help me not to have such attacks any more." Her voice sounded very angry.
"You came to me to learn to accept the fact that you are only a human being and as such, until you are an old lady, you may experience a few more hyperventilation attacks. When it happens in the future, instead of being angry with yourself, you should smile and say inwardly: "Grandmother Lucy came to warn me that a predator tries to hurt me and that I should raise the level of my Stress hormones in order to defend myself." I suggest you to be nice to her, give her a glass of water and explain her that her techniques do not help modern people. Send her back to her cave. After she leaves, do some relaxation exercises" (For more information about grandmother Lucy, read the chapter: Evolutionary Psychology in the site.)
"O.K Dr. I'll do what you said." She answered with a smile.

    Tami arrived for the fourth session with a very good mood. She claimed that during the week, she hardly had any hyperventilation attacks, and that she walked around their block many times. During the last two evenings her husband stood in front of their house and she walked by herself around the block. Whenever she arrived close to him, they waived to one another and she continued to walk. I pretended to look disappointed. I told her that I wish that next week she would experience a few times hyperventilation. She answered with a smile, indicating that she knew what I meant.

    On that session, I focused on helping Tami to overcome dangerous people. While her eyes were closed, I instructed her to imagine that she is a director of a movie, besides being the main actress. In her movie, she is a teenager, walking with her girl friend in NYC. Suddenly, a strange guy grabs her hand and demands money. Since she is the director of the movie, she has to finish it with a happy ending. After being quiet for a minute, she started to talk.
"I see the guy, he looks very mean. He demands money. I give him five dollars. As he stretches his hand to grab the money, I spray his eyes with a special chemical. He starts rubbing his eyes screaming with pain. A police officer arrives and takes him away."

    I asked Tami to direct another movie in which her husband and she are the heroes. They are a young couple on their honeymoon. The same mean guy stopped them demanding money. Tami did not need a long time to plan the happy ending of the second movie. On the spot, she described how both of them overcame the mean guy, and again a police officer arrested him.

    The fifth meeting was our last one. Tami came with her husband. She described how they practiced walking in different places while her husband was a few yard behind her. They walked in a mall, in a supermarket and on the boardwalk. They bought a small empty spray bottle and filled it with vinegar. Tami held it in her hand, while being ready to defend herself against anyone who might try to hurt her.

    I encourage every one who suffers from hyperventilation or from agoraphobia to try self-help by practicing relaxation and mental imagery techniques. If it is not sufficient, it is recommended to seek the help of a psychotherapist.