Wednesday, February 9, 2011

Character Diagnosis: Agoraphobia vs. PTSD

Today's post will be in answer to a question sent in by Rachael, of Writers' Chasm:
My female MC (Kaye) lives on a ranch and she hasn't left it in almost a year. Her mother died in a car crash on her way back to the ranch from a horse auction. Ever since, Kaye has been deathly afraid to leave her home because she's afraid that she won't come back. I was wondering if there was a medical term for this and how it could be overcome.
Hmmm. This calls for a little differential diagnosis. See, when someone comes into my office and tells me something like this (er, except, someone unable to leave a ranch probably wouldn't come in ... but I'll get to that later), the first thing I do is gather more information.

First, it's clear Kaye has an anxiety disorder (hint: the "deathly afraid" part kinda gave it away). I emailed Rachael and asked her a few questions about what's going through Kaye's head when she either leaves the ranch or thinks about leaving the ranch. The reason why: I have to figure out what type of anxiety disorder Kaye is experiencing.

What Rachael told me in answer to my questions:
  • Kaye avoids leaving the ranch and gets anxious even thinking about it
  • When she does have to take a trip into town, she has a panic attack when something unexpected happens, even though it's minor
  • She is hyperaware of her surroundings when she's not at the ranch
  • Her fear of leaving the ranch sometimes involves thoughts of her mother
Now, if Kaye came in for an intake session, I'd have an hour to figure this out. I'd get a detailed history and rule out a lot of other disorders. But since I have only a few sentences, I'll just narrow it down to the two most likely possibilities:
  • Agoraphobia (and then I'd have to figure out if it's accompanied by Panic Disorder)
  • Posttraumatic Stress Disorder (PTSD)
A previous post on PTSD can be found here. It reviews symptoms of that particular disorder as experienced by a certain super-popular werewolf.

The other possibility, Agoraphobia, includes the following symptoms:
  1. Anxiety about being in places/situations where escape is difficult or in which help would be unavailable in the event of a panic attack or panic symptoms. Feared situations often include traveling in cars, being in crowds, and being in public alone.
  2. The feared situations are avoided or endured with intense distress/panic (the person often requires a companion to get through it)
  3. Symptoms aren't better accounted for by another anxiety disorder (including PTSD)
Diagnosing anxiety disorders is all about figuring out what the person is afraid of.

I don't actually have enough information to make that call here, but I'll say this and let Kaye's creator, Rachael, decide:
  • It's more likely to be Agoraphobia if Kaye is most afraid of panicking or of being unable to escape and get back to her house.
  • It's more likely to be PTSD if Kaye is most afraid of being reminded of her mother's death AND is showing other symptoms of traumatization.

And why is it important to figure out what she's afraid of? Because the treatment for the two disorders is (somewhat) different.

BOTH treatments would probably involve some cognitive behavioral therapy to help Kaye change the way she thinks.
  • If Agoraphobia, her therapist would help her interpret her physical symptoms in a way that helps her avoid a full-blown panic attack, and help her identify and challenge her fearful thoughts about leaving the ranch.
  • If PTSD, her therapist would help her understand how certain thoughts about the trauma (her mother's death) might increase her stress and fear (like blaming herself).
AND THEN, there's the exposure. This is one of the essential components of many anxiety treatments, and research shows it's pretty much the most effective. But it's not fun.

That's because it involves exposing yourself to the very thing you fear.

  • If Kaye has Agoraphobia, she's gonna have to leave the house and cope with being out in public.
  • If she has PTSD, she's gonna have to expose herself to the MEMORIES of the trauma.
In summary, for Kaye, treatment will involve first figuring out what exactly she's afraid of, then helping her think about it differently, and then exposing her (gradually) to what she fears.

Treatment for Agoraphobia can be a little tricky because the person may have trouble coming to appointments. This is where insurance-funded treatment can be so frustrating--insurance companies usually won't pay for treatment that doesn't take place in an office. The exposure therapists I know like to do their work in the field whenever possible. They get out there with their clients and expose them to what they fear until it's not so scary anymore. It's totally fascinating to hear them talk about it. Seriously, one of them had a client who was really afraid of farting in public ... so guess what the treatment was? Anyone interested in a post on exposure therapy?

On the Sisterhood of the Traveling Blog front, check out Lydia's post on critique.


  1. And I always thought Agoraphobia was just fear of wide open spaces. Things are never that simple.

    Your writing related psychology posts are always so fascinating Sarah!

  2. Oh no, I think I have Agoraphobia. Maybe.


  3. hi miss sarah. i got wondering for that mc kaye could it make a difference for knowing what shes got because she didnt have it til her mom got killed? so maybe its not some thing shes been having for her whole life. for that doing what youre scared of one of my brothers was real scared of flying and he went and did real short flights and got past it and then on a surprise he went and did flying lessons. wow how cool is that!

  4. Matt--other common fear situations for folks with agoraphobia do include being on bridges or standing in line ... and it literally translates as "fear of the market place", so your understanding was partially true. But you're right, it's not that simple. And--thanks so much!

    JD--I don't think so, based on what I know of you!

    Lenny--that's a good point. Still, trauma causes a lot of different problems, but it doesn't always mean the diagnosis is PTSD. It helps to know she didn't have symptoms before her mom died (if that's true), but we still need to do a complete assessment of what exactly is causing her anxiety and panic--fear of driving, fear of being in public, or fear of being around things that remind her of her mother's death. Does that make sense? And it sounds like your brother did his own brand of exposure therapy! Good for him!

  5. Thanks so much Sarah! :) I, like Matthew, always thought agoraphobia was just a fear of open spaces. I'm thinking Kaye is agoraphobic rather than having PTSD. Thanks for taking the time to answer my questions. I love all of your psychology posts.

  6. This is a great post. It shows how important it is to understand which diagnosis you're going for in order to create the credible character and circumstances.

  7. This is SO interesting! Every time I come here, I learn something new and I've always been interesteed in whats behind human behavoir and different phobias. Really neat, keep it up!

  8. Great post Sarah! I often have to email back to get more details. It's all in the details!

  9. I think I had temporary agoraphobia during jury duty yesterday.

  10. Love this. I need to make better use of my own Psych background (though not as extensive as yours).

  11. A post on exposure therapy would be very interesting!