Panic Attack, Agoraphobia and PTSD: An Abuse Survivor’s Journey

Dedicated to my Therapist and to all Survivors who will make the same journey

Please note: The following article is my experience of panic disorder with agoraphobia and its relationship to Post Traumatic Stress Disorder (PTSD), and not intended to be predictive for everybody — nor should it substitute for consultation with a professional. If your experience isn’t the same as mine, it doesn’t mean there’s anything strange about you, just that people can experience different symptoms. One thing I can tell you is that with the right treatment and support, you will get better. Panic attack is very common, and most people do make full recoveries. I hope this article will be a comfort to you; please believe that you are not alone. Please also be warned: except to open with giving the PTSD I’ve had some context, I have not been heavy on descriptions of abuse, but what follows may contain some triggers if you are a survivor.

Background: Traumatic Beginnings

I am a survivor of child sexual and physical abuse, as well as domestic violence and rape in my young adulthood. The sexual abuse commenced when I was four with a series of oral assaults which I told about but nobody acted; I was first raped when I was eight by a family friend whom I thought would kill me — this went on until I was ten. The physical abuse involved being punched, kicked, stampeded on, handfuls of hair torn out of my head; having my head held underwater when I was four, strangled, and chased with kitchen knives. My childhood was not safe, or the small reprieves of safety never lasted. Love, peace and safety could be whipped away in seconds. There was nobody to go to, because those I could go to either didn’t protect me or were doing the abusing. When I was twelve, I’d had enough and attempted suicide, instead making myself very ill. I am thankful I survived though, and what helped was that I seemed to retain a belief in goodness and beauty. However, as some survivors of child abuse unfortunately do, I learned that I was not actually worth safety. This was to help set me up for a violent partner who beat and raped me, and from whom I eventually fled for my life at the age of twenty with two young children into a relatively safe future.

As survivors sometimes do, I began to process these events at a time when I was safer. For many years, I worked hard to overcome the worst ravages of these experiences, and had enjoyed a degree of success in doing so. I have had moderate to severe PTSD, and I had come to accept that I would probably always be left with certain PTSD symptoms – for example, I can’t remember a time when I haven’t been hypervigilant (on the lookout for danger), or easily startled. Healing involved creating some belief in safety. This was hard, because while there was now no external threat, internally I continued to perceive the world as a threatening place. I have been an anxious person for most of my life, offset by a warped sense of humour and good coping skills. As my healing advanced, I learned to accepted my little trigger pockets, and just nursed myself through them, asking for support if necessary. I had had some years of good counselling, and as a rule, I coped successfully — in fact sometimes I was quite blasé about it all, and enjoyed assisting other survivors to the knowledge that they could heal. I have successfully raised children in an environment of love, I have a happy marriage and am a university graduate with a published book to my credit. Yes, it was a good life; I was very glad to have survived and healed.

Exacerbation of PTSD in my 40s

Judith Herman writes that survivors of child abuse may find that PTSD symptoms are precipitated by events such as the birth of a child, a failed marriage, or a change in family relationships (1992, p.114). In 2008, I experienced a dramatic change in family relationships. It was to trigger the severest bout of PTSD I have experienced to date.

I had always believed that I was the eldest girl of three. In March 2008 my mother told me I had a sister 6 years older than myself. Because my mother had been prone to making up wild stories in order to manipulate me, I initially wasn’t sure whether to believe her. But it was true. This girl had been relinquished for adoption in 1960. Finding out about her has been one of the best things that ever happened to me; this beautiful woman, Sue, and I are now the closest of friends.

It was a tremendous shock and I had a lot of emotion — compassion for my mother and incredible grief for this sister I’d missed for more than four decades. For the sake of my own emotional safety, I had had only limited contact with my mother for some years. But at the time of my sister finding us, I made myself available for emotional support to my mother. Despite what she had done to me, I really felt for her, and I was angry at a hypocritical society that visited so much punishment on unwed mothers. As the mother of beloved children, I simply could not imagine the utter wrench of being parted from them. I felt enormous empathy for my mother, and at this time, I believed that I was in sufficient control to engage in more contact with her.

When Sue’s existence was verified, I cried almost non-stop for twenty-four hours. I was shocked, yes, but also felt very very sad that in her search for her mother, I knew exactly what Sue would find. Even if she didn’t have any expectations, I felt actual agony that it would not be nicer and better for her. A moral dilemma I faced was wondering how much to tell my sister about the abuse. I did not want to stymie any relationship she might develop with my mother. But I knew that she was on a search for truth; she urged me to tell her the truth. So I selectively and gently disclosed that it had not been easy to be a child growing up in our household (Note: My parents did not sexually abuse me; they beat me and the emotional cruelty was severe). I also wanted to be objective and fair, selecting anecdotes to share that were positive, because there were those too – we come from a line of intelligent, creative and funny people. I was preoccupied a lot with what to tell her or not. I did much private crying too; even though my sis had not been through the abuse that I had, the very thought that she might have had to endure it if she’d been the eldest instead of me broke my heart. In my ability to imagine it happening to Sue, the terror and hurt of my childhood dawned on me in a deeper sense than it ever had before.

As I was reflecting that I was glad for her sake that my sister had not shared my upbringing, I was aware that I was somewhat triggered into powerful emotions around my childhood, but I supposed that this was only natural and accepted it with relative — if tearful, equanimity. I was not to know that my history would become a tsunami that would cause me to feel as if I had achieved no healing at all.

The Emergence of Panic Attack and Agoraphobia

I noticed that I was becoming very uncomfortable when out in public — I felt trapped, and felt the urge to run. Believing it would go away, I studiously ignored it, and generally functioned normally.

About 4am in the morning of June 26th 2008, I woke up ruminating about Sue, my mother and the fate Sue thankfully missed again. I certainly did not begrudge my mother and sister the relationship they were developing, and I respected that my sister’s journey with her would be very different than my own — indeed, I wanted to support her in it. It was hard in some respects though, because this was the mother who could not love me, and whose love I had tried to win until I moved into acceptance that there would be no change. But watching her have a relationship with this other daughter was tremendously confusing to the little girl in me. It was not jealousy…it was something sadder. Like another abandonment, maybe. I was also scared by a feeling of, well, weirdness about it all. Yeah, watching their relationship unfold was strange. I considered that my mother must have been really damaged by the time I came along, but did that translate to treating a daughter the way she’d treated me? Even though I had survived bad things, I thought that I would rather die than treat my little daughter in that way; my little daughter, who, I reflected, was the tender age of eight. Eight — and a real frisson of horror grabbed me as I thought about how I was eight when I was raped. I thought, “Why is this causing me to freak like this?” I was not usually afraid anymore to think about this — even as I know how traumatic it was. I hated the creepy, horrible feeling, and determined to try and get some more sleep. Miraculously, I did

At about 8am that morning, I was getting my children ready for school, and wondered why the floor felt as if it were moving underneath me. It seemed as if I was reeling when I walked. Suddenly the thought occurred to me that I was going to faint. Abject terror seized me; my heart began to pound, my chest and throat tightened painfully, and I felt as if somebody had punched me very hard in the stomach. On jelly-legs, I tottered into my study and closed the door, sure I was going to die of a heart-attack in front of my kids. On a cold winter morning, I peeled off my thick dressing-gown because sweat was pouring from me. To my relief, the symptoms began to subside, and, having a reasonable working knowledge of PTSD and survivor issues, I knew that what I had experienced was a panic attack. I had experienced them before, (possibly not as bad as this one), but they had been isolated. I expected that this one would be too. I knew I was under stress. Although the attack had been so dreadful, by lunchtime that day I felt much better and went out and bought binders and fancy marble-paper to make a family tree for my new sister.

But, in the following weeks, the general unease did not go away. I continued to feel very nervous and depersonalized sometimes. I would reel in supermarket aisles, and couldn’t wait to get to the safety of my car. In late July, my husband was away for a weekend. I love being the only adult in the house for a couple of days, and on Saturday night, feeling warm and content, I poured myself a pint of Guinness and put on some 70’s music, which I had loved as a child. Suddenly, I had the most intense flashback — it engaged me at every level — emotionally, physically and mentally. I stood up, and was gripped by terror and reeling; I dropped into a squat because I was terrified of fainting and remained in that position until the fear passed.

Early August: I was driving into town and came to a stop at a set of red lights. My heart began to pound; I felt as if something terrible was about to happen. A full-blown panic attack engulfed me. Desperate for escape, I wound down my window, wondering if I could abandon my car and run away from it screaming. Knowing that I would be likely to be locked up if I did any such thing, I sat there. It was pure torture. I felt utterly trapped. Of course it passed, and I somehow made my way home. Something cracked; I became really frightened that there was something seriously wrong with me; something that felt unbeatable. I cried hysterically and wondered if I would be declared insane and hospitalized.

After this, I became frightened of going anywhere, to the extent that even parking outside a milkbar caused me to panic. Particularly, waiting at counters to be served caused me shocking fear — I wondered if shopkeepers would think I had Parkinson’s disease because my head would be shaking horribly, not to mention my hands when I passed them money. I no longer felt able to drive anywhere except pick-ups and drop-offs of my children at school. The fear of red lights had extended itself to waiting at T intersections. McDonald’s drive-throughs were a thing of the past; the sense of entrapment I felt having cars in front of me and behind me caused fully-blown panic. I saw myself becoming somebody who could not leave the house at all, and this depressed me. I felt weak and crazy. It was so bizarre that if I looked at an item I had bought whilst panicking, I would become frightened. I cried with shame because I felt unable to pick my daughter up from the train-station when she visited, making a dumb excuse and paying for a cab. If I knew I was expected to go somewhere, I would feel scared silly for hours or even days before.

What was worse was that often, the panic attacks would leave the most dreadful aftermaths. I would go into states of anxiety and hysterical crying that could last up to 48 hours. Every time I dropped off to sleep, a burst of terror would awaken me. Panic and anxiety are closely related, but I experienced them with some difference:

Panic — a sense of stark terror and threat, that peaks and lasts for minutes before subsiding.
Anxiety — a sense of general dread and unease combined with a horrible sense of inescapable hopelessness, often came in the wake of panic, and could last much longer than the panic attack. The anxiety felt as if it was continually threatening to turn into another panic attack. Anxiety also had its own physical symptoms, such as a sense of weakness and tickling in my arms, and a fluttery feeling that sat at the top of my ribcage.

I could have understood if the memories of abuse from my childhood were distressing, but I experienced a state in which even good or benign childhood memories (which I did have, and which had been a comfort before) were suddenly completely terrifying too. I did not feel safe anywhere.

It seemed as if an emotional buffer within me had eroded. I like my favourite rock bands loud, yet loud music suddenly caused my nerves to go to water. Fighting between my younger children could cause near-panic. I could not afford to become angry, because too much emotion triggered panic. Tingling in my fingers — a common calling-card of panic attack — seemed almost constant. I wondered if this was what people used to call a “nervous breakdown.”

I looked up articles on the internet, but at the time, they offered me no comfort because I was certain that me and my case were somehow different — weirder — than those of other panic attack sufferers. I could feel no joy or happiness; it seemed that the sense of control over my life I thought I’d had, had been an illusion.

Much of the time, I felt very childlike; like a helpless little girl in inescapable danger. I craved a sense of safety; reading books about good mothers made me cry.

Throughout my childhood, I was forced to conceal even the worst fear, trying to “act normal” and cover up what was going on. As I got older, I also had a tendency to project an “I’m fine, thankyou” image to the world. Now, as a terrified adult, I was scared and ashamed of telling anybody how I felt, but for the first time in my life, I found that I could not feign being okay. I could no longer follow this lifelong pattern. I decided to tell. I started with my beautiful adult daughter, shaking and crying and apologizing. She urged me to tell my husband. I did, and he was wonderful. My adult son was incredibly compassionate, offering to drive me anywhere I wanted to go. My two best friends also put themselves out to go shopping with me. Without question, without judgment. I was moved to tears by their kindness. I learned that the people who love me actually wanted to help me. Actually, I now recognize that the eroding of my ability to pretend was a blessing.

I had been utterly frightened of telling my new sister about the panic. I didn’t want Sue to feel as if she’d walked into a situation full of nutjobs, and most importantly I did not want her to feel responsible in any way, nor did I think it was her role to take care of me. Eventually, I did tell her, and as I was attempting to do so, she said, “Louise, you’re wheezing.” So scared was I that telling her would spoil our new relationship that my throat closed to a pinhole, and the shakes started. But she was so lovely and understanding. I explained to her that I would not swap her coming into my life for anything, and that what was happening to me was not her fault but the fault of my horrible history. I am still touched that she was so supportive. It’s great to have a big sister.

It occurred to me that there was something positive about feeling more trust that those closest to me to wanted to help me, but this was suffused with shame at expecting people — especially my own kids — to squire me around like a helpless five-year-old. I felt so inadequate. I had been a strong and competent, if sometimes vulnerable woman. The loss of my sense of competency was horrifying. I felt as if I didn’t know myself anymore, or had lost the self that I knew. I didn’t know if she would come back, or if I would ever get better.

Of course I knew too, that much of what I was feeling — the entrapment, the certainty that something terrible would happen to me, the chronic sense of unsafety — were all things I had felt before. I had felt them as a child, and as an abused young woman, where terrible things I couldn’t escape did happen. But I dared not think about those things, because by themselves they triggered panic and anxiety. This caused a sense of having irretrievably back-pedalled in my healing. For years I had been able to handle even the worst events of my childhood, and I did not trigger easily. Now, the intensity of the memories could send me into a terrified tailspin for days. I really could not believe how bad the flashbacks were, and how rotten I felt after them. I felt myself being beaten, raped, fearing for my life, and having nowhere to turn literally as if it was happening now. Sometimes, if I was not remembering actual experiences, I felt a sense of the atmosphere of my childhood; the location, the smells, and the pervasive sense of thudding dread

I knew I needed help. In early September, I looked up a therapist who works with panic attack and PTSD, emailed her and booked an appointment.

Getting Help — the Turning Point

I was frightened to the point of tears of attending therapy again. What would this woman say to me? Would she think I was crazy? Would she push me to face my fears before I was ready, and blame me if I failed to do so? What if she thought I was a malingerer, carrying on about my childhood at the age of 42? I was terrified. And as it turned out, those fears were baseless. This wonderful woman was to teach me just how many of my fears were baseless.

I hope that my reader will pardon the obscenity, but I entered her consulting room shaking like a dog shitting razor-blades. I decided to tell her I was frightened of being there. She immediately put me at ease, telling me that many people feel that way when they’re revealing things they may be ashamed of to a stranger. I sobbed parts of my childhood out to her, as well as about the advent of my sister, and the subsequent eruption of panic attack and agoraphobia. In that first appointment she suggested several things that at least reassured me I was not going mad:

That given my history she was not surprised I had experienced panic attack She said that what I was experiencing was expected from people with a history like mine. (I remember I physically sagged with relief when she said this).
That people who were abused as children often develop actual physical changes in their brain chemistry/structure which means that they don’t process stress and fear the way non-traumatized people do. She said — and this was just so helpful to my understanding — “You’re responding like the eight-year-old.”
That it was certainly not uncommon for survivors, even those advanced in healing, to believe they’re doing okay but be triggered very badly by a life-event. Although I understood triggers and panic, I had not experienced them to such a debilitating degree before. It was a relief to know that there was nothing unusual about it.
That it was okay not to force myself to do things before I was ready. If there were days I was not up to going anywhere that was okay too. She said, “If your child was not well, would you force him to go to school? Little Louise is frightened and you may need to go gently sometimes.”
That I would get better; that Louise as I had known her would come back; she’d just “had a fright.”

I walked away feeling respected, normalized and hopeful.

PTSD and Panic — the Connection

Former agoraphobic and panic sufferer Bronwyn Fox writes, “Panic disorder can be secondary to post-traumatic stress disorder. On occasions, people will seek treatment for their panic disorder but will be too frightened or ashamed to speak of the traumatic event or events that preceded it. This is especially so in matters relating to childhood abuse.” Further: Despite the shame many of us feel over these issues, they need to be dealt with for our long-term well-being. (2010, pp. 33, 87).”

If you are a survivor or a professional reading this, I’m assuming that you know what PTSD is. If you have experienced more than one trauma, you may have developed Complex PTSD. In any case, when your safety has been called into question by rape or other violence, it’s quite normal to fear for your safety for a time. But it can turn into a pervasive sense that dominates your life. Panic attack can remind you of earlier, actual unsafety. And, like panic attack, PTSD is itself an anxiety disorder.

Understanding more deeply what was happening to me within the framework of PTSD enabled me to feel more compassion for myself. Many people who have no history of trauma also develop panic disorder and of course they should feel no less compassion for themselves. But I think that in my case, PTSD complicated panic disorder, because I was feeling fears that I had actually felt in the past, and based then on realistic grounds. With some embarrassment, I told my therapist about the red-light panic attacks, and I said, “There was no real trauma, but I feel just as traumatized as if a masked gunman had presented himself in my passenger seat.” And she said “But Louise, you have experienced real trauma, and when you panic, the traumatized part of your brain acts as if you’re back in the original trauma.” It was as if the traumatized part of me didn’t know the difference between then and now; all terror was interpreted as then with the same sense of powerlessness.

For me, feeling the panic exacerbated PTSD, and the PTSD in its turn fuelled panic. I felt as if I was facing both external triggers i.e. shopping malls, red lights etc., and internal triggers — powerful flashbacks and memories that were a lot scarier than they had been for a long time. As well, the symptoms of panic themselves triggered reminders of abuse; the terror, the urge to run, the sense of doom — and even the physical symptoms: The tingling in my fingers reminded me of having my wrists gripped hard enough to cut off circulation in my hands, and the sense of strangulation was also familiar. Importantly, although working with panic attack to maximize how I cope in the here and now has been a priority, my counsellor does not underrate that I have been traumatized in the past, and permits me to speak about this and its impact.

Panic and Cognitive Behavioural Therapy (CBT)

My therapist is a psychologist who works with Cognitive Behavioural Therapy (CBT). This was recommended to me by my friend Jes, and is considered a first-line treatment of panic and phobia. It works on altering thoughts that are causing you pain. It proved immensely helpful to me.

Although it is definitely nobody’s fault they have PTSD and may develop panic disorder with or without phobia, the way that we respond to it can fuel its continuance. If you have had a panic attack, you may feel, as I did, that you have had a brush with death. Whatever the case, you have been badly frightened in a certain place, time or context. Naturally, you want to avoid feeling that way again, so you avoid the situation in which you panicked (very similarly to the way rape survivors might avoid objects or places which remind them of the assault). Avoidance reinforces the likelihood of another panic attack, and leads to the development of a phobia. People feel as if they have no choice but to keep avoiding feelings so dire, but the phobia gets fed and reinforced by the avoidance. The panic attack leaves an imprint in your brain so that when confronted with a situation similar to the one you panicked in, you are programmed to respond the same – which is how somebody like me could go from driving into town without thinking about it for 20 years, to being too afraid to drive into town anymore after a 90-second panic attack. Without help, it can get worse over time; sufferers find that panic spreads into other contexts. Their worlds get smaller and smaller as they avoid more feared situations. And as we’ve already seen, if you have PTSD, you already have some fearful tracts laid down in your brain that can cause panic to erupt if you perceive yourself, however wrongly, to be trapped or otherwise endangered. CBT can help with PTSD-based responses too.

I found, as many people with panic disorder do, that when I felt the first symptoms — such as tingling fingers or wobbliness on my legs — that I would immediately think a panic attack was on its way, and this increased the likelihood of actually having one. CBT taught me that although these symptoms are unpleasant, they are not dangerous. Panic attack springs from how we interpretthese symptoms, and that is one of its dirtiest tricks. When we interpret symptoms differently, we begin to master panic. Another example: The sense of reeling would start, then I would get dizzy, think that I would faint, and have a panic attack. But the panic was a product of my thoughts about the dizziness, not of the dizziness itself. As I was to discover, panic was a product of what I told myself: “I can’t handle this.” “I just know it’s going to get worse.” Essentially, the symptoms of panic attack tell you lies, and you have to continually practice telling yourself the truth. CBT effectively retrains your mind to think the way you did before the panic pathways that developed into phobia were laid down. You can develop skills for handling it that will enable you to have control.

If you have suffered from panic disorder with agoraphobia, you may now understand that what you actually fear is the fear itself, not the shopping-mall or whatever other shape phobia has taken for you. It’s panic-attack you fear, but you have attached the fear to a certain situation and become phobic. That is the panic trick, and it really is a trick. Like me, you may have known intellectually that there was nothing to fear, but the trouble is, you don’t really believe that. You have been frightened so badly that you don’t believe yourself when your logical brain tells you there’s nothing to fear. For example, even though I had survived each panic attack, I was convinced that the next one might kill me — or at very least, cause me to collapse in a public place. CBT teaches you to practice facing the feared situation, and to believe, despite the panic symptoms, that you will be okay.

Let’s put it this way: As you’ve healed from rape or child sexual abuse, you may have found that healing in some ways begins intellectually — for example, you began to know logically that sexual abuse can never be blamed on a child — only to find that at deeper emotional levels, you didn’t really believe that, in fact you still very much felt to blame. Later, as your healing advanced, integration happened; you began to understand at those deeper levels that it was’t your fault. You changed the way you thought, and you feel better as a result. So it is with panic attack. What was so maddening was that I knew at intellectual levels that my fear was irrational. But I was still terrified; I hadn’t integrated the truth that I would be okay and could have control. Learning to understand and really believe that was a major turning point.

My therapist got me to explore what my fears were — fainting was one of the worst, and behind that, the fear that if I fainted, I would die. We explored the actual likelihood of this happening. The light-headedness that promoted the fear of fainting, I learned, was a product of my incorrect breathing (it’s called hyperventilation and is a common symptom of panic attack). Best of all, I learned that he biological changes that happen when you’re panicking mean that you actually are less likely to faint. That is a medical fact. I just needed to accept it.

I began to take small steps, such as going to the shop on my own for milk and newspapers. I was proud when I spent fifteen whole minutes in a larger store with just my two younger kids; it was hard but I did it. I had said to my therapist that I didn’t think I could stand more than five minutes in a shop. Once again, using CBT, she challenged that panic-feeding belief: What will happen if you stay longer? Why, really, can’t you stand more than five minutes? The time-limit thing is another lie of panic; there is actually no set time that you have to leave; no such thing as being too long in a shop. I was learning to observe where my thought processes went wrong — for example when I had such a thought as “If I have to stay in this supermarket any longer, I will lose control”, it lead to the likelihood that I would lose control and panic. When I changed my response to “There is no set time beyond which I must lose control”, I began to be able to tolerate longer increments in stores.

I still preferred though to have somebody with me for larger shopping trips. Because I still didn’t really believe I had what it took to conquer this, I did find that it was a battle to keep panic at bay, and sometimes I felt very tired emotionally from fighting so much fear. Still, I was making some progress; my therapist was pleased. I often found that if I spent a little time with myself in the mornings practicing deep-breathing and thinking proactively about what I was frightened of, I could feel near-normal by breakfast time. I had many good days where I could feel the improvement.

Setbacks

I had come to believe that if I went shopping with somebody else, I would be okay. Unfortunately, agoraphobic people can develop dependency on their “safe person” and this reinforces the (false) belief that they can do nothing outside their homes without the presence of this person. But one morning in late November, my best friend, Helen, took me shopping. I was aware that I was quite scared; my vision was funny, I was shaking and my fingers were tingling furiously. And, in the shampoo aisle, I fell for the panic trick that was telling me I was losing control. I had a complete meltdown panic attack. Sure that I was about to faint, I dropped into a crouch and breathed. It was harrowing getting the rest of my shopping done. Two weeks later, I experienced another terrible panic attack when I was out with my husband.

I was hysterically frightened and tearful about what this meant: Was there nothing safe anymore? Would I become completely housebound and start expecting people not only to take me shopping, but to do the shopping for me? This was worse! Perhaps I really would never get any better. I had a family holiday coming up — would I ruin it for everybody by not going out at all? What about the Christmas shopping? I started a descent into almost continual anxiety — I felt frightened most of the time; my fingers tingled and I reeled constantly. I became too frightened to even enter small shops again. I became depressed, and I believe that this was a response to believing I was getting worse. (Note: Anxiety and depression often go hand-in-hand. If you feel suicidal, please, please talk to somebody. And please know that this will NOT last forever. If you get help, it will look so different on the other side that you’ll hardly know how you got so low.) A complete low came for me the afternoon my husband wanted to go shopping for Christmas decorations. I, of course, was terrified and I persuaded him to take me to the pub for a couple of drinks before going to the shopping center. I truly didn’t think I could face it otherwise. Fortunately I did know that to continue this way would be creating more problems than it would solve (and it is now hard to believe I was really that scared). I was completely obsessed with my symptoms, continually checking in with them and worrying about recovery. This agony lasted a month until just before Christmas.

In desperation, I made an emergency, pre-Christmas appointment with my therapist. I was terrified she would think that I was a “failed” case. Oh, the things we tell ourselves!

My therapist explained that setbacks are a normal part of recovery. You cannot have a setback unless there has been recovery. She questioned whether it should even be seen as a setback, and asked me to consider the positives: Having had panic attacks with others present did not mean I was getting worse, but rather that I would learn to conquer panic in all contexts without developing false dependencies on “safe” people. She was absolutely right, and the following week saw me experience a powerful — and lasting — surge in my recovery. I was not sorry that the “setback” had happened; I learned from it and my therapist’s encouragement cemented my resolve to beat it.

Not all setbacks may result in feeling panic and anxiety to the same degree either. At the time of this writing (April 2009), I have been experiencing a mild setback; I feel a bit more scared when I’m out again. But I have not panicked because I know I can control it; I view it with objectivity and compassion and I feel cheerful and upbeat. I know I will be okay.

Recovery

Feeling a bit stronger, I decided that I would use the week leading up to Christmas with all the shopping and crowds it entails, to actively face the renewed fear. Best thing I ever did. Instead of something to be avoided, I viewed it as an opportunity to open up a can of whup-ass on agoraphobia. I still preferred to have somebody with me because it was more comfortable and I was quite fragile, but I knew that they couldn’t protect me from panic attack – I, Louise, would have to beat it without relying on a mediator. That I could do this was the most useful and transformative thing I learned from the “setback”. The fear tells us we “can’t” beat it but we in fact can.

I went shopping with my best friend for my husband’s Christmas presents, I watched Helen beside me, and wondered how she could be so calm. Then it occurred to me that Helen was not frightened because Helen knew the truth: That the shopping center was not dangerous. I know it sounds like a cliche, but I “saw the light.” Helen’s reality began to become my reality again. I looked around at the other shoppers: They too, knew that it was safe. Safe for them, safe for me too, despite my feelings. Something clicked: I began to integrate that if I could shop for 15 minutes, I could shop for an hour — more time didn’t become “more” dangerous. A couple of days before Christmas, my husband took me out shopping for a pretty nightie. I was very frightened, but determined to pick that nightie. I was scared silly and shaking horribly, but you know what? I found that if I stayed with it and did what I needed to do, the panic lifted! When it did, I felt great! I laughed at the panic, and even if I was scared, I decided to create excuses to stay longer in shopping malls. I felt pretty bad a few times, but I knew that it was “only panic” and would not kill me. I got the urge to run away many times, but I stood my ground, and thus learned to believe that there is nothing to run from.

Christmas Eve was spent wrapping gifts I’d shopped for, and celebrating with real joy the beginnings of the return of Louise as I knew her.

Although in the earlier stages, it was necessary to take care of myself and not push myself too hard, or not to push myself at all on very vulnerable days, now I knew that I was ready to push myself a bit more. I began to go out despite feeling vulnerable, or even because I was vulnerable. It was like saying “Bring it on!” Thus, I reinforced that the uncomfortable feelings do not lead to disaster; they stop. Panic can scare you, but it cannot hurt you. Flip it off and get on with what you want to accomplish.

I turned a corner. Although the symptoms were still there and still not pleasant I believed that they did not purvey disaster. I cannot tell you how happy I was to finally understand this at a level where it made a difference. But I can tell you that it was actively practicing facing the fear with some good CBT principles on board that did it.

I stopped fearing the fear. The beautiful thing about this is that when you stop fearing the fear, you are no longer engaged in this exhausting battle. You can accept that you might still be scared sometimes, but you know you will be okay. I got there. And the symptoms began to alleviate.

Where I am at Now

Even though I would love to say I am “cured” of agoraphobia and panic, it’s more true to say that my recovery is a “work in progress”. While I can now shop on my own, I continue to experience agoraphobic symptoms such as the sense of disorientation and foreboding. The difference is that I now know it cannot harm me; I have control over it instead of the other way around. Despite what I feel, I am not the least bit frightened to go shopping. I have not experienced a fully-blown panic attack whilst out and about for, oh, four months. I believe that what was brought up for me last year blasted a bit of a hole in my internal trauma container, letting out a very wounded child. I’m stitching it up; I am succeeding. It is not nearly the horror-show that it was last year; I feel much happier and more confident. I believe that I will make full recovery from panic attack even as I accept that PTSD will still pop its head up from time to time.

While I say that going out can still feel unpleasant, there are times when I actually forget the fear and feel completely normal. It is a joy to reclaim my life again. I have felt real exhilaration from counting out change slowly to a shopkeeper. I can now tell myself that checkouts are not traps, and believe it. I love the boring, normal mornings getting the kids ready for school without reeling around the kitchen trying to quell fear. I know the glory of standing my ground in that shampoo aisle by myself. And oh, the joy of persuading my husband to go to the supermarket for me – not because I’m too scared, but because I’m too lazy!

What is lovely also is that my “buffer” has begun to reform; I can feel a normal range of emotion without triggering anxiety.

I have made limited progress with my driving; while I am no longer afraid of T intersections, I am still funny with red lights. I am a bit more fearful of experiencing panic at the wheel of my car, but I have every confidence in overcoming that too. What inspires me is my knowledge that other people have achieved this; I love to hear the words “former panic attack sufferer.” I know there’s nothing odd or different about my case; one day in the not-too-distant future, I too, will be saying “former.”

I have more compassion for myself; I don’t think this happened to me because I was weak, but because I have been traumatized. I have a new tenderness for the frightened little girl inside me; I have been reminded of just how deep her pain and fear were, and I feel as if, because we’ve made it through this, she knows that I can and will take care of her. She feels a little bit safer again.

I also have the most tremendous compassion for people out there who may have just begun experiencing this horrible condition. I want to wrap them up in a big, safe hug. I wish I could take them shopping. You wouldn’t wish it on your worst enemy; it’s the worst feeling in the world. If you are such a person, you may be feeling desperate, but again, please know that you can and will recover. You just need and deserve help. The worst thing you can do with panic attack and phobia is to do nothing.

UPDATE: August 2011

It has been three years since the agoraphobia was in full swing. Just before my birthday in September 2010, after two years of avoiding traffic lights, I began to drive again. It occurred to me that I wanted to do it. A mental shift happened; I just knew I would be okay. I had to practice and practice, but I got there

I still have agoraphobic symptoms sometimes. On certain days, being out or driving can still feel uncomfortable. Some times are worse than others, but the great thing is that I can handle it. In the last year I have had two near-fully blown panic attacks – one in the car and one in a store. Both times, I was tired and stressed, but, wonderfully, I found that the skills I’ve learned meant that I did not fear having another panic attack – thus starting off the whole phobia-feeding process again. I still have to be careful of avoidance and how quickly it can breathe life back into irrational fear. For example, there have been times when I thought I could not manage driving in a certain intersection, and avoided it, and then found I have a harder time driving in that intersection again. If you choose to avoid something when you’re well into recovery but just not feeling so great on a certain day, that is fine, but don’t go on avoiding it will you?

I am making strides into being able to think about the bad aspects of my childhood again. This was something I tried to avoid because of panic. I have remained somewhat fearful of bad memories sucking me back to where I was three years ago. But as I have allowed myself to think, this has not happened, even if I have felt a bit shaky at the time. My therapist suggested to me that if I just sat with scary feelings instead of trying to outrun them, they would alleviate and I’d be okay. She was right. Not only am I okay, but turning my thoughts to these matters again has enabled some further and powerful healing. There are things I am able to make far better sense of now.

I have never returned to drinking caffeine, because it can promote panicy feelings very quickly. I am happy to have given it up.

Just as I accepted that I have PTSD many years ago, I now accept with real calm and strength that I may have agoraphobia for some years, and that there may be times it will feel worse than others. But I honestly am not bothered by this; I know I’m stronger than it, and when I don’t feel stronger, I accept the vulnerability and take care of myself, knowing that next time, I will be stronger again. To all intents and purposes, having agoraphobia but being able to manage it effectively is not so different from not having it. I never relish the thought of another panic attack, but if it does happen I know for a fact I will cope, and I do not fear that prospect.

I’ve said above that I wished for the return of “Louise as I knew her.” But – and this is very very okay – I am not exactly the same as I was before this condition came into my life. In some ways, I am more fragile, and in others, immensely stronger and more understanding. Whatever is the case, I feel a depth of understanding and acceptance of myself and my life that I had never thought possible. This is wonderful.

What helped me — and may help you

Therapy:
You need to find a therapist who works with CBT for panic attack but who is also knowledgeable and compassionate around PTSD. It is important that you can trust this person, even if not straight away. If you are a survivor, you probably won’t want to work with somebody who isn’t conversant with trauma and abuse issues, and definitely not with somebody who doesn’t take them seriously. If you are experiencing PTSD concurrent with panic, you may not feel safe exploring traumatic memories without a safe person — in fact, I recommend that you do not do so. Aphrodite Matsakis writes that one criteria of effective therapy is that the therapist must “See the trauma as real and important in itself, apart from any pre-existing psychological problems and any current social, family, or personal stresses (1992 p.342).” While learning to conquer panic to maximize functioning was a priority for me, both I and my counsellor recognized that trauma was having an impact. She has also offered me education about trauma which has furthered my understanding of why I respond to present-day fears as I do — and how this can change. I reproduce for you the preliminary email I wrote to check her out:

Dear _____,
I was very glad to see your advertisement in the local yellow pages as it seems you work with some issues I am facing at the moment. I would be interested in making an appointment with you.
May I ask a few questions?
How long is your waiting list?
What do you charge?
Do you have an understanding of the long-term effects of childhood abuse?
Do you allow for some psychodynamic exploration as well as offering CBT?
I look forward to hearing from you at your convenience.
Yours sincerely,
Louise McOrmond-Plummer

Her response was eminently satisfying. She is safe, and she has aided my recovery immeasurably. When I say safe though, I don’t mean to imply that she doesn’t challenge me – and this is such a necessary part of recovery. She has a knack of making challenge non-threatening. It was she who told me that if phobia isn’t to be fed, the fear must be faced — but in my own time, all the while arming me with strategies for countering it. You deserve help; there is no shame in seeking and receiving it.

I do recommend seeing a psychologist rather than a counselor with a lesser degree, because psychologists have CBT training as well as special training in the science of panic and PTSD. See below for some links on finding a therapist.

Know what to expect:

Panic attacks. On my third appointment, I recall going to my therapist in tears because I’d had two panic attacks between appointments. I thought this meant I was failing. She actually made me laugh when she calmly said “Louise, part of recovery means that you might have another one!” As we face our fears, it will be distressing, But through facing them, the distress diminishes.
Re-emergence of traumatic memory: As I’ve said above, flashbacks and terror around events I hadn’t felt particularly scared of for years really shocked and surprised me. The memories can be powerfully intrusive, and so distressing that you try to avoid them. Please be aware that this is not happening because you haven’t healed, and it isn’t because you’re going backwards. You may also be a person who hasn’t had any help, and who has spent a lifetime trying not to think about abuse you experienced. You may now feel terrified and crazy. You aren’t – remember that this, however dreadful – happens to may people who have shared your experiences. Panic disorder can open up traces in your brain where traumatic memory is stored. You might find that this also happens when you’re facing trigger situations (Matsakis 1992 p. 104). So be very kind to yourself. Nurture the self who was hurt. Get support (by now you hopefully have a counselor and you have established that he or she is safe to talk to about abuse issues). You can also get online support from other survivors who have moved through a similar process at Pandy’s.
Changing symptoms: Panic attack can be a slippery devil. My symptoms tended to alter over time; sometimes the distorted vision was worse; sometimes the giddiness and sometimes the palpitations. It can throw a range of funny symptoms at you. In fact, I’ll tell you on the world wide web what I didn’t tell anybody else out of sheer embarrassment: I started noticing that anxiety attacks began in my bottom. I didn’t know – and just in case you didn’t either – people’s anal muscles involuntarily lock in response to perceived threat (Davis, Eshelman & McKay, 2008 p. 2). So, I knew I was in for a bad time when I felt that odd and irritating sensation in my backside. For a couple of weeks what bothered me the most was a sense of depersonalization that would be with me as soon as I got out of bed. Depersonalization can be part of panic disorder, PTSD and abuse survivorship. Initially the changing symptoms scared me a bit, because just when you think you’ve got a handle on the symptoms, another may emerge, or take precedence over the others. At the moment, the top symptom for me is a sense of my voice reverberating in my head (and that’s because anxiety causes your hearing to become more acute). Don’t worry — other sufferers do experience this too. It’s all part of the same panic poop-cake 🙂

Educate yourself:
Demystification can make something a bit less scary. If you read about panic attack, you’ll see that it is a complex array of biological responses to danger built into us since primitive times. It’s called the fight or flight response, and you may also have experienced this when you were assaulted. As a response to real threat, it is adaptive and life-preserving; it is not our enemy. But in panic attack sufferers as well as PTSD sufferers, this response now kicks off in response to falsely perceived danger. Also, understanding how trauma may have affected you biologically can help you go easier on yourself — as a trauma survivor, you are actually wired to respond in certain ways, and though some of the biological changes are irreversible, a good therapist can help you learn to respond differently.

Diaphragmatic Breathing
Panic attack can be exacerbated by the symptoms of hyperventilation, or how we’re breathing. Please see the links below for information on breathing in the way that can avert panic attack. You should also be aware of Aphrodite Matsakis’ warning that breathing exercises aggravate PTSD for some people (1992 p. 120). Speak to your counsellor. For me, breathing worked sometimes, but by itself was insufficient until my mental attitude towards panic changed. Mostly, I found it useful for night-time anxiety.

Know that you are, in fact, normal:
Panic attack feels anything but normal, especially if you know intellectually that there’s nothing to be afraid of. But if you have PTSD, you are at risk for panic attack. Don’t beat yourself up because things that were once routine have become frightening. You are still a competent person, but you’re having a bad time, and you can get help and get through it.

Avoid Caffeine:
If you love your cuppa as much as I do, get a good brand of Decaf to enjoy. I learned that the caffeine kick was just not worth my shredded nerves. You’ll see warnings to avoid nicotine too. I imagine that this advice is correct but being a disgustingly addicted smoker I didn’t take it. Indeed, I don’t think I needed to be wrestling with getting off the smokes as well as everything else.

Have a good cry:
Sometimes, letting go and having a really good cry about what was worrying me could shift the symptoms of anxiety and help me feel a bit stronger.

Watch your alcohol intake:
People experiencing panic and anxiety may drink to calm themselves because they’re so desperate to stop the fear and tension. I made the mistake of banging down a glass of wine a couple of times, and it made things worse. It seemed to lower the threshold for anxiety. It just doesn’t work.

Remind yourself of fact
Panic attack neither causes insanity nor is the result of insanity — ever. Panic attack never causes heart attack and seldom causes fainting.

Practice, Practice, Practice:
If phobia is not to limit your life, you will need to face the fears as you are ready and with plenty of support. You may need to do it many times before you truly feel confident. But start slow. Be gentle. You don’t have to conquer it all at once; in fact forcing yourself to face too much could overwhelm you – and you know just how easy getting overwhelmed is right now. You may want to start by imagining yourself doing the feared action. If it is shops, it doesn’t matter if at first all you do is make it to the door. Arrange for quick exits if you can. I found that it helped to ask a salesperson where the items I wanted could be found. When I was able to shop alone again, it was because I finally understood that my “safe people” were not actually keeping me safe from anything. You’ll get there too. You can conquer this. Reward yourself for trying. That is a big step.

Allowing Panic

When I first heard that some people recovering from panic attack do so by allowing or inviting it, I couldn’t believe it. How is it possible to deliberately court something so terrifying? Yet, I found that it was absolutely crucial to develop a “bring it on” attitude towards the panic. Going out became an opportunity for facing it down again and again, until I finally knew that I could stand my ground and be okay. Believe it or not, I actually got to a point where I could contemplate having an attack and say, “So what? I shall survive it!” If I was going out and the panic started telling me it was coming too, I could say, “Great! That gives me another chance to flog your ugly ass again!”An attitude of allowing makes the battle much less tiring too. If you’ve experienced panic disorder, you’ll know all too well the desperately tired feeling of fighting the fear; so much energy goes into fighting the mounting dread. As you address the fears of what will happen if you have an attack, you’ll get a place where you feel strong enough to test yourself and find out that the worst thing that happens when you have a panic attack is that it passes. The reward can be a great feeling of euphoria and strength. You will become far less frightened; the attacks will lose their strength.

Don’t worry about what people think:
People generally cannot see the signs of panic, even if you think they must be obvious. In the end, if I dropped into a crouch in the supermarket, it just looked as if I were examining the bottom shelf! I ceased worrying about what people would think if I bolted from a shop, or was visibly shaking. The important thing was for me to take care of myself.

Watch a tendency to “check in” with symptoms and feelings :
Now that this horrible condition is part of your life, you may continually obsess and worry, as I did, and check in 157 times a day to see where the anxiety is at, fearing that it will get worse. As you get better, your CBT mantras will enable you to ignore symptoms and feelings, however unpleasant, and get on with functioning. Panic doesn’t thrive when we rob it of attention.

Medication?
I chose not to use medication but I am not sure that I would recommend that choice to others. It’s up to you; it may give you a much-needed respite from anxiety as you work on your fears. Some people need it. And that’s very okay.

Humour
As I moved through recovery, I found things to laugh at. For example, when I got weak legs, it occurred to me that I walked like a toddler with pants full of ca-ca. I called it “the ca-ca walk.” Also, a Scottish friend of mine has a very rude expression she loves to use that, frankly, delights me: “Get tae f*ck, ye bawbag.” I dubbed my panic “The Bawbag” and swore at it (silently of course) when I was out, and often wound up laughing. I had a panic attack in a bakery, and my younger sister said “What’s the worst that can happen, death by pie?” While learning about changes to the brain in traumatized people shook me for a little while, I could also reflect with sour but genuine mirth that I was, literally, “Effed in the head.” Like many people, I have an eye-rolling exasperation about unannounced visits from in-laws. But at the height of all this I didn’t like being on my own and so I burst into tears one day because my in-laws were LEAVING! I’d felt abandoned and had wanted to plead with them to STAY, and was even tempted jump in their car and go home with them! I laughed through my tears at that; it really was crazy.

Find out what works for you
My therapist, as with all good CBT practitioners, offers not one but many strategies for beating panic attack and phobia. As you heal, you may also discover strategies within yourself. Don’t worry if you try things that don’t work, and don’t get discouraged – there will be something else that will work. It may be that as you get stronger, things that didn’t seem particularly helpful will work after all. For example, I initially found it useless to tell myself I could control panic. I erupted into a panic attack anyway, because I was not yet in a place where I believed I could control it. You can try ridicule – imagine the panic as a stupid blob in the corner. While my symptoms used to be terrifying, I can now poke fun at them: “Whooooh – It’s the jelly-legs again! I’m soooo scared.” I abused it with obscenities. Some people take a gentler approach when “speaking” to the panic: “I know you are trying to protect me from danger, but you don’t need to because there isn’t any danger.” I have also found it helpful to be kind to my inner little girl. One day in the supermarket, fear shifted because I gave her an internal hug and bought her a pretty pink china cup with kitties on it. Whatever works. You may also find that there will be specific CBT-based mantras that will work for you. For example, saying to myself “Louise, there is no set time beyond which you suddenly cannot cope with shopping centers” works every time.

Recognize panic attack for what it is:
The messages panic attack sends you are FALSE. It is like a snot-nosed punk who thinks it’s funny to set fire alarms off when there is no fire. Panic attack is like the schoolyard bully; stand up to it often enough and it will lose its power. If you want to be kinder, it is a part of you trying to get you out of perceived danger. But the perception is false. It really is. From a physical and rational point of view, it is a function of your brain, not a statement of reality.

Reading
There are a few excellent books on the market, and some are listed below. One of the best things I read was a book called Living With ‘It’: A Survivor’s Guide to Panic Attacks, by Bev Aisbett, a former sufferer. It was not heavy and full of exercises, but it helped me immensely at a time when I didn’t feel able for anything too cumbersome. Bev has created delightful cartoons of her “panic monster” and her process of recovery. I highly recommend it. There are books listed below, too, that will help you understand and consolidate CBT principles as you recover.

It’s true that, as some people say, there’s a lot of bullshit on the internet. But there is also some really excellent stuff about panic attack. If you read material by other panic attack sufferers, you become aware that there are other people out there who were just as frightened as you, just as uncertain as to whether they could beat it, but who nevertheless did. It inspires hope.

Don’t compare yourself to anyone else:
You may know people who recovered from panic attack and agoraphobia relatively quickly, and feel that because your journey is a bit longer, you are inadequate. I got scared when I read internet articles stating that a person needs about 8-10 CBT treatments to get them right. Certainly, it is such a good treatment that a few sessions should see some progress. But my therapist assured me that she wouldn’t be chucking me out if I wasn’t completely well within a certain time-frame. If there is no improvement after a time, meds might help things get moving.

On the other hand, you may have been very frightened — as I was — of becoming the stereotype of an agoraphobic; somebody who hasn’t left home for twenty years, not even for a child’s wedding. I have read of people who are so debilitated they cannot even go to their letterboxes (I have also read of people recovering after many years). There is no reason, however, for you to think this will be the case with you. With the right help, it won’t be. Be aware too that agoraphobia does not mean just not leaving the home, but may be anything you go out of your way to avoid. My driving fear is a form of agoraphobia.

Even if you have suffered agoraphobia for many years to a really debilitating extent, recovery is still possible for you — and I have by now read of people who were housebound for seventeen years and who got help and recovered. I hate to think of what you suffered in the past limiting your life anymore.

Remember that now is not then

It can be hard to convince yourself that you will be okay when you are feeling revived terror from a time when things were definitely not going to be okay. It feels so much the same, but you already know that it isn’t my friend, verbally remind yourself of the fact.

Self-Awareness
Be aware that if you’re tired, hormonal or otherwise facing extra stressors, you may feel extra panic-prone. Take the best possible care of yourself at these times.

Don’t put up with ignorance
Not everybody understands why people develop fear of going out, red lights or other, and some people may tell you you’re being silly and to “get over it.” Don’t listen. It’s not your fault this happened to you. You are not weak in any way. Do you know that my therapist told me she has treated doctors and scientists with panic attack? It is not the province of silly people.

Self-Care
It helped me feel more in control if I got dressed properly every day, and did my hair and face (guys might want to modify that). Try also to eat and sleep enough — you may have to practice deep-breathing and mindfulness meditation for sleep, or again, meds could help. Other people find that an exercise regime helps, and some find it can exacerbate the problem. Rest too – facing this much fear can be draining. You might decide to have some days in which you don’t force yourself to face any fear, but instead watch a nice DVD and paint your nails. Nurture yourself and your fearful child. Do what works to help you feel better within healthy parameters.

Remember you are courageous
When I told my therapist how frightened I was of facing my fear, she said, “But Louise, haven’t you already faced so much real fear from truly dangerous situations, and survived? Yes, I have. And if you are reading this as a trauma survivor, so have you. You are a lot stronger than you may feel right now.

Keep the faith — hang in there
There may be times you’ll feel discouraged, unsure of whether you can beat this fear, tempted to give in and just bolt your doors and never go anywhere again. I know I was. Keep going, my friend, you are worth the fullest life you can live. The fears are false. With good support, soon you will believe it. Recovery can be slow, and you need to be patient with yourself. Remember that you can get support from other survivors who have experienced panic attack at Pandy’s.

Links

Agoraphobia & Panic Disorder Recovery – I have used this site for my own recovery from panic attack and agoraphobia. Simple yet effective, easy to read articles by fellow sufferers. Be sure to read the section on Cognitive Behavioural Therapy
The Panic Attack Prevention Program – I cannot vouch for the program – I haven’t done it, but I really like the explanations of panic attack and its workings.
Mindfulness techniques as a recovery technique from anxiety.
Anxiety Disorders Association of America – Anxiety and Fears- Browse resources on nightmares, post traumatic stress, phobias and more.
How a Panic Attack Works — find out the tricks it plays on you
Diaphragmatic breathing – a helpful demonstration of how it is done.
http://www.vvaa.org.au/ptsd.htm – Although this site is for Vietnam Veterans rather than survivors of abuse, I still found it really useful.
The difference between panic attack and panic disorder
Trauma, PTSD and Panic Disorder
Changes in the Brain Caused by Childhood trauma
PTSD and the Fight-or-Flight response
Gift From Within – Terrific PTSD resource
PTSD Fact Sheet — Information on biological changes and more
Cognitive Behavioural Therapy for Panic Attack

Therapy Links:
USA: Find a Therapist at Psychology Today
Canada: Find a Therapist
New Zealand: Find a Therapist
United Kingdom: Counselling Directory

Bibliography

Davis, M., Eshelman., E, and McKay, M. (2008) The Relaxation & Stress Reduction Workbook, New Harbinger Publications Inc. California
Fox, B, (2010) Power Over Panic: Overcoming Panic and Anxiety, The Penguin Group, Victoria
Herman, J. (1992). Trauma and Recovery: The Aftermath of Violence – from domestic abuse to political terror. BasicBooks, USA.
Matsakis, A. (1992) I Can’t Get Over It: A Handbook for Trauma Survivors, New Harbinger Publications Inc. California