Dear Dr. Ford:

I am a married 52-year-old woman. For many years I have been afraid of crowded places such as stores, malls, and theaters. I worked full-time before I was married, but then was able to stay home once I got pregnant with the first of our two sons, who are both grown now and out of the house.

In the aftermath of 9/11, things got much worse. It seemed as if all my worst fears were coming true. A couple of times my heart was beating so hard I thought that I was having a heart attack, but my doctor says these are panic attacks. He wants me to take medication, but I am afraid of getting dependent.

My husband is very kind and has done the shopping, etc., for as long as I can remember. But I am afraid I am becoming a shut-in. And every time another shooting happens, like Las Vegas, it just gets worse. What can I do? It always seemed like the world is a dangerous place —and it turns out I’m right.

Marla

Dear Marla:

You are right when you say that the world is a dangerous place, and it always has been. There’s no question but that it is safer to stay indoors, but, as you know, there is much you have to give up if you do that. Preparing for disaster doesn’t work either. The authorities in Las Vegas had known their city was a target, but the sheriff said last week that it was impossible to anticipate the kind of attack that actually occurred and they are limited in the number of controls they can impose in a city like theirs without its becoming a police state.

Meanwhile, everyone suffers after incidents like this. By their very nature, they give us the sense that anything can happen, anywhere, and we have no control. That is the point: to instill a terror that random events can happen, and they will. We are only able to conduct our daily business, to a certain extent, because we do not think about all the things that can happen while we are out. People have lost the ability to “deny” danger, and after an incident like Las Vegas, you have plenty of company.

While some people go on high alert after such an incident, others become inured, and feel less and less as the bodies mount. As reported in the Miami Herald, Alan Lipman, a clinical psychologist and director of the Center for the Study of Violence in Washington, D.C., says, “There’s what we might call a natural post-traumatic stress disorder reaction. . . . More and more, what we see is a kind of emotional numbing—an acceptance that this is part of the reality of life.”

Some people respond to these events with post-traumatic-stress disorder (PTSD) and, like you, will avoid certain areas or situations for some time afterwards. Dr. Carol North,  a crisis psychiatrist in the Department of Psychiatry and at the O’Donnell Brain Institute at UT Southwestern Medical Center, says that “During such extreme and terrifying events, time moves slowly, stretching the danger into a long-endured ordeal. The adrenaline response is intense. It may take many days for jitteriness to begin to subside. People may feel unsafe, especially in open areas, and may want to avoid outside spaces. Hypervigilance may continue for a long time.” But she stresses that most people do bounce back and eventually are able to function normally.

While your fears have been exacerbated by these events, you say they have been bothering you for a long time. What you are describing in your letter sounds like a form of “agoraphobia” to me. Taken from the Greek word “agora,” which means the marketplace where most business was conducted, it is sometimes referred to as “the fear of open spaces.” But it is not exactly that, nor is it the opposite of claustrophobia, the fear of small spaces. Agoraphobics are generally afraid of being away from home, be it in a crowd, a mall, a theater, etc.—anyplace where they do not feel they can escape to safety easily. For many, fears of driving, trains, and other modes of transport are included. Anything that carries one away from home can induce a feeling of fear.

Usually, the physical symptoms of agoraphobia are similar to, or the same as, a panic attack (the two are often closely related):

* Hyperventilating or rapid/shallow breathing

* Feeling of choking or difficulty swallowing

* Sweating

* Shaking and trembling

* Nausea and other gastrointestinal distress

* Dizziness or lightheadedness

* Ringing or buzzing in the ears

Often, a rapid pulse accompanies these and people often think they are having a heart attack (though it is important to always rule that out when you have palpitations, etc.).

The psychological symptoms include these:

* Fear of losing control or going crazy

* Fear of dying

* Feeling ‘unreal’ or detached from oneself

* Feelings of depression, dread or anxiety

* Having low self-esteem or low confidence