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posted: 10/14/2013 5:55 AM

Agoraphobia can take many forms

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Q: My daughter's new roommate is afraid to leave a 10-block area around their apartment in New York City. She has something called "agoraphobia." What is that?

A: Agoraphobia is the fear of certain situations in which an individual feels threatened and trapped and unable to escape.

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Most often, the fear is of being in open or public places. In the most severe cases, people with agoraphobia become afraid to leave home at all. Fortunately, your daughter's roommate's problem is not so severe. That's a good thing; it suggests that -- especially with help -- she may be able to increase her range.

There are other situations that some people with agoraphobia fear. They might avoid driving, or specific types of public places (such as restaurants or shopping malls). They might fear entering a doctor's or dentist's office. It's my understanding that the former New York Gov. Mario Cuomo hated to fly; it may have affected his otherwise successful political career.

Ironically, a few people with agoraphobia fear being home alone and actually seek out places with other people -- even crowded places. They behave in exactly the opposite way that most people with agoraphobia do.

People with agoraphobia often suffer symptoms of severe anxiety when they are in a situation they fear. They may experience a racing heart, difficulty breathing, sweaty palms and shakiness. This just increases their desire to avoid those situations.

We don't know why agoraphobia develops. As with other forms of anxiety, agoraphobia is partly learned. For example, a person may have a panic attack in a crowded or unfamiliar place. Afterward, the individual starts to fear that similar situations will trigger more panic attacks and starts to avoid them.

Treatment depends on the particular symptoms and their severity, but it usually involves some combination of talk therapy and medication.

Cognitive behavioral therapy is a type of talk therapy that modifies ingrained patterns of negative thoughts and behaviors. CBT has two parts: Cognitive therapy helps people modify thoughts that are preventing them from overcoming their fears. Behavioral therapy helps change a person's actions in situations that trigger anxiety.

Often CBT is combined with exposure therapy and relaxation techniques. A mental health professional might first help the patient relax, then ask the patient to imagine a situation that provokes fear (like riding the subway). In some cases the health professional might actually accompany the patient as he or she ventures into those situations. The goal is to desensitize the patient to the situation so that it is no longer so scary.

Relaxation and other psychotherapy can help many people learn to manage their fears, but some patients will also need medication. Options include antidepressants and anti-anxiety medications.

I suspect that agoraphobia is triggered by chemical changes in a person's brain -- changes that the person could not control. That's unproven. Whatever its cause, there now are treatments that help.

Q: Former Massachusetts Gov. Paul Cellucci recently died from complications of ALS. Can you tell me more about this disease?

A: ALS stands for amyotrophic lateral sclerosis. You may know it as Lou Gehrig's disease, named after the famous baseball player who suffered from it.

There are many different kinds of brain cells. Some do our thinking, some move our muscles (when the ones that think tell them to), and other brain cells do other things (such as see and hear). ALS primarily causes a slow degeneration of the nerve cells that control muscle movements. As a result, people with ALS gradually lose the ability to control their muscles.

In people with ALS, the capacity to think and remember things is affected only in fairly subtle ways, and may not be affected at all. ALS does not usually cause dementia.

ALS generally strikes patients between the ages of 50 and 70. We don't know what causes ALS. As a result, there is no way to prevent it. Some cases appear to be inherited.

The weakness and wasting (atrophy) of the muscles involves the arms and legs, the breathing muscles, and the muscles of the throat and tongue. The weakness worsens over time. Eventually, people with ALS are trapped in their bodies, but completely alert. They understand what's going on around them, including people speaking to them. But when the disease progresses to the point where it withers the muscles of their throat and tongue, they cannot answer.

As the disease progresses, a person may experience:

• Muscle twitching, cramps, stiffness, and muscles that tire easily;

• Slowed speech that becomes progressively harder to understand;

• Difficulty breathing and swallowing; choking;

• Weight loss because of muscle breakdown and poor nutrition caused by problems swallowing;

• Changes in the way the person walks. Eventually, loss of the ability to walk.

There is no cure for ALS. People with the disease live an average of three to five years after symptoms begin. (The famous British physicist Stephen Hawking has a disease similar to ALS and has lived with it for 50 years. But apparently he does not have ALS.)

Riluzole or Rilutek is the only drug approved by the U.S. Food and Drug Administration for ALS. It can prolong survival in some people. Medications may help to manage symptoms of ALS; pain medications and muscle relaxants may help with painful muscle tightness.

Mechanical devices can make self-care easier for people with ALS. Examples include dressing aids and special utensils for eating. A cane or walker may help patients who have difficulty walking.

Patients can consider using a mechanical respirator if they become unable to breathe on their own. Artificial ventilation can help some patients survive for years, but many patients choose not to be kept alive under these conditions.

Researchers are making progress in understanding the causes of ALS and in finding treatments that help. Hopefully, the pace of new discovery will speed up and a cure will be found for this terrible disease.

• Dr. Komaroff is a physician and professor at Harvard Medical School. To send questions, go to AskDoctorK.com.

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