Agoraphobia

Agoraphobia is a form of anxiety disorder characterized by feeling of discomfort and fear, sometimes rising to the disabling level of full-blown panic attacks, precipitated by entering, or contemplating entering, large open spaces such as football fields or open plains, as well as large open spaces in buildings such as stadiums, airports and large malls.  The disorder also includes other spatially related phobic reactions, such as discomfort at being engulfed in a large crowd, or simply traveling to an unfamiliar location.  The panic attacks that develop entail more than simply merely intense uneasiness and discomfort.  During a panic attack, epinephrine is released in large amounts into the body, triggering the natural fight-or-flight response:  symptoms may include palpitations, rapid heartbeat, sweat, trembling, nausea, disorientation, as well as fears of dying, losing emotional control, and embarrassing loss of control over one’s behavior.

Often regarded as a kind of counterpart to claustrophobia (with which it does in fact share certain cognitive similarities), agoraphobia is a unique disorder, with unexpected links to gender, medication usage, and the cognitive processing of audiovisual data.

Subjectively, agoraphobia is similar to claustrophobia in that the experience is generally one of fear of loss of control, triggered by a particular environmental condition.  Just as the claustrophobic is not afraid of an enclosed space as such, but rather of suffocating or being crushed or left helpless in an enclosed space, so the agoraphobic becomes anxious in open spaces not because of an aversion to the spaces themselves but because of rapidly-generated thoughts and fears of being more easily “open to attack” or more likely to experience social embarrassment as a result of falling uncontrollably in public into a panic.

In both disorders, environmental triggers launch subjective anticipations of loss of control and personal threat, but agoraphobia has unique characteristics that give it a special place of its own.

Differences in Gender
Agoraphobia occurs about twice as commonly among women as it does in men. Research has not yet produced an accepted explanation as to the gender difference in the condition, although controversial theories ranging from a greater vulnerability women to assault in patriarchal societies, to higher levels of anxiety among women when placed in public situations, have been put forward.  None has gained common acceptance among observers of the phenomenon.

Drugs and Agoraphobia
Also, agoraphobia has been linked to the usage of certain drugs, as well as to substance abuse of those drugs.  The chronic use of tranquilizers and certain form of sleep-inducing substances, such as benzodiazepine, has been shown to precipitate agoraphobia, and when dependence on benzodiazepine is reduced and then halted, the decline and disappearance of agoraphobic symptoms follow.

The Visual-Spatial Connection
Research has also unearthed unexpected but clear connections between agoraphobia and problems involving spatial orientation and visual-spatial data processing as well.  Studies involving responses to virtual reality experiences have shown that those with agoraphobia tend to show higher rates of impaired processing when dealing with shifting audiovisual data.  Even common everyday geometrical planes can prove challenging:  sloping, irregular are less easily gauged by agoraphobics and may cause confusion.

A disproportionate large number of those who suffer from agoraphobia also have weak vestibular function, a brain process whereby visual processing and spatial orientation significantly contribute to balance and spatial coordination.  Those whose vestibular functions are weak are more dependent upon visual or tactile signals in the immediate environment to orient themselves.  When such cues are sparse, as in vast open empty spaces, or when they come as a relentless cataract of impressions, as in crowd situations, the result is a disorientation that, for the agoraphobic, can lead easily to panic.

A Genesis in Panic?
Agoraphobia is also striking in that reports show that most people who approach mental health specialists with the condition of agoraphobia develop agoraphobia after the onset of repeated panic attacks.  One might reasonably speculate that panic responses could be a precipitating factor in the genesis of agoraphobia.  Yet there are other rarer cases where agoraphobics do not meet the criteria used to diagnose panic disorder at all.

The High Costs of Avoidance
As with claustrophobia, however, the main deficit of the agoraphobic experience may not be the experience itself, but the avoidance response that it so easily generates.  Panic attacks in open spaces may be a rare scene in an agoraphobic’s life, but the loss of the experiences and opportunities that follow an avoidance of so many common places of interaction can be significant.  There are notable agoraphobics — filmmaker Woody Allen and billionaire Howard Hughes among them — who have borne the affliction well, but other notables, such as singer-songwriter Brian Wilson, have endured stretches of considerable isolation.  Indeed, science fiction editor H. L. Gold spent more than twenty years of his life unable to leave his apartment.

Treatment Options
Agoraphobia can be successfully treated in many cases through a very gradual process of systematic desensitization, sometimes also known in some circles as graduated exposure therapy, a technique developed South African behavioral psychologist Joseph Wolpe and known as systematic desensitization.

Systematic desensitization involves having a client go into a state of complete physical and emotional relaxation, and then asking the client to imagine each of a series of carefully graded scenes or stimuli geared to provoke agoraphobic anxiety.  When the client proves capable of experiencing the once-anxiety-producing scene with a reasonable degree of stability; he or she moves on to a more anxiety-provoking scenario until that scene too becomes tolerable and unremarkable.  Gradually even the most aversive scenes are calmly entertained, and the patient is asked to go through a similar graduated exposure of anxiety-provoking real-life situations until they too lose their sting.

Agoraphobia is commonly classed among the panic and anxiety disorders, and as with those disorders, cognitive therapy approaches too are a common means of attacking the problem.  Cognitive therapists tend to focus on the conscious content or thoughts presented by the patient and try to modify the thoughts directly through analysis and discussion.  When the patient realizes that the situation truly holds no especial dangers, negative reactions should minimize on the heels of the insight.  And in many cases they do, just as the application of simple relaxation techniques have a positive benefit.

But the correlations of agoraphobia with phenomena rooted heavily in the physiological, from gender to reaction to soporific drugs to visual-spatial processing, may prove agoraphobia more resistant to cognitive restructuring than other members of the anxiety disorder family.

For that reason psychopharmaceutical treatments may be a more compelling alternative, and drugs are commonly prescribed for treatment of agoraphobia, including anti-depressant medications of the selective serotonin reuptake inhibitor (SSRI) class, such as paroxetine, fluoxetine, and sertraline. Tranquilizers of the benzodiazepine class, as well as MAO inhibitors and tricyclic antidepressants are also occasionally prescribed.
An alternative treatment sometimes used as well, perhaps because of its visual emphasis, is Eye Movement Desensitization and Reprogramming (EMDR).  However, studies employing it as a possible treatment for agoraphobia have so far shown only poor results. EMDR is only recommended in cases where cognitive-behavioral approaches have proven ineffective, or in cases where agoraphobia has developed following trauma.

For severe cases of agoraphobia, examination and treatment by experienced medical professionals is always appropriate.  But for mild cases, mild remedies have a more than anecdotal record of effectively improving conditions.  The employment of relaxation practices such as autogenic training, meditation, physical exercise such as yoga and aerobics, and minimizing uneasiness in open places by going there in the company of friends and social peers have all been shown to be helpful in minimizing the discomforts of mild agoraphobia.

Opening a space within so as to enjoyably try such approaches may very well help sufferers to enjoy the open spaces without.

References
Magee, W. J., Eaton, W. W. , Wittchen, H. U., McGonagle, K. A., & Kessler, R. C. (1996). Agoraphobia, simple phobia, and social phobia in the National Comorbidity Survey, Archives of General Psychiatry, 53, 159–168.
Agoraphobia Research Center. “Is agoraphobia more common in men or women?”.
Professor C Heather Ashton (1987). “Benzodiazepine Withdrawal: Outcome in 50 Patients”. British Journal of Addiction 82: 655–671.
“Panic, agoraphobia, and vestibular dysfunction”. Am J Psychiatry 153: 503–512. 1996.
“High sensitivity to multisensory conflicts in agoraphobia exhibited by virtual reality.”. Eur Psychiatry 21 (7): 501–8. 2006 October.doi:10.1016/j.eurpsy.2004.10.004. PMID : 17055951.
J. Davidson, (2003). Phobic Geographie
J. Holmes, (2006). “Building Bridges and Breaking Boundaries: Modernity and Agoraphobia”, Opticon1826, 1, 1, http://www.ucl.ac.uk/opticon1826/archive/issue1
Goldstein, Alan J.; Goldstein, Alan J., de Beurs, Edwin, Chambless, Dianne L., Wilson, Kimberly A. (2000). “EMDR for Panic Disorder With Agoraphobia : Comparison With Waiting List and Credible Attention-Placebo Control Conditions”. Journal of Consulting & Clinical Psychology 68 (6): 947–957.doi: 10.1037/0022-006X.68.6.947.

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