RATING OF PANIC PROVOCATION BY AGORAPHOBICS* Activity Panic-Provoking No Problem

Driving freeways 42.6% 29.4% Airplanes 38.8 17.7 Closed-in places 24.5 17.1 Heights 23.1 17.9 Audiences 22.0 20.2 Department store 20.4 27.4 Crowds 18.1 15.2 Bridges 14.8 39.3 Supermarket lines 11.2 34.9 Parties 10.8 34.7 Being alone 10.8 50.8 Elevators 10.0 37.2 Restaurants 09.6 36.1 Unfamiliar places 07.9 20.9 *N = 477

Adapted from S. L. Williams, “On the Nature and Measurement of Agoraphobia,” Progress in Behavior Modifi cation 19, 1985, pp. 109–144.

into their restricted life. There is some evidence that dependency and perfectionism are associated with a subgroup of people who develop agorapho- bia. There is also substantial clinical evidence that emotional suppression is strongly associated with the development of agoraphobia.

One theory about the cause of agoraphobia is that experience in certain individuals’ learning pro- cess conditioned them to regard the world as a dan- gerous place. Many agoraphobics have had at least one agoraphobic parent, and many have had at least one parent who is somewhat fearful. In some cases, they received mixed messages from their parents; while they were encouraged to achieve, they were not well prepared to deal with the world, either because they were overprotected, taught that home is the only safe place, or underprotected, having to take on too much responsibility at an early age.

When agoraphobics seek treatment, they are often in a constant state of alertness, have a pas- sive and dependent attitude, and show a tendency toward sexual inhibition. Typically, the agorapho- bic admits to being generally anxious and often expresses feelings of helplessness and discourage- ment. However, many agoraphobics were formerly active, sociable, outgoing persons. Some agorapho- bics abuse alcohol and drugs, and researchers are beginning to uncover the extent of such abuse. Some current estimates place 30 percent of alcohol- ics as having a primary anxiety disorder that leads to the chronic use of alcohol.

General Symptoms. A common characteris-

tic of agoraphobia is a history of panic attacks in which the individual experiences symptoms of extreme excitement, distortion of perceptions, and an overwhelming sense of imminent catastrophe, loss of control, or fear of public humiliation. A fear of the fear then develops in which the indi- vidual begins experiencing anxiety in anticipation of panic reaction. The result is avoidance of the feared situation.

Situations that bring on anxiety in agorapho- bia have common themes involving distance from home or other safe places, crowds, and confinement. Crowds and confinement bring on these anxieties because the individual often feels trapped and can- not leave easily, for example, in a waiting line for a bus or train, or in a crowded department store.

Still other agoraphobics are afraid to be home alone or to be outside alone. They require constant companionship. Casual observers sometimes feel the agoraphobic is lazy and shirking routine respon- sibility, but this is not true. Most individuals who are agoraphobic fear that they will lose control over their own reactions and that their fear may lead to a panic attack. Some are afraid of fainting, having a heart attack, dying among strangers, scream- ing, attacking someone, or otherwise attracting unwanted attention and causing embarrassment.

Agoraphobic people avoid specific fear-provok- ing situations in different ways. Most tend to avoid places that might trigger their phobia. Some pho- bic individuals feel better with someone they trust and may habitually depend on having a companion when they go out because a reassuring person can make a frightening situation seem safer. Some ago- raphobics feel better in a public place just knowing there is a policeman or doctor nearby. Generally, stimulation (physical, emotional, perceptual) will trigger anxiety, so agoraphobic individuals gener- ally avoid such situations as crowds, noisy places, traffic, bright lights, and movement.

Symptoms include general anxiety, spontaneous panic attacks, and occasional depersonalization. DEPERSONALIZATION is a change in the perception or experience of the self so that the feeling of one’s own reality is temporarily lost. This is manifested in a sense of self-estrangement or unreality, which may include the feeling that one’s extremities have changed in size, or a sense of perceiving oneself from a distance (usually from above). Depersonal- ization occurs in the absence of any mental disorder when an individual is experiencing overwhelming anxiety, stress, or fatigue. Experiences of deperson- alization, in and of themselves, are common (nearly 50 percent of adults report having had a deperson- alization experience).

For some individuals, anxiety in agoraphobia may be aggravated by certain predictable situa- tions, such as arguments between marital partners and general STRESS. For some, the anxiety is nearly always relieved somewhat in the presence of a trusted companion. Some individuals relieve their anxiety by having with them a dog or an inani- mate object such as an umbrella or shopping cart (SOTERIA).

Some agoraphobics develop ways to live more comfortably with their disorder. For example, those who go to movie theaters or churches may be less frightened if they sit in an aisle seat so that they can make a fast exit if they experience a panic attack. Having a cell phone available is another comfort.

In severe cases, individuals may also have panic attacks, depression, feelings of depersonalization, obsessions, and other symptoms. Historically, other terms that were used to describe agoraphobic symp- toms include anxiety hysteria, locomotor anxiety, street fear, phobic-anxiety-depersonalization syn- drome, anxiety syndromes, phobic-anxious states, pseudoneurotic schizophrenia, and nonspecific inse- curity fears.

Many agoraphobics have episodes of depression. The first episode may occur within weeks or months of the first panic attack. Individuals complain of feeling “blue,” having crying spells, feeling hopeless or irritable, with a lack of interest in work and dif- ficulty in sleeping. Agoraphobia is often aggravated during a depressive episode. The increased anxiety may make individuals less motivated to work hard at tasks (such as going out) that they previously did with difficulty.

Some agoraphobics are also claustrophobic. Usu- ally claustrophobia is present before the agorapho- bia develops. The common factor between the two phobias is that escape is blocked, at least tempo- rarily. Some people fear confinement in a barber or beautician’s chair, or a dentist’s chair; some fear taking a bath in the nude. Some individuals who

are phobic about bridges fear them because long, narrow bridges with open sides high above a river offer no way out except to cross. Others fear tun- nels and elevators for similar reasons.

Many agoraphobics develop some sexual dys- functions due to anxiety and depression. Dr. Isaac Marks reported in 1969 that inability to achieve orgasm is not uncommon in agoraphobic women. Some agoraphobic men complain of general impo- tence or premature ejaculation. Anxiety from any cause reduces capacity for sexual enjoyment, and panic attacks and background tension are features of agoraphobia. Many women report that general- ized anxiety and panic in agoraphobia tend to be worse just prior to and during menstruation.

Symptoms of the phobic anxiety in agorapho- bia may include the many physical sensations that accompany other anxiety states, such as dry mouth, sweating, rapid heartbeat, hyperventilation, faint- ness, and dizziness.

The mental sensations an agoraphobic experiences include a fear of losing control and behaving in a dis- inhibited way, of having a heart attack because of the rapid heart action, of fainting if the anxiety becomes too intense, and of being surrounded by unsympa- thetic onlookers. Following is a table indicating the thoughts (cognitions) of some agoraphobics.

Panic Attacks. Panic attacks are specific peri-

ods of the sudden onset of intense apprehension, fearfulness, or terror, often associated with feelings of impending doom. During panic attacks there are symptoms such as difficulty in breathing (hyper- ventilation), palpitations, chest pain or discomfort,

PERCENTAGE OF AGORAPHOBIC PEOPLE REPORTING