Agoraphobia - fear of open space

Wide-open spaces such as streets, squares, tunnels, highways, and bridges become places to be feared and avoided. The same is true for large indoor spaces like shopping malls, banks, cinemas, and theaters, as well as crowded open areas. In cases of agoraphobia, it's not uncommon to encounter an intense fear of riding public transportation, with the exception of taxis and personal vehicles.

In its typical manifestation, agoraphobia is characterized by panic attacks, a fear of fear, and avoidance behavior. Mobility and activity decrease significantly, leading to an impoverished life. Sometimes, the person becomes so attached to their home, which represents safety, that their movement is restricted to that space, from which they don't leave for days, weeks, or even years. People with agoraphobia also often display a specific trait not found in other forms of phobias, which is the need to have one or more trusted people with them who become their protectors and constant companions.

It's not uncommon for this disorder to be accompanied by other forms of anxiety, especially claustrophobia and a fear of travel, which clinical practice regularly confirms.

Epidemiology

The ECA study found that the prevalence of agoraphobia ranges between 2.7% and 5.8%. The latest research shows similar results in the USA and the European Union.

It has been found that agoraphobia is significantly more common in women. Unfortunately, a valid explanation for why women get sick more often than men has not been found. The most accepted explanations are found in the cultural dimension of the phenomenon. It was long ago established that it is simpler for women to accept and express fear and to be dependent than it is for men.

Clinical studies have shown that agoraphobia very rarely occurs in childhood, and the first symptoms appear in the early years of puberty. The first surge happens around age 18, and the second around age 30.

Classification

In ICD-10-1992, Agoraphobia has two forms—Agoraphobia with panic disorder and Agoraphobia without panic disorder—and is classified in the group of phobic anxiety states.

In DSM-IV-1994, there are two categories in which the agoraphobic syndrome is part or the essence of the clinical condition—panic disorder with agoraphobia and agoraphobia without a history of panic disorder.

However, the DSM has further classified it and talks about the dynamic link between the disorder and other anxiety states and disorders. Accompanying syndromes such as claustrophobia and fear of travel often manifest with agoraphobia. Also, agoraphobia and depression can often go together, as can passive-dependent personality disorder, social phobia, histrionic, narcissistic, and borderline personality disorders. Finally, it has been found that the agoraphobic syndrome arises in the complex dynamics of partner/family relationships.

Clinical Picture

The disorder can begin to develop slowly and gradually, or abruptly and unexpectedly. When it develops slowly, one must most often look retrospectively at the life history of the person.

It can be said that from early childhood, they show a series of characteristic traits: pronounced hypersensitivity, fearfulness, enuresis, nightmares, refusing to go to school and separate from parents, homesickness, etc. However, these early signs often remain unrecognized until early adulthood, and even later, certain life events become "the last straw" that leads to agoraphobia.

Regarding a sudden and unexpected onset without a cause, a person who had previously felt well and functional experiences agoraphobia suddenly in a place away from home. Although the person is not consciously aware of the reason for the agoraphobia, a reason exists, but it is neglected and unconscious.

Characteristic events can be: divorce or the threat of divorce, a serious physical illness, the death of a loved one, a parent's long absence, an existential threat like job loss and economic dependence, loss of social status, witnessing accidents, etc.

A person suffering from agoraphobia experiences panic attacks and other related psychopathological phenomena, a fear of fear, and phobic avoidance, as well as many other characteristic symptoms. A panic attack is a special and specific experience. It is a genuine outburst of terror or fear of great intensity due to the immediate experience of a threat of death. The person believes they have contracted an incurable, severe, life-threatening disease, that they are losing control of themselves, and are going insane. All attempts to reassure them that this is not happening are unsuccessful.

The periods between panic attacks are just as distressing for the person suffering. Free-floating anxiety and the fearful anticipation of the next panic attack lead to paralysis, helplessness, and discouragement. Due to the constant feeling of undefined apprehension and the sense that something bad will happen to them personally or to their loved ones, such people are continuously tense and very irritable, and are prone to aggressive behavior.

The feeling of helplessness, which is the basis of all other forms of fear, is a sure cause of the fear of fear. It develops in situations where the clear causes of the fear are not seen, and when an appropriate way to defend against it is not found. An intense experience of the fear of fear can lead to phobic avoidance. First, places and situations where the person experienced this unpleasantness are avoided, and then an increasing number of places and situations that could lead to repeated discomfort are avoided.

Finally, a very specific characteristic is the need for a companion. Without them, the person is unable to be alone or go outside. Most often, this is one constant close person, but it can also be multiple people: mother, father, brother, sister, spouse/partner, and sometimes other people from the person's surroundings.

The characteristics are: hypersensitivity and a constant feeling of tension, shyness and instability, dependency and a constant need for support, difficulty making decisions, a constant premonition of misfortune, striving to meet high standards, a constant fear of making a mistake, and feelings of guilt.

Family and Partner/Marital Relationships

People with agoraphobia often grew up in overprotective families that taught them to solve life problems by avoiding or shying away from them.

Families can also be closed and uncommunicative, encouraging and emphasizing the non-expression or suppression of feelings among family members. It is often the case that there is an inversion of the psychological roles of the father and mother. The father is quiet, passive, and withdrawn, "looking at the tip of his shoes" when a decision needs to be made. The father avoids family obligations and is too often absent from family life.

The mother, as a rule, is a very dominant figure in the family. She wants and likes to be asked about everything, makes all the decisions, behaves in an overprotective way, and thus stifles initiative, independence, and a sense of personal freedom in the child. Due to great indecisiveness towards her mother, whom she loves and hates at the same time, a woman suffering from agoraphobia takes on a series of negative attitudes from her mother regarding marriage, sexuality, and sexual functioning. Because of this, she develops various forms of sexual inhibitions and does not satisfy her partner's demands, even to the point of refusing any sexual relations and fears related to pregnancy and childbirth.

As a rule, the partner/marital relationship is not harmonious and usual, but rather restrictive and impoverishing, and often destructive. The choice of a partner is probably a crucial factor in the dynamics of partner/marital relationships. The person tries to find someone who possesses psychological traits that they lack, which is to say, developed and expressed responsibility, independence, and initiative in solving life problems. The person transfers unresolved problems with their parents onto their partner, expecting them to be capable and strong, a "strong personality" who will solve their problems of dependency and indecisiveness easily and quickly. Unfortunately, this does not happen, because the person they find usually has similar problems, but has denied, ignored, or concealed them. It is much more common for him to be a "wimp, weak, clumsy person" or even "stubborn, dull, who doesn't understand anything and is always against everything" (client statements). He is often negativistic, explosive, jealous, with sudden and explosive reactions, with a strong tendency to withdraw without feeling the need to support his partner.

Immediately upon entering into marriage, a "psychological struggle for dominance" or "supremacy in the psychological space" begins, which often takes place unconsciously between the partners.

Treatment

The treatment of agoraphobia is a very complex and specific process, especially because its main goal is to suppress and/or eliminate panic attacks. Treatment is always integrative, often using a cognitive-behavioral, partner-family, and psychoanalytic framework in psychotherapy, sometimes with the addition of medication.

Author: Nemanja Kurlagić, psychotherapist using the O.L.I. method