Agoraphobia

This is a continuation of my series on the most common psychological disorders in Australia. This list is drawn from the most recent National Survey of Mental Health and Wellbeing by the Australian Bureau of Statistics in 2007. This article is a fitting companion to my last blog in this series, Panic Disorder. As Covid-19 keeps us away from one-another, I predict a massive increase in agoraphobia in the months to come (which I’ve kind of written about here).

Life Under the Glass Dome

Imagine you stand in the centre of a giant transparent dome. This dome is your comfort zone. If you are comfortable in many places, your dome is vast. If you are always awkward and uneasy, your dome barely covers your own body. This dome may expand or contract as you move though life, in fact, it is never stationary.

As I’ve written elsewhere, the natural urge associated with anxiety is avoidance. When we feel anxious, we invariably have some tendency to stay away from something. If we do stay away from the target of our nervousness, we have “cured” our anxiety, and we experience relief.

When we habitually cure our anxiety by avoiding certain places, activities, people or things, our comfort zone contracts. It becomes ever harder to face the anxiety-target. Our comfort zone is never still. And the more we avoid, the harder it is to stop avoiding. The comfort zone-dome walls accelerate toward us.

Fear of the Marketplace

Agoraphobia is the fear of places that are difficult or embarrassing to escape from. However, the word Agoraphobia comes from ancient Greek and literally translates to Fear of the Marketplace. And this definition is quite apt, because the most common place that my clients with agoraphobia are uncomfortable in is large shopping malls.

Take Betty*. Betty has always been a nervous person but has always been able to function. Then, last year, she nearly fainted when doing the Christmas shopping at the local Westfield. She was helped by some passers-by and made it home safely. She was wary about shopping for the next few weeks and had a minor anxiety attack while waiting in a long line at the returns desk in January. Then Covid hit, her husband took over grocery duty, then she discovered online grocery shopping. Betty hasn’t been to the shops in person for months and refuses to leave the house for anything but the absolute necessities.

Betty’s experience is typical of someone who was developed Agoraphobia. First, she had an initial frightening and embarrassing experience. This experience highlighted the threat of the marketplace. Second, another episode of anxiety occurred, driven in part by her already high discomfort, which consolidated the fear. Her pattern of avoidance was then entrenched by the Coronavirus restrictions. Now she had a specious (seemingly valid) reason for not going to the shops.

Betty’s comfort zone contracted around her when she stopped going to the shops. But unfortunately, it didn’t just stop with the shops. Agoraphobia is a slippery slope. Betty became nervous not only in the marketplace, but the local strip of shops in her suburb and on the train. Even leaving the house started to feel intimidating.

Catastrophising and Panic

When asked why she wouldn’t go to the shops, Betty said that “she didn’t want to embarrass herself”. She had lost confidence in her ability to remain in control when in crowds. The times that she had pushed her comfort zone, her body’s fight or flight mechanism kicked in, which reminded her of the time she had almost fainted in the pre-Christmas crowds.

Catastrophising Thinking is almost always a part of the agoraphobia experience. Very often, the catastrophic thought is of having a panic attack. Agoraphobia and panic disorder co-occur. Between 30%-50% of people with agoraphobia have panic disorder preceding it. In other cases, it is the fear of embarrassing oneself, or of being in some kind of threat, that underlies this disorder.

Treatment

Agoraphobia is treated by gently pushing the edges of the glass dome (comfort zone), regaining confidence in public. This process is called Graded Exposure. Exposure to physical signs of the fight or flight response can help too. It is important to see anxiety as a normal bodily response and not something to be feared. Analysing catastrophic fears also builds confidence that we will be able to cope after all.

Nine months after her initial scare, Betty made it back to Westfields. Her comfort zone-dome now back to full size.

* Betty’s story is an amalgam of previous clients’ experience. Not based solely on a real person.