The term agoraphobia originally meant fear of the marketplace, or open spaces, in general. It has come now to be used more loosely to refer to people who avoid, or feel uncomfortable in a variety of places, including, for example, bridges, tunnels, restaurants, airplanes and elevators. There is an overlap between agoraphobia and panic disorder. In fact, it is the fear some phobics have that they may have a panic attack suddenly and be unable to escape that makes these places threatening. Elevators and airplanes represent a physical restraint. Phobics can’t escape physically if they are trapped in a stuck elevator or on an airplane in mid-flight. The other places they avoid seem to trap them also because of social constraints. They feel they cannot without embarrassing themselves leave a restaurant in which they are eating with others, or leave from a theater where they are sitting in the middle of a row, or from church, or even from a conversation with someone in the back yard. Other places are scary because the exits may not be immediately apparent or accessible: shopping malls, arenas, highways, and so on. It is usual for someone suffering from panic disorder and agoraphobia to avoid many of these places. Sometimes, the fear spreads quickly and with devastating effect, so that the whole outside world is off-limits. I have made home visits to agoraphobic patients who have not been out of their house for twenty years. The treatment of agoraphobia is directed to the patients learning two things: that they are not really trapped, even in an airplane and that the panic attack, no matter how severe cannot cause them to lose control and do something dangerous or embarrassing.
But there are other places that phobics avoid for their own particular reasons:
1 Some phobics report that they feel uncomfortable outside of a perimeter, usually centered on their homes. They are still afraid primarily of having a panic attack, but, for some reason, the further they are away from home, the more they feel in danger. Sometimes, the perimeter is not symmetrical. It is possible to go further north than south, or in some other direction. This always has to do with one place being more familiar and, therefore, safe. Sometimes, someone with a perimeter can go a considerable distance, perhaps even on an airplane if it is to a place that person has visited frequently.
2. Some people are afraid of heights, particularly open windows or a terrace high up in a building. Or a subway platform. The underlying fear is similar to that experienced in a panic attack; the fear of loss of control. The phobic person feels he/she will fall or, possibly, jump from these dangerous places.
3. Commonly, places are avoided simply because the phobic person has had a panic attack there previously. The difference between one place and another seems arbitrary and idiosyncratic, even peculiar. One bridge and not another. One restaurant and not another. Even one stretch of road, and not another. Sometimes it is not a place at all, but some other ordinary aspect of life. Some people get panicky in bright sunlight, or, more commonly, at dusk. They don’t know why. But it is a self-fulfilling prophecy. They get panicky there because they expect to get panicky there.
Another patient: Me: How come you always get panicky on Thursday and never Tuesday?
Patient: BECAUSE IT’S THURSDAY!
Another patient: “I was in this car with my friend, in the backseat. I was eating a ham sandwich. We were going to Brooklyn.The ride was very bumpy, and I started to choke. Now, I won’t go to Brooklyn anymore.”
“WHAT?” I said, mentally stamping my feet. “What do you mean? In the first place, just because you choked once, it doesn’t mean it’s ever going to happen again. It never happened before did it? Besides, I can see you not wanting to eat in the backseat again. I can even imagine you avoiding ham sandwiches; but Brooklyn?”
“That’s the way I see it.”
I had another patient who used to get up in the middle of night to check to see if the sky was overcast, not always easy to do. If the sky was overcast, he had to leave his apartment and spend the rest of the night in a diner. If the sky was clear, he went back to sleep.”
I couldn’t understand him either. (c) Fredric Neuman 2012 Follow Dr. Neuman's blog at fredricneumanmd.com/blog