Agoraphobia; madness or map

Sally wanted to walk to the local shop. She stood at her front door looking out at the street. She felt her heart begin to beat faster and faster. She began to feel light headed and her vision seemed to go fuzzy. “I can’t do it” she said to herself.

She closed the front door and went into the lounge to calm down. She was annoyed she couldn’t do such a simple thing that used to be no problem. She had been feeling like this for four months now and, if anything, she worried she was getting worse. Thoughts raced through her mind. “What’s wrong with me? Will it ever go away? I want to be normal again.”

Sometime ago she had told her GP about these feelings. He’d said it was agoraphobia a common mental health problem that many people suffer from. He’d prescribed medication which she had been taking for a few months. At first giving it a name and taking the tablets had helped a bit but she still had her bad days; sometimes it seemed worse than ever.

For Sally the downside of calling it a mental health problem was that it painted it as an unpredictable condition with little logic to it. She felt helpless. It seemed she just had to wait for it to go away or for the tablets to work.

To understand the problem from a psychological point of view we need to put Sally back at the centre of her experience. We need to ask what she’s been trying to do.

Feeling anxious about going out often starts after an episode when a person feels unexpectedly anxious when they’re out. They find this episode difficult to make sense of. Often there will be important emotional issues in the background of their lives; ones they haven’t fully recognised. Because they’ve felt unaccountably anxious in a particular situation, it is easy for them to wonder if It was something about that situation. Just the thought of going there again can make them feel anxious. But what was it about that situation? What other situations are similar and might cause the same feelings?

This thinking is not necessarily a conscious attempt to work things out; the person won’t necessarily be aware of what they’re doing. The thinking can operate at a more background, automatic level. We can understand this better if we think of how we react after, say, a road traffic accident. The sudden shock of an accident can leave many of us jumpy and more sensitive to loud noises and other sensory aspects of the accident (eg lorries if a lorry was involved, what vehicles are behind us if it was a rear shunt). These changes after an accident work at a very automatic level of our thinking but they are thinking nonetheless.

Once Sally blamed a situation for making her anxious, she tried to work out where and when she might feel like it again. In effect she started to draw a map of her world; a map of safe and unsafe places. This was not just a simple map; it included a list of places she could only go if someone was with her, or if she was able to take certain precautions (eg sitting near the exit or having her car so she could leave quickly without relying on anyone). The details for each person are always very personal. They have an internal logic that makes sense to the person. Over time the map can become more detailed and restrictive as they work harder to protect themselves.

To call this agoraphobia and to see this as a disorder or condition that happens to people is to miss what the person is doing. It denies them the opportunity of seeing the internal logic of their map and how they have inadvertently changed their world. It denies them the opportunity to find ways of ripping up their map.