agoraphobia crowd

Agoraphobia: a mental health problem that everyone’s heard of and yet receives little attention in media or movies.

In this week’s Freudian Script, we will explore the definition of agoraphobia, its connection to panic attacks and other mental health problems, notable examples and writing tips on how to portray agoraphobia sensitively and accurately.

DISCLAIMER: This blog post is designed for writers of fiction. If you are concerned that you or someone you know has symptoms of mental health problems, please see your doctor.

What is agoraphobia?
From the Greek “fear of the market/gathering place”, agoraphobia is an anxiety disorder characterised by fear, anxiety and panic in public places, mostly open or crowded spaces, resulting in avoidance. The phobia part is similar to any other phobia – spiders, heights, small spaces – because a phobia is an exaggerated anxiety response leading to avoidance.

I’m emphasising avoidance here because it’s a really key part of agoraphobia. The definition hinges on the anxious person’s splitting of the world into Safe and Unsafe places (mostly unconsciously). To avoid feeling fear and anxiety, the person avoids the Unsafe places and keeps to the Safe places. As more and more places become labelled as Unsafe, the person may become confined to the house or even a single room, the only place where they feel Safe.

As in any good movie, there is often an Inciting Incident. For example, say you have the ‘flu and you go to the supermarket to stock up on paracetamol and vitamin C. Unfortunately, the exertion is too much for you and you collapse in front of the orange juice.

You are mortified. Crippled with shame, you beat a hasty retreat home. But next week, you think about going to supermarket. What if you collapse again? What if the collapse was nothing to do with ‘flu but actually it was the supermarket? Maybe you just can’t handle supermarkets. You decide to try the corner shop instead.

But maybe it’s shops in general. You start to feel anxious in the local Co-op. Maybe, in fact, it’s being in the presence of all those people, witnesses to your probably repeat collapse. You avoid the shops, the high street, public transport, school/work – until, finally, you figure its better to stay inside, because you never feel anxious at home.

Anxiety is tied up in the adrenaline-based “fight or flight” response. Situations that are non-threatening are inappropriately tagged by the brain as threatening and trigger an adrenaline surge. By avoiding anxiety-provoking situations or leaving “threatening” situations when feeling anxious, the person experiences relief – a drop in anxiety level. This is rewarding and makes them less likely to enter the situation again.

Connections with other mental health problems
Until DSM-V (the American mental health categorisation system), agoraphobia was a subsection of panic disorder. This is because agoraphobia and panic attacks are often highly linked.

Experiencing a panic attack in a public place can be a trigger for avoiding that place and other related places. While I am fortunate to have never experienced a panic attack myself, I am told they feel like dying. Rapid heart rate, increased breathing (because you feel you can’t get any air), chest pain, tingling in the fingers and face – who wouldn’t want to avoid feeling that way?

Agoraphobia can also be linked to social phobia – the fear of being critically watched by other people. As social situations often occur in public places, these may then be avoided – but the root problem is social anxiety. Depression can be the result of the isolation caused by agoraphobia, exist alongside it, or mimic it – the severe fatigue and loss of pleasure in depression can mean that leaving the house is a terrible burden. Severe obsessive-compulsive disorder can look like agoraphobia, because repetition of rituals or obsessive fears related to the outside, can confine a person to the house.

Notable Examples
The problem with agoraphobia as a subject is the general public equates agoraphobia with housebound. And when a protagonist is confined to the house, that can limit the story-telling potential.

Therefore, the temptation is to drag that suffering character out of that house. In Nim’s Island, Alexandra Rover is an adventure writer with agoraphobia who’s called to save a little girl – in person. The scene below deals with her leaving the house, with the help of Alex Rover, her fictional adventurer:

Anticipatory anxiety is very common – and can be more severe than anxiety in the feared situation. However, notice how Alexandra reacts as soon as she’s outside the door: nothing. She throws up in the taxi afterwards and appears nervous, but where are the anxiety consequences of such a momentous step? While the visual battle between the two sides of Alex is amusing, it fails to address the fallout.

For a more positive example, I want to turn to a short film a filmmaking friend of mine James Hickey shared with me – Thinking Inside the Box. It’s a light-hearted portrayal of the agony of agoraphobia (with a bit of OCD) – and a unique solution to extending the Safe Space of the home:

Writing agoraphobia
Writing agoraphobia is a particular passion of mine because it is the main mental health complaint of my hacker protagonist Amy Lane.

Amy’s agoraphobia “inciting incidence” isn’t revealed in Binary Witness. By the time the reader meets her, she hasn’t left the house in ten years. A mental illness that begins as a teenager has a big impact on the general mental health of a person, often leading to a more severe illness and an impact on development of social skills and personality.

As mentioned above, anticipatory anxiety can be worse than being in the feared situation. Talking about entering the feared situation can induce a panic attack. In the following excerpt, Jason – her new cleaner and assistant – forces the issue in a fit of anger. Here’s the resulting fallout:

“If you want to find this woman so badly, why don’t you find her yourself?” Jason was deliberately baiting her now. His head was starting to ache and he was not in the mood to fight with Amy about what he did and didn’t want to do for her. This case had taken over his life already. He’d spent most of his weekend trying to find out stuff for her, and now she was acting like he was slacking off just because he was a bit late? He’d been staying late every day to help her out, and this was the thanks he got? Typical bloody woman.

“Maybe I don’t want to.” Amy turned back to her keyboard with a huff.

Jason stalked over to her and turned her chair around, hesitating at the flicker of fear in her eyes. “I get it—you don’t want to go outside. What’s so scary about outside, Amy? Would a little sunlight kill you? You’re not a bloody vampire.”

With that, he threw open the curtains, allowing the light to stream into the room through the grubby windowpane. Amy shielded her eyes as if it burned her, whimpering softly at the onslaught of sunlight. “Don’t, please, just…put them back…”

Ignoring her pleas, Jason found a key on the windowsill and thrust it into the rusted window lock. “Something wrong with fresh air? Do you good. Sun and fresh air and outside.”

“No, don’t open it!” she cried out, grabbing for his sleeve. “I don’t want it—”

Jason wrenched open the window and a cold gust of air swept into the stuffy room, the bite of encroaching winter in its ice. He turned back to Amy to find her shuddering in her chair, curled in on herself and gasping for breath. “Amy…?”

Her breathing showed no sign of slowing, as she huddled in her ball of terror like a startled hedgehog. Jason quickly slammed the window and drew the curtains, returning the room to its usual state. But she did not calm, tension radiating from every fibre of her being.

Jason knelt in front of her, unsure of what to do, his own heart hammering at his impotence. “Tell me what you need. Amy, you have to tell me how to help you.”

“Not going out, not going out, not going out.” The litany that passed her lips was like a prayer, fervent and unanswered. Her breathing quickened further and she clutched her chest as though she was having a heart attack.

Jason grabbed hold of her shoulders. “Amy! Snap out of it!”

Amy cried out, shaking now, tears spilling over.

Jason was terrified and started rubbing her shoulders rhythmically. “It’s okay, it’s okay—you don’t have to go. I’m here. I won’t let anything happen to you. You’re going to be all right.”

She reached out, clutching at his T-shirt, and Jason wrapped his arms around her, soothingly rubbing her back and drawing her close to him. He bent close to listen to her feverish ramblings, but could only pick up fragments: “…hurts…please…don’t let me die…”

“You’re not going to die. I’m right here. Breathe.”

She was clinging to him as if he were a life buoy, her only hope of survival, and he wasn’t sure how long he held her, as her cries subsided and her breathing slowly returned to normal.

“Are you okay?” he said, unwilling to release her until he knew she was going to be all right.

“I’m not going out.” Her words were muffled against his shoulder, and he ran a gentle hand over her hair.

“You’re not going out,” he agreed, shaken to his core by what had just happened. “I won’t make you do anything you don’t want to do.”

“Will you stay?” She looked straight at him with pleading, red-rimmed eyes.

“For as long as I can,” he promised, and that seemed to be enough.

Want to read more about Amy’s agoraphobia and Jason’s ham-fisted attempts to manage it? Order Binary Witness now – launching 5th May 2014!

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