In extreme cases, this could mean quitting jobs and eventually becoming housebound. However, not all people who have agoraphobia become housebound. Many of us manage to white-knuckle it from day to day, cleverly concealing our fears from family and friends to avoid ridicule and to protect ourselves from further shame. The plight of the agoraphobic is frightening, lonely, and bewildering.
Agoraphobia develops more easily within a person who succumbs to the fear of panic by avoiding situations. By continually confronting anxiety, you desensitize yourself to those sensations. The stereotypical image of the macho male may pressure men to tolerate anxiety and still face fearful situations. In this way, some men learn coping mechanisms that prevent anxieties from building into panic. If women or men allow themselves to give in to fear, they give up ground and agoraphobia steps in.
Amering et al. (1997) interviewed 60 patients with agoraphobia and 30 patients without agoraphobia about their first panic attack. Agoraphobia prior to the first panic attack was relatively uncommon in the sample (10%) and did not predict the presence or absence of agoraphobia at the time of assessment. Feelings of embarrassment about experiencing the panic attack, and whether the panic attack occurred in a public place, were significantly associated with the later development of agoraphobia.
Specific personality traits have also been assumed to predispose individuals to agoraphobia. Agoraphobic patients have been described as dependent, shy, anxious, depressive, unassertive, immature, and the like, but there is little empirical evidence that a clear "agoraphobic personality" exists (Chambless, 1982).
In particular, this research focuses on the gendered experiences of women with agoraphobia. Agoraphobia is diagnosed more frequently in females than males (Cameron & Hill, 1989). McHugh (1996; 2004) has argued that sex linked disorders require us to consider gender-based explanations. Gelfond (1991) suggested that our understanding of agoraphobia could be enhanced by a consideration of the meaning of home to women in general and to women with agoraphobia. "Women's reluctance to leave home can be seen to result from the control, status, identity, and personal meaning embedded in the place and concept of home." (Geldond, 1991, p. 253).
Agoraphobia is also a major source of revenue for pharmaceutical companies, whose annual sales of the indicated antidepressants and minor tranquillizers reached a combined total exceeding $1 billion in 2002 alone. As profitable as the disorder has been, it comes at great personal cost to those who suffer from it, especially, as epidemiological and clinical studies have shown, in terms of quality of life (see Mendlowicz and Stein, 2000). For instance, people with anxiety disorders sleep less, and lack of sleep along with the drugs many of them take to manage their disorders place them at greater risk of having automobile accidents.
The symptoms of agoraphobia are: fear of being alone, fear of losing control in a public place, fear of being in places where escape might be difficult, becoming housebound for prolonged periods, feelings of detachment or estrangement of others, feelings of helplessness, dependence upon others, feeling that the body is unreal, feeling that the environment is unreal, anxiety or panic attack. Agoraphobia affects about a third of all people with panic disorder. Typically situations that invoke anxiety are avoided and in extreme cases, the person may never or rarely leave their home.
For our purposes, though, characterizations of agoraphobia fall roughly into two groups. One group, best represented by Freud and psychoanalytic orthodoxy, understands the illness as, primarily, a self-fear displaced onto a fear of the street. I'll come to their explanation of this later. The salient point here is that the focus of the agoraphobe's anxiety is not so much the street, but the opportunities for encounter offered by it. It is the crowd incubated by the street which alarms him, because it tempts him to plunge into its anonymous mass and lose himself. Our other group is more urbanistically inclined.
In American and European societies, the vast majority of individuals diagnosed with agoraphobia are women. Indeed, the epidemiological study conducted in the United States reported more than twice the prevalence of agoraphobia among women as men. Though compelling, this ratio is considerably lower than those reported in other investigations of agoraphobia, in which the relative percentages of females range from 63 percent to 95 percent. In the clinical literature, agoraphobia is consistently referred to as a "woman's syndrome."
Why do agoraphobic symptoms tend to appear after the age of twenty (especially since most phobias originate in childhood)? It is suggested that these patients have an agoraphobic disposition that is not expressed until a change of circumstances activates it. For example, M. R. Liebowitz and D. F. Klein (1982) postulate that these individuals have a lowered threshold for panic attacks associated with separation, and thus are vulnerable to "episodic autonomic discharge."