Claustrophobia, Agoraphobia, & Acrophobia
A "Phobia," is an irrational, intense, persistent fear of certain situations, activities, things, or people. The main symptom of this disorder is the excessive, unreasonable desire to avoid the feared subject. When the fear is beyond one's control, or if the fear is interfering with daily life, then a diagnosis under one of the anxiety disorders can be made. Phobias are the most common form of anxiety disorders. An American study by the National Institute of Mental Health found that between 8.7% and 18.1% of Americans suffer from phobias. Broken down by age and gender, the study found that phobias were the most common disorders among women in all age groups and the second most common disorder among men older than 25. (From Wikipedia, the free encyclopedia)
This chapter focuses on three common phobias:
Claustrophobia means fear of enclosed or confined spaces. People with this phobia are afraid of finding themselves in a situation from which there is no easy exit should they suddenly feel the need to retreat to a safe place. Examples of closed spaces are anything from cars to
elevators, MRI, and even small rooms.
Agoraphobia means fear of open spaces. It is one of the most common phobias. People with this phobia feel that they are unsafe while out of doors and that they need to get home or retreat to somewhere where they feel secure. Examples of open spaces include large public gathering areas like sports arenas, shopping malls, and airports.
Acrophobia means fear of heights. People with this phobia are afraid of falling from a very high place. Examples of high places are high buildings, steep mountains, and flying.
Most people who suffer from phobias will try to avoid the objects or situations they fear, in order to avoid the anxiety they arouse. Claustrophobia, agoraphobia and acrophobia may be the outcome of heredity, environment or the combination of both. (Nature vs. Nurture)
From the heredity point of view, phobias may be identified in early age. Some babies may cry when their parents lift them very high whereas others may laugh. Some may cry when left alone in a small space whereas others may be playful. Some may cry when left alone in a shopping
mall whereas others may watch with interest strange people around them.
From the environmental point of view, a traumatic experience that had occurred in a confined space, in a high space or in an open space may cause the onset of a phobia. Also, imitating a phobic parent may lead a child to suffer from the same phobia.
In many cases, phobias may be the outcome of both factors. When a child is born to a phobic parent, he/she may inherent the genes that lead to phobic reactions. On the other hand, if the phobic parent succeeded to master the phobia, and teaches the child not to be fearful in such spaces, the chances are that the child would not suffer from phobia.
It is obvious to me how a traumatic experience may lead to a phobic reaction. For example, falling from a roof of a house may cause a phobia of heights, being stuck in an elevator for a long period may cause a phobia of close spaces and being left alone in an open apace, during childhood, may cause a phobia of open spaces. I wondered about the genes that cause phobias. Since genes have undergone a process of
mutation during human evolution and most of the genes that remained in our genetic pool contributed to survival and procreation of our ancestors, how did phobias contribute to survival?
I suggest the following evolutionary explanation for the existence of phobic genes. Through mutation, nature provides every creature in the world with a body structure that helps it survive and an instinct that directs it to choose the best response to a threat. Animals that survive by fighting are provided by evolution with sharp nails, long horns or strong teeth. Animals that survive by escaping are provided by nature with quick legs, wings or the ability to climb high trees. Animal that survive by hiding in small cracks in the ground, are provided by
nature with a thin and flexible body structure. I propose that the goal of phobia is to direct each creature to avoid spaces where it cannot use its natural capacity to survive. For example, a lizard, which survives by hiding in small cracks, may experience phobia if it is
placed in an open space. Deer, which survives by running in open places, may experience phobia if it is placed in a confined space or in a very high space, where it cannot run.
I asked myself, what did nature provides humans as a way of survival? We do not have horns, nor sharp teeth and no thick skin. Nature provided us with a large brain, so we could invent tools that would help us survive. For example, swords and knifes instead of horns and teeth, metal shield and tanks instead of heavy skin, and airplanes instead of wings. Can we assume that nature provides humans with instincts that direct us to avoid certain places? We may refer to that avoiding instinct as a phobia. May be each of us is born with an inclination to prefer different style of survival. As a result, the survival of a family's genes increases. When three siblings encountered a predator while hunting, the one who did not fear heights climbed a tree, the one who did not fear open spaces ran quickly and the one who did not fear narrow places, hid in a small cave. Since each sibling had genes that directed him to avoid different modes of escape, one of them had better chance to survive and to spread his genes.
My assumption is that phobia is an instinct that helped the survival of our ancestors. Unfortunately, that gene is imbedded in the genetic pool of modern humans. As in any gene that relates to our emotions, some people are born with higher potential to experience it and as a result, they experience phobias, while others are born with a milder potential.
I encourage everyone who suffers from phobias, to try self-help by practicing relaxation and mental imagery techniques. If it is not sufficient, it is recommended to seek the help of a psychotherapist.
A Case Presentation: Hyperventilation & Agoraphobia
Tami, a 26-year-old woman, suffered from hyperventilation a few times a day, and from agoraphobia. Tami could not go out of her apartment by herself. The fast breathing made her feel dizzy, lightheaded and tingling. She claimed that all her symptoms had started about two months earlier, and that she did not have the slightest idea what caused it. During our first meeting, I gathered information about her personality and the onset of the symptoms.
Tami was born in Chicago to Israeli parents. When she was 16, the family immigrated to Israel. She described a happy childhood. After serving in the Israeli army as a secretary, she worked in a civilian office, apparently enjoying her employment. She was married about two months
previously, and her symptoms started during her honeymoon. She described her husband as a wonderful person, who loves and cares for her very
much. From the way she described her life, up to the onset of her symptoms, I could not find any clue to explain why she felt suddenly so anxious. I asked her to describe her honeymoon. Since she was born in the USA and had not returned there since she left for Israel, she decided to spend her honeymoon there, and to visit Chicago where her grandparents live, and also briefly tour New York City. The trip to Chicago indeed turned out to be very exciting. She enjoyed meeting her grandparents and showed her husband her old home and school, and they met some of her old friends. Their plan was to spend a week in NYC before returning home. While the plane from Chicago was descending toward
the JFK airport, she suddenly started breathing very fast and felt heart palpitations. She feared she might faint. The couple took a cab to a
hotel near the airport, proceeding immediately to go to the emergency room of the nearest hospital. A physician diagnosed her symptoms as a panic attack and prescribed medications. All night long, Tami walked in her room, from wall to wall and did not stop crying. In the morning, the couple flew back home. An Israeli physician changed her medications, and recommended psychotherapy. The following day she tried to go out for food shopping, but she returned immediately since she felt very strong heart palpitations and she feared she might faint. Since then, she was staying most of the time in their apartment, feeling very anxious. She claimed that the medications hardly helped her.
During our second meeting, we focused on trying to understand what had triggered Tami's anxiety attack. I suggested her to close her eyes and visualize her honeymoon, as if she was watching a movie, and to describe it to me. She re-experienced the positive feelings she had while visiting her grandparents in Chicago and their preparation for the trip to NYC. I asked her if she had visited NYC while living in the States as a child. She answered in a very tense voice: "No, my parents did not allow me to go to NYC. They said that it is too dangerous."
"Tell me more about it." "It was during summer vacation, just before we immigrated to Israel. I planned a week's trip from Chicago to NYC with my girl friend. We discussed the possibility of staying with her relatives. However, my parents refused to let me go, stating that NYC is too dangerous for two 16 years old girls to walk there by themselves. They were sure that we would be robed, raped or even murdered on the first night there."
As Tami told her story, her breath accelerated and her entire body was very tight. On the other hand, I felt relaxed. Her story gave me a hint on what had triggered her symptoms, and I started planning ways to help her. My first step was to re-label her symptoms. Instead of relating to her as a neurotic woman, who suffers from agoraphobia and hyperventilation, I would describe it as an exaggerated reaction of a normal instinct.
"You should be proud of yourself, Tami" I started in a supportive voice. Your hyperventilation and your accelerating heartbeat started as your plane was descending toward the JFK airport. Such symptoms indicate that your body and your mind were prepared to cope with a dangerous situation. It seems that part of you agreed with your parent's view of NYC and was afraid of being hurt there."
Tami opened her eyes and gave me a bewildered look. I explained myself. "Yes, you were ready to face people who might attack you or to flee
from them." I want on to explain the evolutionary theory of
"Fight or Flight"
and the fact that hyperventilation must have been a useful tool that helped our ancestors to survive, but that this reaction seems to interferes with coping in modern times. (For more information, read the appropriate chapters in the site). It appeared that the evolutionary
explanations helped Tami to feel somewhat better about herself. I suggested her to share the theory with her husband and to ask him to
join us in the next meeting.
During our third meeting, I instructed the couple with a variety of relaxation techniques and Mental Imaginary exercises. I suggested to Tami to practice relaxation by listening to a Relaxation CD twice a day, once in the afternoon, and once while going to sleep (For more information, read the appropriate chapters in the site). I suggested to Tami's husband to practice with her going out of their apartment. Every afternoon, when he comes back form work, they should go out together. He should walk a few steps behind her without talking. Tami should feel as if she is walking alone but feels secure because he his right behind her. When she feels somewhat more comfortable to walk like that, he should walk even farther away behind her. I suggested to Tami to focus on stimuli around her, such as looking at cars, at houses, at trees or at flowers whenever she feels frightened. At the end of the session, I applied a Paradoxical technique.
"I hope until our next session you would have at list five and a half hyperventilation attacks." I said with a smile. "Why do you wish me to have such attacks? I pay you to help me not to have such attacks any more." Her voice sounded very angry. "You came to me to learn to accept the fact that you are only a human being and as such, until you are an old lady, you may experience a few more hyperventilation attacks. When it happens in the future, instead of being angry with yourself, you should smile and say inwardly: "Grandmother Lucy came to warn me that a predator tries to hurt me and that I should raise the level of my Stress hormones in order to defend myself." I suggest you to be nice to her, give her a glass of water and explain her that her techniques do not help modern people. Send her back to her cave. After she leaves, do some relaxation exercises" (For more information about grandmother Lucy, read the chapter:
Evolutionary Psychology
in the site.) "O.K Dr. I'll do what you said." She answered with a smile.
Tami arrived for the fourth session with a very good mood. She claimed that during the week, she hardly had any hyperventilation attacks, and that she walked around their block many times. During the last two evenings her husband stood in front of their house and she walked by
herself around the block. Whenever she arrived close to him, they waived to one another and she continued to walk. I pretended to look
disappointed. I told her that I wish that next week she would experience a few times hyperventilation. She answered with a smile, indicating that she knew what I meant.
On that session, I focused on helping Tami to overcome dangerous people. While her eyes were closed, I instructed her to imagine that she is a director of a movie, besides being the main actress. In her movie, she is a teenager, walking with her girl friend in NYC. Suddenly, a strange guy grabs her hand and demands money. Since she is the director of the movie, she has to finish it with a happy ending.
After being quiet for a minute, she started to talk. "I see the guy, he looks very mean. He demands money. I give him five dollars. As he stretches his hand to grab the money, I spray his eyes with a special chemical. He starts rubbing his eyes screaming with pain. A police officer arrives and takes him away."
I asked Tami to direct another movie in which her husband and she are the heroes. They are a young couple on their honeymoon. The same mean guy stopped them demanding money. Tami did not need a long time to plan the happy ending of the second movie. On the spot, she described how both of them overcame the mean guy, and again a police officer arrested him.
The fifth meeting was our last one. Tami came with her husband. She described how they practiced walking in different places while her husband was a few yard behind her. They walked in a mall, in a supermarket and on the boardwalk. They bought a small empty spray bottle and filled it with vinegar. Tami held it in her hand, while being ready to defend herself against anyone who might try to hurt her.
I encourage every one who suffers from hyperventilation or from agoraphobia to try self-help by practicing relaxation and mental imagery techniques. If it is not sufficient, it is recommended to seek the help of a psychotherapist.
People suffering from claustrophobia, agoraphobia or acrophobia, tend to have a cautious personality more than their peers. Since “knowledge is power”, it eases for self-acceptance and positive coping with variety of anxieties symptoms, reading of the chapter
"Cautious vs. Daring" is recommended.