On ” Agoraphobia” (so-called)
265 Art. VIII.? . :Author: Henty ENRY Sutherland, M.D. An able Paper on ” Agoraphobia” has been published by M. Legrand Du Saulle in the Annates Medico-Psychologiques, and analysed by Dr Aldridge in the London Medical Record of April.
M. Du Saulle, not satisfied with the term ” Agoraphobia,” proposes to re-christen this disorder, giving it the name of ” La peur des Espaces.”
Several cases which appear to be distinguished by symptoms justifying their being classified under this head having been lately under the observation of the writer, he ventures to offer a few remarks upon a malady which he believes to be more common than is usually supposed.
With regard to nomenclature, the writer is of opinion that neither the term ” Agoraphobia,” nor ” La peur des Espaces,” expresses more than a symptom of the disorder. Some more comprehensive title must be sought.
” Agoraphobia” implies that the etiology of the disease is objective, but if the symptoms are carefully considered they will be found to depend in reality upon subjective influences. Want of self-confidence is at the root of the disease. Fear that the patient will be unable to walk a certain distance; hold out for a certain time without food; support existence for a certain period without fresh air; perform a certain journey without fainting on the way, and the like. Fear of self?that self will be unable to fulfil certain duties?is undoubtedly the most prominent feature of this disease. The writer therefore ventures to suggest that, until a better name is found, the disorder should be known by the title of ” Autophobia,” or Fear of Self.
” Concerning the etiology of the malady,” says M. Du Saulle, ” I have very little notion.”
But in one of the cases, to be presently described, the origin of the disorder was clearly traced to overwork. In other cases there was a history of more or less excess in alcoholic stimu- lants. In one of these the patient devoured habitually three times as much meat at each meal as is usually taken by a healthy person. In another the patient confessed to an habitual indulgence in sexual excitement, but unaccompanied by natural gratification of the stimulus.
In all the cases the symptoms were undoubtedly aggravated by habitual indulgence in groundless fears. M. Du Saulle enumerates the following symptoms in cases of so-called ” Agoraphobia” :?The patient is afraid of space, equally in the street, in the theatre, in church, or on a bridge. He feels he will never be able to walk up a street. The fear lessens if he see a carriage or take a person’s arm. This agony manifests itself by a sudden feeling of the heart being grasped. The heart palpitates, the legs tremble, and this tremor occurs in the most robust people. In some cases M. Du Saulle has observed a lessening of the intensity of these phenomena by the use of spirits, or after a good dinner. These attacks usually com- mence in persons who are in good bodily health. Nervous pre- disposition, insanity, and epilepsy have been noted in the families of patients affected.
It has often been confounded with simple vertigo, with that proceeding from the disorder of the stomach (Trousseau), epileptic vertigo, and hypochondria. But it is distinct from all these, and particularly from stomach vertigo, in that the patients have usually a good digestion.
The point upon which most stress is laid, however, by M. Du Saulle and other writers is, that these groundless fears are excited by the sight of any large space of ground or exten- sive structure. There is the same agony in the presence of a flying perspective, of an extended facade, of a bridge with numerous arches, of a long roof sustained by columns. Yet these phenomena are produced, but in a less degree, in an omnibus or cab, which can scarcely be called an extended space; and, moreover, some patients only experience this feeling in cities, being able to bear the sight of a wide green plain. These two facts sufficiently indicate that the disease is not purely the result of seeing an extended space, but must depend upon some other cause, which cause the writer has every reason to believe proceeds from within, and not from without. The cases which it appears would be appropriately classified under the head of ” Autophobia” will now be briefly described. Case 1.?An artist, aged between 30 and 40, a personal friend of the writer. He attributes his symptoms to the facts that he drinks six glasses of strong sherry every day (some- times more), and that he is much exposed to sexual excitement from contact with the nude models in his studio, but without gratification of the stimulus. After leaving the studio, when he enters the street, his knees tremble, and he feels as if his legs would give way under him. This feeling passes off, and he becomes more reassured, when he arrives at a thoroughfare frequented by cabs, as he knows that if anything happens to him, he can then call a cab, and drive home. He usually manages to walk an hour or two every day, but sometimes, ON ” AGORAPHOBIA.” 267 although quite near home, he becomes alarmed, and has doubts that his strength will hold out until he can reach his front door. He has more than once taken a cab to drive home in when in sight of his own house.
He suffers on such occasions from the feeling that the heart is being grasped, which he sometimes finds relieved by striking his chest with his fist, breathing rapidly, and running or jumping, under pretence of avoiding a vehicle, as he crosses the road. Walking with a male companion affords relief; but, if walking with a lady, the attempt to avoid stepping on her dress makes him giddy. He is an athlete to a limited extent, and has at times felt these symptoms come upon him in the street after unusual exertion at the gymnasium. Sculling in a boat has no bad effect upon him, especially if the boat is heavy enough to lie down in; but he feels nervous in a canoe, although he can manage it properly, and although he is also an expert swimmer, as he misses the moral support of the sculls on either side.
Walking along near a wall also affords him similar relief. He feels that he might lean against it if anything happened to him, although he does not touch it in any way. He is unable to walk much before lunch when at work at his profession, but can take almost any amount of exercise in the morning when out of town for a holiday, as the chief cause of his malady is then removed. He is a great dancer, but is positively afraid to join in a quadrille or lancers, as he says that turning his partner in a circle produces vertigo. That this is pure nervous- ness and not vertigo is proved by the fact that he is able to waltz as vigorously as other men.
He is perfectly aware of his symptoms, but has not the strength of mind to abandon the habits which produce them. Unlike the hypochondriac, he does not ask for drugs to relieve him, feeling confident that the only cure for his malady is an abandonment of his habits. This is sufficiently proved by the perfect restoration to mental equilibrium which occurs when he is absent from town on a holiday.
Case 2.?A literary man, aged nearly 40. In this instance there is no history of sexual abuse of any kind. Alcoholic stimulants are taken in full, but not excessive, quantity. The only points that can be laid hold of as being likely to produce the disorder are, first, that this gentleman eats three times as much meat per diem as a person ought to consume who is in robust health; and, secondly, that he has allowed the habit of indulging in groundless fears to grow upon him, instead of resisting it. He rises, goes to bed, and takes his meals punc- tually at the same hour every day. He scarcely ever leaves the house, never goes into society, and devotes himself to literary pursuits, to playing on the pianoforte, and to walking up and down a room for so many hours a day, with the window widely open in all weathers, at the same time wearing a hat and great coat. Originally a man of independent character, he has allowed himself, through mere habit, to degenerate into a chronic state of nervousness about trifles. As the disorder advanced his walks became shorter, and at length he ceased to go out almost altogether. When he goes out of town for his yearly holiday, he always puts off the day for starting several times, under the pretext of suffering from diarrhoea, although he is never afflicted with this complaint at any other time. When once out of town he orders his life in the same manner, only varying the programme by sitting in the back garden of the house, if theie is one. He actually cuts his own hair to avoid the necessity of going out to a shop, and all his dealings with tradespeople are conducted by correspondence, or by their attendance on him at his own house.
Case 3. A letiied government official, aged about 50. The symptoms were produced by overwork. This gentle- man is unable, through nervousness, to walk outside his own gates. He leads an active life, spending a good deal of time in gardening. Hypochondriacal notions are present to a limited extent, as lie believes he is suffering from an obscure bodily disorder which the most skilled physicians in London have been unable to detect. His bodily health is apparently good. A few cases where these symptoms have existed temporarily may be briefly touched upon.
^ASE c^er8yman5 aged 36. Formerly a splendid gymnast. Three months after marriage he informed the writer that he was afraid to walk in the street. His legs seemed to bend under him. Being a gentleman of peculiarly bad temper, the wnter refrained from volunteering any advice in his case, and froin alluding to what was suspected to be the removable cause of his symptoms.
Case 5. A cavalry officer, aged 36, in robust health. Was delayed at Dover, when starting for his honeymoon, by bad weather. He stated that he was scarcely able to “crawl”about the town, as he was so much reduced by the unusual calls made upon his physique during these first few days of married life. Case 6.?A merchant, aged 40. Although married, some- times absented himself from home for days together, indulging at such times in excessive and promiscuous sexual intercourse! The case was complicated with spirit drinking. After these debauches he was unable, through nervousness, to walk down the stairs of his office without leaning on the arm of a clerk. In the three last-mentioned cases all the symptoms disap- peared entirely when their cause was removed.
This condition of so-called Agoraphobia can scarcely be called a disease. It occurs in healthy men. It is incapable of being alleviated by drugs. It disappears when the physical cause is removed. Nevertheless, it is as well that we should be acquainted with it. It may lead to more serious disorders, as general paralysis or progressive locomotor ataxy. By the omis- sion of daily exercise in the open air, the tone of the whole system is lowered, and the patient is rendered more liable to disorders to which he is predisposed by heredity.
That a fear of open spaces is only one symptom out of the many which are common to the disorder is sufficiently evident to anyone who has studied nervousness in the persons of his friends, as in the cases detailed above. The disorder can only be observed amongst the intimate acquaintances of the phy- sician, as he is rarely consulted about such cases professionally. Summary.
Agoraphobia, so called, is not a disease, but a symptom. The disorder of which it is a symptom is want of self-con- fidence?fear of self, and may therefore be called Autophobia. Autophobia is usually caused by sexual indulgence, alcoholic excess, and by habitually yielding to groundless fears. It is not to be relieved by drugs, but by the removal of the cause.
It occurs in persons who are in fair bodily health, and whose mental condition is normal.
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