Unfitting Stories: Narrative Approaches to Disease, Disability, and Trauma

Agoraphobia, Social Order,and Psychiatric Narrative

Taking its name from agora, the Greek word for public square or marketplace , “agoraphobia” is the term given to the fear of public or open spaces. This phobia develops in response to previous experiences of overwhelming anxiety in everyday situations such as in crowds, on buses or trains, or even while driving—situations from which a person may be unable to escape or get help, and where they are at great risk of embarrassment. These symptoms can range in severity, of course, but “attacks” may include rapid heartbeat, chest pain, shortness of breath, gastrointestinal distress, faintness, dizziness, sweating, fear of losing control or going insane, fear of dying, or a sense of impending doom. People who experience these feelings avoid phobic situations—places where they have experienced anxiety —and in extreme cases they rarely leave their homes without a trusted companion. The prevalence of agoraphobia has been estimated to include as much as five percent of the population (Rosenbaum et al 1995, a4). In the US, this translates to approximately twelve million people—most of whom are women. Although there are a few references to these kinds of symptoms in early nineteenth-century writings, and general references to phobias that appear as early as the fourth century bc (in the writings of Hippocratic physicians ), agoraphobia was first described formally in 1872, in an article written by German neurologist Carl Otto Westphal (1833–90). His article described the symptoms of three Berliners, all of whom were male, who complained of the difficulty they had walking through open spaces, crossing streets and squares, and of being in crowds and enclosed spaces. After Westphal published this article, the written clinical discourse of 247 shelley z. reuter Agoraphobia, Social Order, and Psychiatric Narrative agoraphobia developed a life of its own, and continues to thrive today. Indeed, a recent search on Medline turned up nearly two thousand references published in the last three decades alone. Together these publications have provided a forum for physicians to theorize about the phenomenology (signs and symptoms), causation, and treatment of agoraphobia, and many authors still cite Westphal’s report even today. Contained within this clinical discourse is what I refer to as the “psychiatric narrative.” Specifically, while the disease describes very real physiological experiences of suffering, a socio-cultural account of society is implicit in this discourse. Taking a genealogical approach, this article examines the literature on agoraphobia with a view to disrupting the assumption that psychiatric knowledge does not itself constitute a type of narrative. Several themes emerge: these include the relationship between urbanization , social change, and mental life at the turn of the nineteenth century; the relationship between agoraphobia and gender, “race,” and class; and the shift in recent decades within psychiatry from an emphasis on biopsychosocial explanation for mental diseases to an emphasis on strictly biological explanations. Together these themes demonstrate that the question of what it means to be “normal” underpinning psychiatric accounts of agoraphobia has historically signalled a more fundamental and normative question of what it means to have social order. The City and Social Change In the late nineteenth and early twentieth centuries, an expanding medical profession led many doctors to specialize in psychological medicine (Porter 1997, 498), and it was not uncommon for physicians to describe modern urban living as a dangerous strain on mental health. Urban living itself increasingly came to be pathologized, and a “generalized fear of [the] metropolis” manifested in many physicians’ writings (Sutherland 1877, 266). As Sigmund Freud wrote, for example, a tension existed between “living in simple, healthy, country conditions” as the “forefathers” did, and living in “the great cities,” which caused “increasing nervousness of the present day and modern civilized life” (1963, 21). An American physician, Dr. Charles Atwood, argued similarly that “our rapid and over strenuous life,” unaccompanied by sufficient rest, caused an “increase in nervous and mental derangement” (1903, 1070–2). A parallel discourse developed among some classical social theorists such as Karl Marx (1964 [1884]), Emile Durkheim (1933 [1893]), Max Weber (1958 [1904–05]), and Ferdinand Tönnies (1957 [1887]); each, in his 248 the larger picture own way, was concerned about the changes of modernity and its associated social problems. Georg Simmel especially focused on mental life and the metropolis, observing that life in the modern (capital) city, with all its “nervous stimulation”—the crowds, the intensity, and the rampant individualism —produced the ideal conditions for the development of mental...