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Agoraphobia: What Westphal Really Said *

Article  in  Canadian journal of psychiatry. Revue canadienne de psychiatrie · April 1992

DOI: 10.1177/070674379203700212 · Source: PubMed

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Agoraphobia: What Westphal Really Said*
KLAUS KUCH, M.D. I AND RICHARD P. SWINSON, M.D. 2
In 1872 Westphal described a series ofpatients who expe-
rienced unexpected and situational panic attacks in squares,
empty streets, on bridges and in crowds. They sufferedfrom
anticipatory anxiety and afear ofsudden incapacitation. The
symptoms of agoraphobia have not changed appreciably in
well over a century.
C arl Westphal's (1833-1890) original description of ago-
raphobia (1) is frequently cited, but his description of
panic is largely unacknowledged. He and his contemporary,
Cordes, described the cognitions of panic (1,2). Cordes him-
self suffered from "mild agoraphobia" (2). We have translated
several key passages from both papers that are relevant to the
current diagnostic classification of anxiety disorders. A full
translation of Westphal's paper is available elsewhere (3).
Passages from Westphal's Agoraphobie
"For a few years now patients have come to me with a
peculiar complaint. They find it impossible to cross open
squares and to walk along certain streets. Fear restricts their
mobility. They want an explanation for their suffering but
reveal it only with embarrassment because they do not want
to be laughed at or, worse, be considered insane. A fear of
going through squares and streets dominates this phenome-
non to such an extent that I named it agoraphobia, the fear of
squares. The term does not describe the phenomenon fully. It
occurs in other situations as well.
The first patient is a slim 32 year old salesman of average
height and healthy appearance. He complains of an inability
to cross open squares. When attempting to do so he feels
attacked by sudden anxiousness that is often associated with
palpitations and with generalized tremulousness. The more
he keeps to the houses that surround the square, the more his
anxiety eases. He is attacked by the same anxiety when he has
to walk along walls, long buildings and along streets after the
stores have closed. On his many travels, he never risks
walking a road alone. He gathers detailed information before
departing, schemes and uses all kinds of tricks to get to his
'Manuscript received November1990.
1Assistant Professor of Psychiatry, University of Toronto; Staff Psychiatrist,
Clarke Institute of Psychiatry; Staff, Smythe Pain Clinic, Toronto General
Hospital, Toronto, Ontario.
2Professor of Psychiatry, University of Toronto; Clinical Director, Clarke
Institute of Psychiatry, Toronto, Ontario.
Can.J, Psychiatry Vol. 37, March 1992
133
destination. His anxiety is inexplicable to him. He cannot
understand why he should get anxious in the first place,
finding that this is an anxiety about anxiety. He describes the
onset of his suffering as follows. Years ago he had been
somewhat anxious in open squares but did not pay attention
to this. Then one day he took a walk to the end of town along
an alley. Once past the last house he experienced a sudden
and utterly miserable feeling and had to tum back after having
reached the fifth or sixth tree. After that day, he was unable
to go out into open country and across squares but was not
bothered by being on the street after closing time. This fear
developed later.
The second patient is a 24 year old businessman who
avoids long walks, rides in rented carriages and public trans-
port. He cannot tolerate situations like the theatre, concerts or
large crowded rooms. All these situations are rendered intol-
erable by a sudden feeling of anxiety starting with a percep-
tion of heat rising from his lower abdomen to his head,
associated with palpitations and often also with generalized
tremulousness and, during moments of great intensity, confu-
sion. When he has an anxiety attack in a square, the square
seems to grow too large to be crossed and his stride seems to
shrink to nothing. The mere thought of having to go out raises
his anxiety about getting into this state.
The third patient is an engineer and about 26 years old. He
presents with a complaint of anxiety attacks that occur in open
spaces and in squares and interfere with his work outdoors.
He experiences a sudden tightness in his chest, as if startled,
and feels constricted around his heart. His face gets red and
hot and he is gripped by severe anxiety that can grow into a
fear of death. He compares his experience to that of a swim-
mer who has moved from a narrow channel into a lake and
fears that he might not make it. He has had anxiety attacks
during lectures and in large meetings, and thought he might
be unable to leave. He gets attacks at home in the wake of
previous episodes or when worrying too much about them,
but finds these easier to suppress. After having failed to cross
a square because of an attack he feels beaten and fatigued for
a day.
The similarity of the three cases is remarkable. It extends
into such small details as a particularly intense fear of one
square. The nature of the disorder is difficult to understand.
All patients insist that they are not aware of any reasons for
their anxiety. It seems to arise spontaneously and suddenly as
an alien force as soon as a square is crossed or approached
with the intention of crossing. With the anxiety, not as its
explanation but as part of one process, occurs the thought of
not being able to cross and an image or perception of an
134 CANADIAN JOURNAL OF PSYCHIATRY
enormous expanse of space. With this perception occurs the
thought that something terrible might happen to the patient in
this state of anxiety and confusion. Company mitigates or
prevents the anxiety state.
The disorder does not seem to progress towards a severe
disturbance. It follows a chronic course with remissions (as
in case three) and exacerbations that continues for a major
part of life (life-long?) more or less unchanged and in form
of a single psychological symptom.... My efforts failed when
I attempted to use the well developed willpower of some
patients. Daily tasks of going beyond the limits of fear pro-
duced no results (1)."
Passages from Cordes
"The symptom of agoraphobia was brought to my atten-
tion by a personal experience. Years ago I was in a state of
severe exhaustion and experienced a sudden attack of severe
anxiety in a crowded theatre that compelled me to leave
regardless of my determined attempts to defeat it. The feeling
kept recurring for years with varying intensity. At times it
reached the level of mild agoraphobia, manifesting itself in a
considerable fear of crossing squares.
Platzangst represents anxieties with varying content that
do not differ in quality but only in intensity. At the lowest
level they represent an undefined fear of something that might
happen to one's body. One fear leads to another. The fear of
the unknown leads to terror, that translates into strong motor
reflexes, enormously intense palpitations, cardiac fear, a con-
stricted chest, shortness of breath, alternating hot flushes and
shivers. A plethora of strange sensations goes through one's
body and intensifies the anxiety even more. There are sensa-
tions of fading strength, mentally as well as physically, dis-
turbed vision, headaches, tinnitus, nausea, muscular
weakness, pins and needles.
Anxiety of lesser severity may be controlled by willpower.
Once anxiety reaches a certain intensity, this becomes impos-
sible. The sound of a trumpet or a bright light does away with
self-control and throws the patient back into renewed terror.
Air polluted with carbon-dioxide and intense psychological
stimuli have the same effect. Alcohol always helps. The
fearfulness in crowds leads to thoughts of suffering a stroke,
collapse or paralysis (2)".
Discussion
Of the six patients described by Westphal in his two papers
on agoraphobia (1,4) and the 29 patients described by Cordes
(2), only one was female. Current epidemiological data indi-
cate that more women than men suffer from agoraphobia (5).
The reason for this difference is likely social. In the late 19th
century, few women would have been required to go out alone
and few may have complained to a male physician about their
inability to do so.
Westphal understood agoraphobia as an anxiety disorder.
He saw the link between the occurrence of abnormal anxiety
and the patient's surroundings, in the anxiety-related restric-
tion of mobility and in the need for a companion away from
Vol. 37, No.2
home. The clinical presentation of agoraphobia has not
changed appreciably in well over a century and the cognitions
described by both authors could have been voiced by our
patients.
The patients in Westphal's case reports would have met
the DSM-III-R criteria for agoraphobia with panic disorder.
Cordes' definition of agoraphobia is less restrictive. He in-
cluded two patients in his report that would be classified in
the DSM-III-R as suffering from social phobia. One was a
public servant with an embarrassing tremor who "begged to
take his meals in private." The other was a college professor
who was incapacitated by panic during public speaking (2).
Social phobias concern some form of active performance in
front of observers, and this characteristic is not included in
Westphal's description of agoraphobia.
Westphal distinguished clearly between agoraphobia and
a number of other disorders. One of his patients had a history
of epileptic seizures (1). He argued that "epileptiform quali-
ties" could be observed in many patients with various other
psychiatric disorders and that it was therefore not a distin-
guishing feature of agoraphobia. Westphal discriminated be-
tween phobic anxiety and hypochondriasis by describing in
detail the case of a fourth patient with a profound and inca-
pacitating preoccupation with somatic symptoms and with
many other worries. This hypochondriacal patient was some-
times reluctant to leave his house but was troubled by his
morbid thoughts regardless of where he was. Agoraphobia
was only "one amongst many other symptoms" (1). In a
separate paper, Westphal also discriminated between obses-
sions (Zwangsvorstellungen) and agoraphobia. His obses-
sional patients suffered from intrusive and persistent thoughts
of an unacceptable nature, intense anxiety, and some hoarded
various objects (6).
The diagnosis of agoraphobia has survived detailed criti-
cism. One of the earliest disputes, which is still ongoing (7,8),
concerns the symptom of dizziness. Benedict (9) understood
"Platzschwindel" (dizziness in squares) as an organic condi-
tion. Westphal arranged to have Benedict's patient reexam-
ined by a colleague, who found the patient neurologically and
ophthalmologically intact (1). Williams (3), who was agora-
phobic, occupied the middle ground in this debate. He be-
lieved, that agoraphobia was caused by vertigo with nervous
tension. We believe that Benedict's patient may have suffered
from "space phobia" instead of agoraphobia. Marks (10)
defines "space phobia" as a rare pseudo-agoraphobic syn-
drome characterized by a fear of falling in the absence of
visuo-spatial support.
Westphal described agoraphobia as a paralyzing fear of
being suddenly incapacitated when exposed to crowds, empty
streets, squares and other situations where escape to a safe
place may be difficult or help unavailable. Cordes seemed to
think that panic occurred less predictably. The DSM-III-R
goes beyond Westphal's definition of agoraphobia and dis-
tinguishes between agoraphobia and panic disorder. The
DSM-IH-R defines panic disorder as the presence of "unex-
pected panic attacks that do not occur immediately before or
 136 CANADIAN JOURNAL OF PSYCHIATRY
during exposure to a situation that always caused anxiety"
(3).
The current definition of agoraphobia is generally ac-
cepted. However, a substantial minority of researchers who
were surveyed recently felt that panic disorder as a clinical
entity still requires clarification (11). The distinction between
agoraphobia and panic has its origin in Klein's hypothesis of
the development of agoraphobia. The hypothesis assumes a
developmental sequence that leads from unexpected panic
attacks to learned avoidance behaviour (12). Accordingly,
more frequent and more severe panic attacks would result in
more phobic avoidance. To some extent this is born out by
empirical research (13).
Agoraphobic avoidance depends more on the expectation
of panic than on the actual occurrence of panic (14,15). Panic
also occurs in "non clinical" populations (16,17). Associated
personality disorder is a strong predictor for chronic symp-
toms and social maladjustment (18). These last findings are
more compatible with one of Sigmund Freud's theories of the
development of phobias than with Klein's hypothesis, which
reserves the central pathogenic role for panic. Freud (19)
suggested that phobias develop when a distressing experience
interacts with the anxious expectation of anxiety neurosis.
Without such anxious expectation the distressing experience
would soon be forgotten.
Westphal's and Cordes' papers include the first detailed
clinical description of panic in the modern scientific litera-
ture. Westphal's definition of agoraphobia includes occa-
sional unexpected panic attacks, situational panic,
anticipatory anxiety, catastrophic cognitions and phobic
avoidance. In keeping with his definition, panic disorder
could be defined hypothetically as an anxiety state character-
ized by panic in the absence of anticipatory anxiety and
agoraphobic avoidance.
References
1. Westphal C. Die Agoraphobie. Archive fuer Psychiatrie 1872;
3: 138-161.
2. Cordes E. Die Platzangst (Agoraphobie) [a symptom of paretic
exhaustion]. Archive fuer Psychiatrie 1872; 3: 521-574.
3. Knapp TJ, Schumacher MT. Westphal's "Die Agoraphobie"
with commentary: the beginnings of agoraphobia. Lanham NY:
University Press of America, 1988.
4. Westphal C. Die Platzfurcht [agoraphobia]. Archive fuer Psy-
chiatrie 1873; 7: 377-383.
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Vol. 37, No.2
5. Regier DA, Boyd JH, Burke JD, et al. One-month prevalence
of mental disorders in the United States. Arch Gen Psychiatry
1988; 45: 977-986.
6. Westphal C. [About obsessions]. Archive fuer Psychiatrie 1877;
8: 734-749.
7. Jacob RG, Moller MB, Turner S, et al. Otoneurological exam-
ination in panic disorder and agoraphobia with panic attacks: a
pilot study. Am J Psychiatry 1985; 142(6): 715-720.
8. 0 'Connor K P,Hallam R, Beyst J, et al. Dizziness: behavioural,
subjective and organic aspects. J Psychosom Res 1988; 32 (3):
291-302.
9. Benedict M. Der Platzschwindel. Allgemeine Wiener
Medizinische Zeitung 1870; 40 (15): 488.
10. Marks 1M. Fears, phobias and rituals. Toronto ON: Oxford
University Press, 1987: 318-322.
II. Norton GR, Cox B, Schwartz MAJ. A critical analysis of
DSM-III-R's classification of panic disorder: a survey of cur-
rent opinions. Journal of Anxiety Disorders (in press).
12. Klein D. Delineation of two drug-responsive anxiety syn-
dromes. Psychopharmacologica 1964; 5: 397-408.
13. Buller R, Maier W, Benkert O. Clinical subtypes in panic
disorder: their descriptive and prospective validity. J Affective
Disord 1986; 11: 105-114.
14. Craske MG, Barlow DH. A review of the relationship between
panic and avoidance. Clinical Psychology Review 1988; 8:
667-685.
15. Cox BJ, Swinson RP, Norton RG, et al. Anticipatory anxiety
and avoidance in panic disorder with agoraphobia. Behav Res
Ther 1991; 29(4): 363-365.
16. Norton GR, Dorward J, Cox BJ. Factors associated with panic
attacks in non-clinical subjects. Behav Ther 1986; 17: 239-252.
17. Cox BJ, EndlerNS, Swinson RP. A comparison of clinical and
non-clinical panic attacks: is there a panic-anxiety continuum?
Research Report # 182, Toronto ON: York University Depart-
ment of Psychology Research Reports, 1989.
18. Noyes R, Reich J, Christiansen J, et al. Outcome of panic
disorder, relationship to diagnostic subtypes and comorbidity.
Arch Gen Psychiatry 1990; 47: 809-818.
19. Freud S. [On the justification of separating the symptoms of
anxiety neurosis from neurasthenia.] Neurologisches
Centralblatt 1895; 12: 50-66.
Resume
Les patients de Westphal etaieni surpris de panique en
places publiques, rues desolees, sur les ponts et dans les
Joules. Ils subirainent d' anxiete previsionelle et de peur
d'incapacitation soudaine. Les symptomes de l' agoraphobie
n' ont pas changees depuis plus d' un siecle.