Constraint and loneliness in agoraphobia: an empirical investigation

While progress in the aetiopathology and treatment of panic disorder is indisputable, research regarding agoraphobia lacks behind. One significant-yet untested- theory by Guidano and Liotti, suggests the existence of inner representations of fear of "constraint" and fear of "loneliness" as two major schemata, important in the pathogenesis and manifestation of agoraphobia. Activation of these schemata may occur in situations in which the patient: (a) feels as in an inescapable trap (constraint) or (b) alone, unprotected and helpless (loneliness). Upon activation, the "constraint" schema elicits such symptoms as asphyxiation, chest pain, difficult breathing, motor agitation and muscular tension, while the "loneliness" schema elicits such symptoms as sensation of tachycardia, weakness of limbs, trembling or fainting. Activation of these schemata by content-compatible stimuli is expected to trigger various, yet distinct, response patterns, both of which are indiscriminately described within the term "agoraphobia". In order to investigate this hypothesis and its possible clinical applications, several mental and physical probes were applied to 20 patients suffering primarily from agoraphobia, and their responses and performance were recorded. Subjects also completed the "10-item Agoraphobia Questionnaire" prepared by our team aiming at assessing cognitions related to Guidano and Liotti's notion of "loneliness" and "constraint". Breath holding (BH) and Hyperventilation (HV) were selected as physical probes. BH was selected as an easily administered hypercapnea - induced clinical procedure, because of its apparent resemblance to the concept of "constraint". Subjects were instructed to hold their breath for as long as they could and stop at will. Similarly, it was hypothesized that HV might represent a physical "loneliness" probe, since it can elicit such symptoms as dizziness, paraesthesias, stiff muscles, cold hands or feet and trembling, reminiscent of a "collapsing type" symptomatology. Patients' responses and performance were recorded by visual analogue scales and heart rate and respiratory rhythm were being registered continuously. Although the overall elicited symptoms were not differentiated in a meaningful way, a significant correlation was registered between duration of physical probes and scoring of the "10-item Agoraphobia Questionnaire". Duration of BH was inversely correlated (r=-0.456, p <0.05) with the score of the 5 "constraint-type" agoraphobic items while duration of HV was inversely correlated (r=-0.479, p <0.03) with the score of the 5 "lonelinesstype" agoraphobic items. Assuming that our questionnaire taped the "loneliness" and "constraint" schema threat, our hypothesis derived from Guidano & Liotti's assumptions was partially confirmed.