Agoraphobia

ABSTRACT

Agoraphobia emerged as a named disorder in the 1870s. Since then a wide variety of models - both clinical and non-clinical - have been devised to explain it. This paper describes four of these models to demonstrate and explore the significance for mental health promotion of their different conceptualisations of agoraphobia in relation to the city, to public space and to the individual. Of particular interest is the shift in the gendering of agoraphobia: while late 19th century accounts tended to feature men, by the mid 20th century the archetype of someone who experiences agoraphobia had become female. The implications of this variance and subsequent decisions about intervention and cure, it is argued, demonstrate the importance of conceptualisation in debates about mental health promotion.

In 1919 the American Journal of Psychology published Confessions of an Agoraphobic Victim. Those confessions were signed 'Vincent' and are, to the best of my knowledge, one of the earliest published accounts of what, 'for lack of a better name, medical men have termed "Agoraphobia" by someone who was not himself a clinician.1 In his 'confessions', Vincent commented:

'I have outgrown the fear of crowds largely, but an immense building or a high rocky bluff fills me with dread. However the architecture of the building has much to do with the sort of sensation produced. Ugly architecture greatly intensifies the fear.

'In this connection I would remark that I have come to wonder if there is real an in many of the so-called "improvements" in some of our cities, for, judging from the effect they produce on me, they constitute bad art.

'But the one thing that I would make plain is that the malady is always present.... The fear, intensified, that comes over me, while crossing a wide street is, it seems to me, an outcropping of a permanent condition.' (Vincent, 1919)

Vincent's compelling five-page account includes a description of the onset of his phobia, an enumeration of the strategies that lessened the intensity of his anxiety (such as gripping a suitcase when out walking, for example, or leaving the house after dark), and the revelation that he had never mentioned his condition to a physician. There are many further questions a sympathetic reader might wish to ask him: why, exactly, did he write his 'confessions' for the American Journal of Psychology? Did the publication of the confessions secure Vincent any professional help? How common was it for a middle class man in the early 20th century to experience agoraphobia?

Questions such as these have been central to the historical research I have been conducting on agoraphobia for a number of years. The question I wish to pose here, however, is one of more direct interest and relevance to those involved in mental health promotion. In what ways was the built environment of the city related to Vincent's experience of agoraphobia? How, in other words, was what Vincent experienced related to the socio-spatial characteristics of the world he inhabited? Vincent himself believed architectural aesthetics to be of great importance; he asserted that 'ugly architecture' greatly exacerbated his fear, and he condemned urban 'improvements' more generally for doing nothing to ameliorate his condition. His comments about city 'improvements' referred, presumably, to some of the large-scale projects transforming many European and North American cities in the late 19th and early 20th centuries. Vincent's account thus locates agoraphobia within wide-ranging debates about how the metropolis might affect the mental health of its inhabitants.

One of the central difficulties in understanding the complex phenomenon of agoraphobia is deciding what precipitates it and why. And since agoraphobia does not work on the model of a direct threat that produces anxiety, what precipitates the anxiety should not necessarily be considered the cause of it. (For someone experiencing agoraphobia, wide streets or department stores may be particularly likely to spark off intense agoraphobic anxiety; this is very different from claiming that it is the wideness of the street, or the store itself, that causes the agoraphobia.) What, therefore, did Vincents castigation of 'ugly architecture' actually imply about the role that architecture, or the built environment more broadly, might play in his experience of agoraphobia?

Any attempt to answer this question will necessarily involve conjuring up particular images of architecture, the built environment and public space - and, indeed, of the individual experiencing the anxiety. Whether you support or reject the contention that the built environment is in some way significant in the experience of agoraphobia, you are necessarily working with a particular conceptualisation of what it is you are endorsing or rejecting. Similarly, whether you consider individual attributes such as gender to be important or irrelevant in illuminating agoraphobia, you are still making specific judgements about how social and cultural relations impinge, or do not impinge, on the mental sphere. As this articles aims to show, images of the built environment, public space and the individual have important ramifications for understandings of intervention and cure and therefore carry implications for the practice of mental health promotion.

History

Agoraphobia emerged as a named condition in the early 1870s (see Benedikt, 1870; Westphal, 1871; Legrand du Saulle, 1878). It immediately provoked animated debates in several neurological and psychiatric journals about its nosology, aetiology and, indeed, its very appellation. Carl Westphal - who is commonly regarded as the 'founder' of the disorder - coined the term 'agoraphobia, and in so doing rejected an earlier published paper by Benedikt that had understood the phenomenon as a kind of vertigo that he termed 'Platzschwindel' ('square dizziness'). Legrand du Saulle suggested the term la peur des espaces ('fear of spaces') instead of agoraphobia - claiming that the sensations were not only experienced in public squares (as the term 'agora-phobia' implied) but also in churches, omnibuses or on bridges (Legrand du Saulle, 1870). In a letter to the Lancet, Walter Dale averred that 'eremophobia (fear of a deserted place) should be used instead of'agoraphobia (fear of the market place), noting that 'agoraphobiacs' apparently feel no fear in densely crowded spots, but feel intense fear in 'exactly opposite conditions' (Dale, 1891).

The debates over appellation were concerned with defining what the individual was phobic about - public spaces, squares, crowds, deserted spaces, 'space' in general - and gestured to the difficulty of deciding what the 'problem' of agoraphobia was about. We should recall, too, that the late 19th century was a period in which fears about metropolitan life, crowds, hysteria, degeneracy and the place of women in the public sphere seemed to intensify (see Walkowitz (1992), for example, for a rich analysis of the proliferation of narratives about sexual danger in late 19th century London). From the start, therefore, discussions about agoraphobia could easily become - and often did - discussions about the problems of crowds, about the dangers of public space, and about the effects of urban transformation.

Thus, from the moment of its emergence as a named disorder, agoraphobia was fundamentally connected to debates about the metropolis. The architectural historian Anthony Vidler has asserted in his own research on agoraphobia that:

'As both medical ailment and cultural metaphor, agoraphobia ... emerged by the end of the [19th] century as a specific instance of that generalized "estrangement" identified by social critics as the principal effect of life in the metropolis. ' (Vidler, 1994)2

There is to this day a continued and unresolved debate about the relations between modernity and the metropolis and mental health. When a healthy metropolis is imagined - one that would help nourish the mental and physical health of its inhabitants - the ideals of mobility and free circulation are frequently raised. Both the mobile urban dweller and the city in which air, people, goods and vehicles circulate freely are commonly seen as markers of healthy bodies and healthy cities.

Thus the question of public space - space that encourages those various kinds of mobilities - is at the heart of such debates. In the words of urban theorist and practitioner Michael Sorkin (1999): 'We judge the good city by the quality of its public life and hence of its public space.' The phenomenon of agoraphobia undoubtedly dents the vision of free circulation, mobile urban dwellers and high quality public life. The agoraphobic individual's panicked response to squares, streets, highways, and trains - to those most characteristic spaces of circulation and exchange - punctures the vision of the city as a space of free intercourse. That agoraphobia today is more commonly diagnosed in women rather than men raises awkward questions about how the legacy of restricted access to public spaces might be coupled with a legacy of fear generated around them. It is difficult to see whether the 'problem' that is agoraphobia lies with the individual herself, with the society in which she is unable fully to participate, or with the built environment that would seem to be the immediate provoker of her terror. How you approach that dilemma results in very different visions of agoraphobia, of the city, and of the routes that might be taken to promote public mental health.

Axes of agoraphobia

To substantiate this claim, I want briefly to discuss four different models of agoraphobia that have been advanced, both by clinicians and non-clinicians, at various points in the disorder's 130-year history.3 These are presented in chronological order to provide some indication of the path agoraphobia has taken from the 1870s onwards. It is impossible in a short paper adequately to sketch out the many turns that the history of agoraphobia has undergone. The four examples serve, therefore, as vignettes representing different visions of the city, the built environment and the individual experiencing agoraphobia. But first, a few general words about how any model of agoraphobia works with three axes: that of the individual, the social world, and 'space'.

The individual

Any account of agoraphobia will of course set out a particular understanding of the individual experiencing agoraphobia. Early on in agoraphobia's history, for example, the condition was frequently regarded as neuropathic - and hence tied to some difficult-to-locate 'fault' in the physiology of the individual. This kind of somatic account is very different from, say, a psychoanalytic account that sees the phobia as symptomatic of psychic conflict and that moves away from the physiology of the individual and towards a conceptualisation of, and focus on, the psyche and the unconscious.

Models of agoraphobia have also regarded identity categories such as gender and class as central or irrelevant to the development of the disorder. While agoraphobia tended to be regarded as more of a 'male' condition in the late 19th century (Callard, 2001), over the course of the next few decades the condition gradually became coded as a 'female' or 'feminine' one. Roberts (1964), for example, referred to agoraphobia using the phrase 'housebound housewives', and clinical papers from this era following the second world war frequently used adjectives to describe those experiencing agoraphobia - dependent, shy, passive - that drew on common stereotypes of women. We see here how clinical descriptions mobilised all sorts of assumptions about the gender, class and lifestyle of one likely to develop agoraphobia. There is, I suggest, much more medical-historical work to be done to understand how and why the gendering of agoraphobia shifted over the course of the 20th century.

The social world

Some interpretations have regarded the organisation of society as of fundamental importance in understanding agoraphobia; others have seen it as entirely irrelevant. Cross-cultural work by anthropologists, sociologists and clinicians has raised difficult questions about the specificity of diagnoses of agoraphobia in terms of both its geographical reach and stability over time. Explanations of why certain populations appear to have far lower rates of agoraphobia than others vary enormously in the assumptions made about whether and how the socio-cultural characteristics of populations affect rates of incidence.

Space

Those experiencing agoraphobia have difficulty inhabiting or moving through a wide range of particular spaces. How the relation between space(s) and the agoraphobic individual is understood similarly varies enormously. Some accounts of agoraphobia have seen the division between public and private space as crucial in explaining when and why symptoms appear. Some historical accounts have attempted to link agoraphobia to the typical perspective and lines of sight of certain kinds of spaces or buildings. Other accounts have looked at how the space was inhabited, or not inhabited, by other individuals or by crowds. Yet other accounts have regarded 'space' as somewhat of a red herring, and have considered the term 'agoraphobia to be a misnomer for a phenomenon that has little if anything to do with where the anxiety breaks out.

How a model of agoraphobia works with these three axes - of the individual, the social world and space -significantly affects how the model imagines mental health and mental health problems. How you set up the model of agoraphobia - which axis you foreground and which you do not - has ramifications not only for how you conceptualise a 'good society', a 'good city' and a 'healthy' individual, but also, crucially, for how you picture the sites of intervention, amelioration and cure. How you conceptualise the key terms with which you are working has a profound impact on how you set out the terrain both for analysis and for practical action.

This is a point that is not unfamiliar to those in the field of mental health promotion. Gilleard has argued strongly in this journal for the importance of conceptualisation when thinking through the terms 'neighbourhood' and 'community' (Gilleard, 2003). If we simply conflate neighbourhood and community, Gilleard argues, we do little to understand the articulation between neighbourhoods (territorially defined shared residential areas) and communities (collectivities that may be symbolic and scattered across, rather than concentrated in, space). Gilleard even claims that the 'lack of conceptual clarity is a potentially serious barrier to developing a more positive community mental health strategy' - not least because weak understandings of what neighbourhoods and communities might be make it very difficult to develop powerful accounts of the precise relationships between mental health and neighbourhood renewal.

Models of agoraphobia

The four different models of agoraphobia are presented to provide further demonstration of the importance of conceptualisation, not to make prescriptive recommendations or to place them in a hierarchy of value. The aim is to sketch out the very different consequences - clinical, social and political - that ensue from each model and thus from the assumptions about the individual, the social world and space that each model mobilises. That similar symptoms have been so differently approached and understood within various historical, geographical and institutional contexts raises fascinating questions about why and how certain ways of seeing and conceptualising become prominent at particular moments and for particular reasons.

The psychiatrist

Westphal, the originator of the term agoraphobia, provided extensive descriptions of three cases of agoraphobia in his famous 1871 paper (Westphal, 1988 [1871]). Each of the three patients was male and each participated in the public world of work. Each became a 'type' whose particular symptoms were recycled extensively in other literature and who thus significantly shaped dominant late 19th century understandings of agoraphobia. The first case was that of 'Mr C, a commercial traveller', about whom Westphal wrote:

'He complained that it is impossible for him to walk through open spaces. ...In Berlin the Dohnhofsplatz is the most unpleasant for him; when he attempts to cross the corresponding square he feels as if the distance were great, that he would never make it across ... the more he diverges to the boundaries of the houses, the less the feeling of safety. On the other hand, being engrossed in thought, it occurred that he walked over an open space without noticing it. Should a vehicle drive across the square, he can, if he stays next to it, reach the other side ...

'The same feelinv of fear overtakes him. when he needs to walk along walls and extended buildings or through streets on Holidays, Sundays, or evenings and nights, when the shops are closed. In the latter part of the evening - he usually dines in restaurants - he helps himself in a peculiar way in Berlin; he either waits until another person walks in the direction of his house and follows him closely, or he acquaints himself with a lady of the evening, begins to talk with her, and takes her along until another similar opportunity arises, thus gradually reaching his residence. (Westphal, 1988 [1871])

Westphal's account of Mr C provides a rich documentation of late 19th century Berlin life. Westphal built up a detailed catalogue of particular places that could not be visited or crossed, and his vignette of Mr C acquiring the help and arm of prostitutes to track a route home provides a fascinating glimpse of who was able to inhabit the public sphere, and in what way, at that time. Indeed Westphal's documentation of agoraphobic symptoms evoked a whole host of urban markers like shops and squares and city streets. Yet in a way, for Westphal, the city, while omnipresent in his account, was entirely unimportant for his enquiries. Although he went so far as to argue that the three cases showed 'agreement that goes into the smallest detail such as places [squares] of a specific city which are feared to be crossed', observations such as these had no analytical purchase for his conceptualisation of this peculiar phenomenon of the fear of spaces' (1988 [1871]). His paper was entitled 'Agoraphobia: a neuropathic phenomenon', and it circled around his attempt to track down the somatic bases for his patients' difficulties. Thus the focus of Westphal's thinking, as an exemplar of continental practices of late 19th century psychiatry and neurology, was the axis of the individual - and a somaticised individual. That all three patients were men was not of any analytical relevance to him. Thus, while Westphal provided a rich evocation of Berlin's built environment, its public spaces, and some of the social relations of its inhabitants, his account fundamentally did not relate his patients' experiences to any of those factors. The 'problem' lay in some neuropathic 'fault' within the individuals themselves.

The architect

Nearly two decades after the publication of Westphal's essay on agoraphobia, and in another European metropolis, the architect Camillo Sitte (1965 [1889]) referred to the Very new and modern ailment' of agoraphobia in the service of his condemnation of the huge changes that were transforming the city of Vienna during the (in)famous construction of the Ringstrasse: the huge ring of private dwellings and public buildings constructed on the belt of land surrounding the old city of Vienna (see Schorske, 1981). Sitte was exercised about how the 'mathematical' nature of the 19th century was resulting in the loss of the artistic practice of city building. In this regard, he was particularly preoccupied with the changing size and shape of city squares:

One naturally feels very cozy in small, old plazas and only in our memory do they loom gigantic, because in our imagination the magnitude of the artistic effect takes the place of the actual size. On our modern gigantic plazas, with their yawning emptiness and oppressive ennui, the inhabitants of snug old towns suffer attacks of this fashionable agoraphobia.'(Sitte, 1965 [1889])

Sitte's allusions to agoraphobia - and his particular focus on individuals being unable to walk across vast squares - were indebted to Westphal's descriptions of his three patients. Indeed, the centrality of the public square to Sitte's argument can be seen in a wonderful passage in which statues are said to experience agoraphobia: 'people formed out of stone and metal, on their monumental pedestals, are attacked by this malady and thus always prefer ... to choose a little old plaza rather than a large empty one for their permanent location' (1965 [1869]). But, not surprisingly, Sitte the architect moved in a very different analytical direction from Westphal the psychiatrist. Agoraphobia for Sitte pointed to all that was wrong with late 19th century Viennese urbanism. In other words, the problem lay in the built environment and in those redesigning it, not in those inhabiting it.

How squares were constructed was critical to Sitte because squares, those most archetypal of public spaces, ought to capture the perfection of perspective and the delight of balanced aesthetics. It does not take much to infer from Sitte's account that he believed that 'aesthetic' cities would promote balanced, serene minds (and, you might add, balanced, serene statues). That Sitte's account of aesthetics functioned as a nostalgic defence of a particular kind of architectural tradition opens up further avenues for exploration in terms of the political implications of his brief commentary on agoraphobia. (As a sideline, we might note that Vincent's castigation of city 'improvements' 30 years later echoes Sitte's lament.)

The Freudian

The category of agoraphobia was extensively discussed and fought over by clinicians in both Europe and North America in the late 19th century. Although Freud wrote very little on agoraphobia specifically, his extensive theorisations of anxiety transformed the way in which phobias were understood. By the middle of the 20th century several of his successors had consolidated Freud's own fragmentary and vacillating understandings of agoraphobia into a strong narrative that decisively departed from the frameworks of both Westphal and Sitte.

Otto Fenichel, the doyen of mid-20th century American psychoanalysis, might be taken as a good example. In his authoritative book The Psychoanalytic Theory of Neurosis (1945), Fenichel argued that agoraphobia symbolised 'either a temptation for a warded-off impulse or a punishment for an unconscious impulse or a combination of both'. Thus he claimed that the idea of the open street in agoraphobia would likely be 'unconsciously conceived as an opportunity for sexual adventures', and that '[f]ear of open streets' often functioned as a 'defense against exhibitionism or scoptophilia'. Elaborating on these comments in relation to a particular female patient with agoraphobia, Fenichel argued that:

'[Her] anxiety attacks ... had the unconscious definite purpose of making her appear weak and helpless to all passers-by. Analysis showed that the unconscious motive of her exhibitionism was a deep hostility, originally directed towards her mother, then deflected onto herself. "Everybody, look!" her anxiety seemed to proclaim, "my mother let me come into the world in this helpless condition, without a penis". '(Fenichel, 1945).

Fenichel thereby sets out a stark Oedipal interpretation of agoraphobia. The rigidity of his account allows us to see very clearly what is at stake here. First, agoraphobia is presented as a characteristically female or feminine disorder. second, the internal, psychic, space of the individual is privileged at the expense of the material world that surrounds her. The characteristics of the built environment - its public spaces, streets and passers-by - are read simply as a stage for the performance of a private, familial drama between mother and daughter. That Fenichel understood open streets as offering the unconscious desire for sexual adventures demonstrates his very particular interpretation of cities, public spaces and, indeed, agoraphobic individuals. 'Cure' in such an account would of course be carried out in the private, intimate space of the psychoanalysts room; to suggest that experiences of agoraphobia might be ameliorated by certain strategies of public mental health promotion would presumably have seemed for Fenichel wholly beside the point.

Accounts such as Fenichel's have undoubtedly not helped the psychoanalytic cause (and, I would add in passing, are far less interesting, and far more dogmatic, than some of Freud's own commentaries on phobias). Several academics with an interest in the history of agoraphobia have been exasperated that psychoanalytic accounts have no real interest in the physical characteristics of cities or the public sphere and focus solely on the internal, psychic world (Brown, 1987; Vidler, 2000).

Arguably, in Fenichel's account it would not matter what the street looked like, since he was interested in the internal world of the patient and not in the characteristics of the built environment. But at the same time, his commentary did require him to conjure up a particular kind of city - its crowds, passers-by and narrow streets. It would be interesting to consider, in this regard, how the urban sprawl and cars and very different configurations of public spaces and pedestrian access characteristic of many megalopolises in different parts of the world today might affect our current understandings of agoraphobia.

The feminists

In 1983 a book was published in the US tided Women Who Marry Houses: panic and protest in agoraphobia. By this point the hegemony of psychoanalytic approaches had been eclipsed in the US and the clinical arsenal for agoraphobia included behavioural and psychopharmacological as well as psychoanalytic approaches. The book's authors, Robert Seidenberg (a practising psychiatrist and psychoanalyst) and Karen DeCrow (an attorney and previous national president of the National Organization for Women), accused the corpus of clinical accounts of agoraphobia of wholly missing the point. For Seidenberg and DeCrow, agoraphobia should be seen 'as a paradigm for the historical intimidation and oppression of women' (1983). In other words, psychoanalytic, behavioural and psychopharmacological accounts of agoraphobia had wrongly privileged 'internal' accounts of the individual and had thereby completely evacuated consideration of the social world from their explanations. For them the axis of the individual was crucial, but only in the sense that it was the gender of that individual that had to form the prime focus for analysis; the disorder of agoraphobia was, as another feminist mental health professional put it, 'a quintessential woman's issue' (Fodor, 1992).

Central to Seidenberg and DeCrow's argument was their claim that agoraphobia was a 'metaphor' and not a disease: they wished to see agoraphobia not as a psychiatric disorder but as a more visible manifestation of the vulnerability that all women faced in negotiating the public sphere. Indeed they argued: Only when society gives just value to the work women do at home, and makes it easier for them to leave the home to do fully accepted and compensated work, will women no longer need to be agoraphobic.' In this way, a person experiencing agoraphobia was seen by them as 'a living and acting metaphor'; agoraphobic women were 'the most completely uncompromising feminists of our times'. The book was filled with urgent demands for challenging the dependency encouraged in women by societal structures. Seidenberg and DeCrow lamented how, in their eyes, behaviourists infantilised and patronised their patients by leading them by the hand during practices of desensitisation. They also condemned Freud for being unable to recognise that marriage could be so destructive for women that it could bring about such '"feminine" syndromes' as agoraphobia.

In Seidenberg and DeCrow's understanding, mental health promotion meant the wholesale transformation of social relations. While their analysis certainly homed in, as Fenichel's had done, on the axis of the individual in the form of the agoraphobic woman, in their view it was only the transformation of society as a whole that would provide the intervention and the cure for the phenomenon. Indeed, they argued it was wrong to speak of 'cure' in relation to the agoraphobic individual herself. Since '[t]he phobic patient is a living caricature of what she is living through', what she was 'living through' had to be altered, not the phobic patient herself. 'Space' certainly mattered in the sense that women must be allowed proper access to all public spaces, but space, in such an account, mirrored the more fundamental domain of social relations.

Conclusion

The psychiatrist, the architect, the Freudian, the feminists. Each account sets out a very particular explanation for the emergence of the painful experience of agoraphobia and provides different suggestions for how it might be studied, treated and cured. And the particularity of each account is dependent on how each account conceptualises the role and relative importance of the individual, the social world and the space she inhabits, and on how it imagines the articulation between those three terms.

The architect Sitte foregrounded the built environment as the fundamental factor in understanding the emergence and prevalence of agoraphobia and had little to say about those experiencing the intense anxiety. he claimed perhaps the most direct causal path between the built environment and agoraphobia. The neurologist Westphal presented a fulsome account of specific agoraphobic symptoms but was stymied in his attempts to understand the complex psychological processes his patients were experiencing in the locations he documented. The feminist mental health professionals Seidenberg and DeCrow certainly regarded the built environment as important, but only in the context of social relations.

We can also see how foregrounding one axis in an account might entail the falling away of another. Seidenberg and DeCrow's emphasis on patriarchal social relations made it difficult for them simultaneously to provide a detailed account of mental life: by situating agoraphobia as a 'metaphor' rather than a disease, and by claiming that the woman with agoraphobia 'has it within her power to relinquish the symptom whenever she feels it is the proper time and place' they discounted the need to address the fact that the transformation of society might not necessarily result in the extinguishing of all mental distress. The psychoanalyst had the potential to understand the complex way in which individuals might relate symbolically and affectively to aspects of the built environment. But the psychoanalyst in the shape of Fenichel closed down that potential by using a rigid Oedipal template that evacuated any consideration of the articulation between external and internal worlds.

In this paper, I have hoped to show that how one conceptualises an analytical 'problem' - in this case the phenomenon of agoraphobia - produces very different ways of thinking about what that problem - that phenomenon - is. On the one hand, it is not remotely surprising that the architect Sitte's interpretation foregrounded the built environment while the feminists Seidenberg and DeCrow concentrated on the sphere of patriarchal social relations. On the other hand, when you are in the middle of tackling an analytical problem, it is, I think, less easy to recognize how your own conceptualisations might be privileging certain terms, modes or scales of enquiry at the expense of others. I hope, therefore, that the four sketches of historical interpretations of agoraphobia will contribute to debates within the field of mental health promotion about the complexity of the articulation between the individual, the built environment, and the social world in which he or she lives.

The reader may notice that I have not included a model of agoraphobia typical of current clinical research on agoraphobia. That was a deliberate decision. Agoraphobia is currently at a fascinating moment in its history. In the US the term panic disorder (which first appeared in the DSM-III in 1980) is, arguably, effecting the eclipse of agoraphobia as a primary diagnosis. There is no doubt that the move towards panic disorder will bring about a new configuration of the axes of the individual, the social world and space. And that new configuration will produce new visions of how the city and public space are, or are not, important in illuminating that condition.

While I certainly have hunches about the kinds of models of the individual, of society and of space that such a shift might be effecting (see Callard, 2001), it is too early to be able to state with confidence the specifics of the transformations that are occurring. But one engrossing question to consider is how the characteristics of late 20th century urban life in the US might be inflecting conceptualisations of panic disorder in the same way that characteristics of late 19th century urban life in Europe inflected early accounts of agoraphobia. That the term panic disorder explicitly turns away from any reference to the 'agora' or the city is itself worthy of further investigation.

Finally, there is another figure not present in my typology of models of agoraphobia. If that typology had included the mental health promoter, what would she argue about the relations between the person with agoraphobia, the characteristics of the built environment and power relations in society?

1 In fact, I have found several accounts of agoraphobia from the late 19th century in which clinicians describe their own experiences of agoraphobia. Vincent, in contrast, makes it clear that he is 'unacquainted with medical literature' (1919), and this makes his 'confessions' different from those earlier accounts. That several doctors did not seem reluctant to identify themselves as suffering from agoraphobia is itself interesting, given that grave stigma was attached to many 'mental disorders' at that time.

2 This is not to claim that agoraphobia was regarded solely as a condition besetting urban dwellers. Vincent's mention of a 'high rocky bluff' makes it clear that the term agoraphobia was also used to refer to symptoms experienced in non-urban settings. However, the term circulated in the clinical - and later the non-clinical - world carried strong connotations regarding the specific vicissitudes of metropolitan life.

3 It should be made clear that I am not maintaining that agoraphobic symptoms did not exist before the 187Os. Rather, it is only from that moment onwards that one can make claims about the condition as a named disorder - and thus can track its medical history.

References

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Felicity Callard

Lecturer in human geography

Department of Geography

Queen Mary, University of London

Contact

Felicity Callard

Department of Geography

Queen Mary

University of London

Mile End Road

London El 4NS

e f.callard@qmul.ac.uk

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