Hello, people… welcome back to the blog! Last week, we finished a two part series on N-acetyl cysteine, the latest and greatest amino acid supplement that’s showing major promise in helping to treat some heavy hitting psych disorders, especially bipolar depression. This week, I want to talk about a very intriguing topic… phobias.
What is a phobia? A phobia is an irrational fear of something that’s unlikely to cause you any harm. I want to highlight the most important point here: irrational fear. Irrational, without rationale. What does that mean exactly? It generally means not thinking, but sometimes it means thinking, but without logic. So a phobia is when you’re afraid of something, often without even thinking about it, sometimes despite thinking about it- which just causes more anxiety btw- and the thing that you’re afraid of is usually nothing to be afraid of in the first place. But despite that fact, the fear can be intense. The word phobia comes from the Greek word phobos, which means fear or horror. Generally, the name of the phobia is a telling label, one basically made up as the need arises, typically by combining a Greek (or sometimes Latin) prefix that describes the phobia, along with the -phobia suffix. For example, the fear of water is named by combining hydro (water) and phobia (fear), so you end up with hydrophobia.
When someone has a phobia, they experience very intense fear of a certain object, thought, or situation. This fear is more extreme than fear in the normal everyday sense, and it develops when a person has an exaggerated or irrational perception of danger about a particular thing. But where’s the line? Being a little wary of spiders isn’t the same as being arachnophobic, right? And btw phobias aren’t always entirely irrational… some spiders ARE dangerous- they can kill you- so they should be avoided. But a phobia will assume that ALL spiders- even a teeny tiny harmless house spider- is a real threat. That’s how phobias are a little different than regular fears, because they cause significant distress, potentially enough to interfere with life at home, work, and/ or school. You’re afraid of serial killers, I’m afraid of serial killers, I imagine everyone is afraid of serial killers. Actually, are serial killers afraid of serial killers? Hmmm… don’t know. Anyway, is this a phobia? Not for most folks, but it sure is for some. What’s the difference? It has to do with interference. Why and how does that phobia, that thing, interfere with your life? Because people with phobias actively avoid the phobic object or situation- that’s another difference- they’ll do nearly anything to avoid it- or else they’ll just white knuckle through it with super intense fear and anxiety. Are you so afraid of serial killers that you avoid going to a nearly deserted truck stop diner at midnight, or so afraid of them that you refuse to leave your house… ever? If you’re the latter, you might have foniasophobia, fear of dying at the hands of a serial killer.
Ultimately, phobias are a type of anxiety disorder. Anxiety disorders are very, very common- I see them all day long- and they’re estimated to affect more than 30 percent of U.S. adults at some point in their lives. Specific phobias affect fewer people, with an estimated 12.5 percent of American adults experiencing one at some time in their lives. You can have a phobia without having a true anxiety disorder, and you can have an anxiety disorder without having a phobia, though I can’t think off the top of my head of a patient with a generalized anxiety disorder that hasn’t told me about a specific phobia, though I’m sure there are some.
In the shrink bible, the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, aka the DSM-5, it outlines several of the most common phobias, and they typically fall within five general categories:
-Fears related to animals, like spiders, dogs, and insects
-Fears related to the natural environment, like heights, the dark, and thunder
-Fears related to blood, injury, or medical issues, like injections, blood draws, and medical catastrophes, like falls and broken bones
-Fears related to specific situations, like flying, riding in an elevator, being on an escalator, and driving over bridges
-Fears of other more random things like loud noises or choking
The thing is, these categories encompass an infinite number of specific objects and situations. A person can conceivably be afraid of anything they can physically do, think about, or feel. And let me tell you, I’ve heard some doozies. Some people are genuinely afraid of some weird stuff! Not even making fun… most of the time, they’ll even tell you it’s weird too. One of my patients that I’ve treated forever has a wind phobia, anemophobia, or sometimes called ancraophobia. Whatever it’s called, she hates wind… anything more than a light breeze is like nails on a chalkboard for her. What’s really wild is that this very specific, and fairly rare phobia appears to be genetic for her- it runs in her family- and she never even knew that until they all “hurricaned” together several years ago. She, her father, who evidently never really admitted it, and her aunt on her father’s side… all three of them were climbing the walls together during the hurricane. And apparently she always hated wind. As a kid, she would get up in the middle of the night… even if, maybe even especially, when it was storming… and hello, windy… and climb up on a barstool to take down her mom’s windchimes! Every one of them, and evidently she had a lot. Why? Because they drove her looney, listening to the wind blow them around… ding!! Ching ching bing!!! Ding ding da ding!!! She told me that they all made different noises, varying tones, high and low, and she said that every one of them just reminded her how bloody windy it was. For her mom, that sound was relaxing, but for her… not so much! Now, was she actually worried that the wind would blow her away, like Dorothy, off to Oz? Nope. She always knew that wouldn’t happen. She knew she was perfectly safe in her concrete block constructed house, but nonetheless, the wind made her beyond anxious. That, my friends, is a phobia. Totally irrational. And she’d tell you so herself.
Phobias come in all shapes and sizes, and because there really are an infinite number of objects and situations, the list of specific phobias is very, very long. Did you know that there’s even such a thing as a fear of fears? Phobophobia. How about that? And it’s actually more common than you might imagine. That’s one of the problems with fear, it often begets itself. If you have a panic attack because you go sailing in a 28 foot sloop in 12 foot seas, you may end up with not just a phobia about sailing, but a phobia of water and waves. And because the impact of the fear was so intense that it produced physical symptoms of a panic attack, you can even wind up with a phobia of having a panic attack. Yep, and you can be so afraid of having a panic attack that you can cause yourself to have one. Kid you not.
While there are potentially hundreds, maybe even thousands of different types of phobias, there are some that affect the population at much higher rates than others. Here are a few of the most commonly diagnosed phobias, along with some interesting points on each.
The fear of spiders, or arachnids, is possibly the most well-known of all phobias, and it’s estimated that arachnophobia affects roughly 1 in 3 women and 1 in 4 men.
Ophidiophobia is the fear of snakes. Interestingly, both ophidiophobia and arachnophobia are thought to be rooted in human evolution, meaning we evolved to fear these critters. It was a matter of survival, so humand learned it generation over generation, to the point it stuck in our DNA. Pretty amazing, no?
This is the fear of heights, which affects over 20 million people. Acrophobia can affect a person in a variety of situations, including air travel, crossing bridges, and even travelling up an escalator. It can be extremely limiting, because this fear in particular is frequently associated with anxiety attacks as well as avoidance of the phobia trigger, and this often prevents people with acrophobia from participating in activities that most of us take for granted.
This is the fear of dogs, and unfortunately, often stems from a personal traumatic experience in the patient’s past, maybe a bite or an attack. I’m a dog lover, and have never had a negative experience with a dog, so while I can’t understand it from an experiential standpoint, I have great empathy for people that are so afraid of dogs for whatever reason that they miss out on the love and companionship they can provide. Cynophobia is an interesting one to me, because it is one of the most commonly treated phobias. In fact, 36 percent of all patients who seek phobia treatment actually do so for cynophobia, which gives you an idea of how much it impacts their lives.
Social phobia involves fear centered around social situations and interactions. Among the most common symptoms of social phobia is fear of public speaking, but it can center on any number of situations, like starting conversations, speaking on the phone, meeting new people, speaking to authority figures, and even eating and drinking in front of others. Social phobia typically first appears during puberty, and it can be lifelong if not properly treated.
Agoraphobia is the fear of entering open or crowded places, of leaving one’s home, or of being in places or situations that trigger a feeling of helplessness, or where a quick escape would be difficult, such as being on public transportation, like an airplane. Agoraphobia is its own unique diagnosis, and is often associated with panic disorder and panic attacks; roughly one-third of patients with an existing panic disorder will also go on to develop agoraphobia as a comorbidity. Statistically, it’s more prevalent in women than men, with two-thirds of patients being female.
Speaking of being on airplanes, aerophobia is the fear of flying, and it affects an estimated 8 million people. Given today’s world of travel and transportation, this one can be particularly difficult to avoid, but it can be addressed with various techniques, like exposure therapy. More on that next week.
That’s a good place to stop. Next week, more on freaky phobias; among other things, we’ll talk about how to rid yourself of them. Because while you might assume that once a person gets to the other side of their phobia and knows they lived through it, that it would go away all by itself… you’d be wrong most of the time. Wah wah waaaah. We’re going to talk about just why the hell that is.
I hope you enjoyed this blog and found it to be interesting and educational. Please feel free to share it with family and friends. Be sure to check out my YouTube channel with all of my videos, and I’d appreciate it if you would like, subscribe, leave comments, and share those vids! As always, my book Tales from the Couch has more educational topics and patient stories, and is available in office and on Amazon.
Thank you and be well people!
Welcome back, people! Last week we continued our foray into all things Xanax and talked about dependence and use disorder. The next step in the chain- withdrawal- can be a special kind of beastie, definitely deserving of its own blog, so this week will be all about Xanax withdrawal.
As I mentioned last week, some folks can take their bit of Xanax a couple of times a day as directed for umpteen years, and never develop a tolerance or pathological dependence. Others start out taking it as directed, but develop a tolerance and maybe start to abuse it- take too much too often- and then begin to develop a more pathological dependency. Others may abuse it recreationally on occasion, to netflix and chill, find they really like it, then develop a severe addiction. It may not sound like these people have much in common, but they do. When they stop taking it, they’re all going to go through withdrawal.
They won’t do so alone, though. In 2017, doctors wrote nearly 45 million prescriptions for Xanax, so it’s no surprise that these prescribing practices have contributed to thousands of cases of abuse and dependence. With those numbers, there has been all sorts of research and stats examined on benzos, and I read that in 2018, an estimated 5.4 million people over the age of 12 misused prescription benzodiazepines like Xanax. That’s a lot of people, people.
To many patients that take their Xanax exactly as prescribed, it seems to come as a surprise that they’re facing a withdrawal experience, but Xanax doesn’t discriminate- so anyone taking enough of it for more than a few weeks will develop a physical dependence. Once you have become physiologically dependent on a drug, you will experience withdrawal symptoms when you stop or reduce your dose. Simple as that.
Withdrawal is different for everyone. Depending on the dose and how often you’ve been using it, the withdrawal experience typically ranges from uncomfortable to very unpleasant, but it can also be medically dangerous. The only safe way to quit is to slowly taper down the dose under the direction of a physician, or in an in-patient treatment center setting, depending on the situation. If you’ve been taking high doses of Xanax several times a day, then quitting is going to take a great deal of time, patience, and determination. Please note that quitting cold turkey can cause extremely dangerous withdrawal symptoms. This can include delirium, which is a state characterized by abrupt, temporary cognitive changes that affect behavior; so you can be irrational, agitated, and disoriented- not a good combo. Sudden withdrawal can also cause potentially lethal grand mal (aka tonic-clonic) seizures. These are like electrical storms in the brain, where you lose consciousness and have violent muscular contractions throughout the body. It’s not a risk you want to take, people- so don’t do this on your own! Even if you’ve been taking Xanax illicitly, that doesn’t mean you have to go it alone. Just fess up to a physician and tell them exactly how much you’ve been taking so they can design a taper schedule for you, or help you find a treatment center. There is a lot of help available if you make the effort.
Tapering your dose is the best course of action for managing withdrawal symptoms, but that doesn’t mean it’s a picnic in the shade. While you taper down the dose, you’ll likely experience varying degrees of physical and mental discomfort. You may feel surges of anxiety, agitation, and restlessness, along with some unusual physical sensations, like feeling as though your skin is tingling or you’re crawling out of your skin. But keep in mind that these are all temporary.
Signs and Symptoms
The major signs and symptoms of Xanax withdrawal vary from person to person. Research indicates that roughly 40% of people taking benzodiazepines for more than six months will experience moderate to severe withdrawal symptoms, while the remaining 60% can expect milder symptoms. It’s very common to feel nervous, jumpy, and on edge during your taper. And because Xanax induces a sedative effect, when the dose is reduced, most people will experience a brief increase in their anxiety levels. Depending on the severity of your symptoms, you may experience a level of anxiety that’s actually worse than your pre-treatment level. Support from mental health professionals can be very beneficial during and after withdrawal, as therapy and counseling may help you control and manage the emotional symptoms of benzo withdrawal.
Physical Withdrawal Symptoms
As a central nervous system depressant, Xanax serves to slow down heart rate, blood pressure, and temperature in the body- in addition to minimizing anxiety, stress, and panic. Xanax may also help to reduce the risk of epileptic seizures. Once the brain becomes used to this drug slowing all of these functions down on a regular basis, when it is suddenly removed, these CNS functions generally rebound quickly, and that is the basis for most withdrawal symptoms. Symptoms can start within hours of the last dose, and they can peak in severity within 1 to 4 days. The physical signs of Xanax withdrawal can include: headache, blurred vision, muscle aches, tension in the jaw and/ or teeth pain, tremors, nausea, vomiting, diarrhea, numbness of fingers, tingling in arms and legs, sensitivity to light and sound, alteration in sense of smell, loss of appetite, insomnia, cramps, heart palpitations, hypertension, sweating, fever, delirium, and seizures.
Psychological Withdrawal Symptoms
Xanax, as a benzodiazepine, acts on the reward and motivation regions of the brain, and when a dependency is formed, these parts of the brain will be affected as well. When an individual dependent on Xanax then tries to quit taking the drug, the brain needs some time to return to normal levels of functioning. Captain Obvious says that whenever you stop a benzo, because it acts as an anxiolytic, you’re going to experience a sudden increase in anxiety levels. While there are degrees of everything, the psychological symptoms of Xanax withdrawal can be significant, as the lack of Xanax during withdrawal causes the opposite of a Xanax calm, which is to say something akin to panic. At the very least, that can make you overly sensitive, and less able to deal with any adverse or undesired feelings. Withdrawal can leave people feeling generally out of sorts, irritable, and jumpy, while some individuals have also reported feeling deeply depressed. Unpredictable shifts in mood have been reported as well, such as quickly going from elation to being depressed. Feelings of paranoia can also be associated with Xanax withdrawal.
Nightmares are often reported as a side effect of withdrawal. I included insomnia in physical symptoms, but trouble sleeping can also be a psychological symptom, as it is both mentally and physically taxing. People can be overtaken by anxiety and stress during withdrawal, and that may cause this trouble sleeping at night, which then contributes to feelings of anxiety and agitation, so it’s a cycle that can be tough to break free of. Difficulty concentrating is also reported, and research has found that people can have cognitive problems for weeks after stopping Xanax. Ditto for memory problems. Research shows that long-term Xanax abuse can lead to dementia and memory problems in the short-term, although this is typically restored within a few months of the initial withdrawal. Hallucinations, while rare, are sometimes reported when people suddenly stop using Xanax as well. Suicidal ideation is sometimes reported, as the anxiety, stress, and excessive nervousness that can occur during withdrawal can lead to, or coexist with suicidal thoughts. Finally, though rare, psychosis may occur when a person stops using Xanax cold turkey, rather than being weaned off of it.
Xanax Withdrawal Timeline
Xanax is used so commonly for anxiety and panic disorders because it works quickly, but that also means it stops working quickly and leaves the body quickly. Xanax is considered a short-acting benzodiazepine, with an average half-life of 11 hours. As soon as the drug stops being active in the plasma, usually 6 to 12 hours after the last dose, withdrawal symptoms can start. Withdrawal is generally at its worst on the second day, and improves by the fourth or fifth day, but some symptoms can last significantly longer. If you go cold turkey and don’t taper your dose, your withdrawal symptoms will grow increasingly intense, and there really is no way to predict how bad they may get, or how you’ll be affected.
Unfortunately, five days doesn’t signal the end of withdrawal for some people, as some may experience protracted withdrawal. Estimates suggest that about 10% to 25% of long-term benzodiazepine users experience protracted withdrawal, which is essentially a prolonged withdrawal experience marked by drug cravings and waves of psychological symptoms that come and go. Protracted withdrawal can last for several weeks, months, or even years if not addressed by a mental health professional. In fact, these lasting symptoms may lead to relapse if not addressed with continued treatment, such as regular therapy.
Factors Affecting Withdrawal
Withdrawal is different for each individual, and the withdrawal timeline may be affected by several different factors. The more dependent the body and brain are to Xanax, the longer and more intense withdrawal is likely to be. Regular dose, way of ingestion, combination with other drugs or alcohol, age at first use, genetics, and length of time using or abusing Xanax can all contribute to how quickly a dependence is formed and how strong it may be. High stress levels, family or prior history of addiction, mental health issues, underlying medical complications, and environmental factors can also make a difference in how long withdrawal may last for a particular individual and how many side effects are present.
Coping with Xanax Withdrawal
The best way to avoid a difficult and potentially dangerous withdrawal is to slowly taper down your dose of Xanax, meaning to take progressively smaller doses over the course of up to several weeks. By keeping a small amount of a benzo in the bloodstream, drug cravings and withdrawal may be controlled for a period of time until the drug is weaned out of the system completely. It may sound like designing a taper would be a no-brainer, but it’s definitely not recommended to taper without a physician’s guidance. Why? Because Xanax is a short-acting drug, your body metabolizes it very quickly. Controlling that is challenging because the amount of drug in your system goes up and down with its metabolism. To help you avoid these peaks and valleys, doctors often switch you from Xanax to a longer acting benzo during withdrawal, as it may make the process easier. And believe me, that’s what you want. If the physician goes this switch route, once you’ve stabilized on that med, you’ll slowly taper down from that a little bit at a time, just as you would with Xanax.
Another reason not to play doctor on this one is if you start to have breakthrough withdrawal symptoms when your dose is reduced, your physician can pause or stretch out your taper. It’s up to him or her, through discussion with you, to design the best tapering schedule for your individual needs. Sometimes it’s a fluid and changing beastie.
In addition, adjunct medications like antidepressants, beta-blockers, or other pharmaceuticals/ nutraceuticals may be effective in treating specific symptoms of Xanax withdrawal, and you’ll need a physician to recommend and/ or prescribe those as well.
Alleviating Symptoms of Withdrawal
An individual may notice a change in appetite and weight loss during Xanax withdrawal, so it’s important to make every attempt to eat healthy and balanced meals during this time. It may sound obvious, but a multivitamin including vitamin B6, thiamine, and folic acid is especially helpful, as these are often depleted in addiction and withdrawal. There are some herbal remedies that may be helpful during withdrawal, such as valerian root and chamomile for sleep. Meditation and mindfulness are very useful for managing blood pressure and anxiety during withdrawal, so be sure to check out my March 15 blog for more on mindfulness. Considering the insomnia and fatigue that may occur during withdrawal, it may seem counterintuitive to commit to exercise, but it has been shown to have positive effects on mitigating withdrawal symptoms and decreasing cravings. Exercise stimulates the same pleasure and reward systems in the brain, so it stands to reason that it can also help to lift feelings of depression or anxiety that may accompany physical withdrawal symptoms.
Xanax Withdrawal Safety
Some of the things I’ve mentioned are so important they bear repeating. Xanax should not be stopped suddenly, or cold turkey, and vital signs like blood pressure, heart rate, respiration, and temperature need to be closely monitored during withdrawal. This is because these may all go up rapidly during this time, and this can contribute to seizures that can lead to coma and even death.
People with a history of complicated withdrawal syndromes and people with underlying health issues should work very closely with their physician during withdrawal, as should the elderly and people with cognitive issues, as there can be unique risks involved. If you have acquired your Xanax illicitly, you can still work with a doctor to taper down your dose. Start by visiting a primary care physician or urgent care center and tell them that you are in, or are planning to be in, benzodiazepine withdrawal. If you don’t have insurance, visit a community health center. If you plan to or have become pregnant, you will need to discuss your options with your prescribing physician and OB/GYN about the risks and benefits of continuing versus tapering Xanax or other benzos. Some women continue taking them throughout their pregnancy, while others follow a dose tapering schedule.
The key to achieving the goal of getting off of Xanax is to follow the tapering schedule to the very end. By the end of your taper, you might be cutting pills into halves or quarters. Note that some individuals may be better suited for a harm reduction approach, in which the taper leads to a maintenance dose rather than abstinence. If you’re very concerned about the risks involved in Xanax tapering for any reason, discuss these concerns with your physician, because you may be better suited for inpatient detoxification. While this is more expensive, it is covered by many insurance plans.
No matter how you slice it, quitting Xanax takes time, patience, and determination. If you’ve been using it for longer than a few months, quitting can be hard, and there will be days where you want to give up and give in. But with medical supervision and support, you can be successful, and in the long-term, the health benefits are considerable. Withdrawal isn’t a picnic, but if Xanax is both the alternative to it, and a problem for you, it beats that alternative hands down.
I hope you enjoyed this blog and found it to be interesting and educational. If you did, let me know. If you didn’t, let me know that too!
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As always, my book Tales from the Couch has more educational topics and patient stories, and is available in the office and on Amazon.
Thank you and be well people!
Agoraphobia (Without History of Panic Disorder)
Agoraphobia Without a History of Panic Disorder is an anxiety disorder characterized by extreme fear of experiencing panic symptoms, of panic attacks.
Agoraphobia typically develops as a result of having panic disorder. In a small minority of cases, however, agoraphobia can develop by itself without being triggered by the onset of panic attacks. Historically, there has been debate over whether Agoraphobia Without Panic genuinely existed, or whether it was simply a manifestation of other disorders such as Panic Disorder, General anxiety disorder, Avoidant personality disorder and Social Phobia. Said one researcher: “out of 41 agoraphobics seen (at a clinic) during a period of 1 year, only 1 fit the diagnosis of agoraphobia without panic attacks, and even this particular classification was questionable…Do not expect to see too many agoraphobics without panic” (Barlow & Waddell, 1985) . In spite of this earlier skepticism, current thinking is that Agoraphobia Without Panic Disorder is indeed a valid, unique illness which has gone largely unnoticed, since its sufferers are far less likely to seek clinical treatment.Learn More
Not to be confused with agraphobia, agoraphobia is a condition where the sufferer becomes anxious in environments that are unfamiliar or where he or she perceives that they have little control. Triggers for this anxiety may include wide open spaces, crowds (social anxiety), or traveling (even short distances). Agoraphobia is often, but not always, compounded by a fear of social embarrassment, as the agoraphobic fears the onset of a panic attack and appearing distraught in public. This is also sometimes called ‘social agoraphobia’ which may be a type of social anxiety disorder also sometimes called “social phobia”.
Not all agoraphobia is social in nature, however. Some agoraphobics have a fear of open spaces. Agoraphobia is also a defined as “a fear, sometimes terrifying, by those who have experienced one or more panic attacks”. In these cases, the sufferer is fearful of a particular place because they have experienced a panic attack at the same location in a previous time. Fearing the onset of another panic attack, the sufferer is fearful or even avoids the location. Some refuse to leave their home even in medical emergencies because the fear of being outside of their comfort area is too great.
The sufferer can sometimes go to great lengths to avoid the locations where they have experienced the onset of a panic attack. Agoraphobia, as described in this manner, is actually a symptom professionals check for when making a diagnosis of panic disorder. Other syndromes like obsessive compulsive disorder or post traumatic stress disorder can also cause agoraphobia, basically any irrational fear that keeps one from going outside can cause the syndrome.
It is not uncommon for agoraphobics to also suffer from temporary separation anxiety disorder when certain other individuals of the household depart from the residence temporarily, such as a parent or spouse, or when the agoraphobic is left home alone. Such temporary conditions can result in an increase in anxiety or a panic attack.
Another common associative disorder of agoraphobia is necrophobia, the fear of death. The anxiety level of agoraphobics often increases when dwelling upon the idea of eventually dying, which they consciously or unconsciously associate with being the ultimate separation from their mortal emotional comfort and safety zones and loved ones, even for those who may otherwise spiritually believe in some form of divine afterlife existence.
Agoraphobia occurs about twice as commonly among women as it does in men. The gender difference may be attributable to several factors: social-cultural traditions that encourage, or permit, the greater expression of avoidant coping strategies by women (including dependent and helpless behaviors); women perhaps being more likely to seek help and therefore be diagnosed; men being more likely to abuse alcohol in reaction to anxiety and be diagnosed as an alcoholic. Research has not yet produced a single clear explanation for the gender difference in agoraphobia.
Causes and contributing factors
Although the exact causes of agoraphobia are currently unknown, some clinicians who have treated or attempted to treat agoraphobia offer plausible hypotheses. The condition has been linked to the presence of other anxiety disorders, a stressful environment or substance abuse. Chronic use of tranquilizers and sleeping pills such as benzodiazepines has been linked to onset of agoraphobia. In 10 patients who had developed agoraphobia during benzodiazepine dependence, symptoms abated within the first year of assisted withdrawal.
Research has uncovered a linkage between agoraphobia and difficulties with spatial orientation. Individuals without agoraphobia are able to maintain balance by combining information from their vestibular system, their visual system and their proprioceptive sense. A disproportionate number of agoraphobics have weak vestibular function and consequently rely more on visual or tactile signals. They may become disoriented when visual cues are sparse (as in wide open spaces) or overwhelming (as in crowds). Likewise, they may be confused by sloping or irregular surfaces. In a virtual reality study, agoraphobics showed impaired processing of changing audiovisual data in comparison with healthy subjects.Learn More