When the world closes in: How megacities trigger anxiety disorders

Sukhada Devalekar braces herself for the worst with each waking moment, rapt for smells, sights and sounds that indicate possible threat. Hypervigilance is her weapon, a means to gauge what situations can trigger a panoply of panic attack symptoms: torrential sweating, breathlessness, shaky hands, nausea, a sense of foreboding. She takes a split second to scan elevators for working fans, odour and holding capacity before deciding to walk in or take the stairs. She reaches her Panvel office at 7-15am for a 9am shift and is the last to leave because to a claustrophobic Mumbaikar, avoiding peak hour crowds is the difference between life and seeming death.

But the month of September gets Devalekar's stomach in a knot. "When I was eight, my parents dragged me to Chowpatty to join the Ganesh visarjan revelry," recalls the 37-year-old, who grew up in Girgaon – the epicenter of Ganesh Chaturthi in Mumbai. For a child high-strung in crowds, whether it came to birthdays or the rush succeeding the bell at the end of a school day, the mere thought of being one in a sea of people was tormenting. But her parents, she continues, did not understand the magnitude of her fear. What followed was a bout of vomiting before Devalekar fainted and was rushed to a hospital. Her body recovered, but her mind remains shackled by the stressor of Ganesh Chaturthi. "Pandals in the middle of roads force you to walk less than an arm's length from passing vehicles," she says. "The noise and clamour during aartis makes me feel like I'm drowning. I just avoid such routes and remain indoors as often as I can during this time."

As an anxiety disorder, claustrophobia – the fear of feeling restricted and being unable to escape – can have as many stimuli as it does the number of people suffering from it (The nearly-20-year-old Phobias: A Handbook of Theory, Research, and Treatment pegged the count at 5-7% of the world's population). Elevators, clothes with high necks, public transport, closed windows, caves, basements and serpentine queues can evoke dread.

Maximum city, maximum dread
A city of ambition where breaths are hurried and inches of space claimed, Mumbai demands that we squeeze ourselves into invisible sarcophagi in order to, well, grow. This is true of some of the world's other Medusan metros – New York, Tokyo, Shanghai, Mexico City, Sao Paulo. In Warped Space: Art, Architecture and Anxiety in Modern Culture, UCLA architecture professor Anthony Vidler writes about how urban planning (or the lack of) propagated anxiety at the peak of 19th century urbanisation. Steel-cage constructions, low ceilings, small windows and gated parks and communities, among others, made claustrophobia and agoraphobia disorders of the modern city.

For architect and urban planner PK Das, the man at the forefront of the Open Mumbai movement, the umbilical link between anxiety and an ill-forming city is painfully obvious.

"The situation in Mumbai is leading to what I call 'congestion trauma'. With no social spaces or amenities, people – especially the urban poor and the homeless – are shorn of a dignified life, exposed to high noise levels and lack of light and ventilation," Das says, which explains the increased likelihood of an anxiety disorder. "In a city that is increasingly barricaded and driven by exclusivity and whose growth is unplanned, the net result is a [literal and metaphorical] breakdown. Most urban ills are traced to a lack of open spaces, planning and design."

Thirty-year-old Naina Mahadevan* echoes Das' refrain. Currently in Vietnam, the Chennai-born freelancer has this to say about Ho Chi Minh: "It's a lot like Chennai, but with trees lining every road, no matter how narrow. Greenery and open spaces are oxygen for claustrophobic people, for whom concrete and more concrete, with few spatial breaks, can be uneasy."

Mahadevan, whose claustrophobia occasionally eats into social life (road trips and crowded parties make her queasy), reckons she's still fine, considering she underwent an MRI – one of the worst scenarios for someone who is claustrophobic.

"The technician threatened to sedate me if I kept thrashing about," she laughs. "I eventually realised that the consequences of not undergoing an MRI would be worse. Getting through that procedure was an achievement."

Bad capital
If confined spaces in Mumbai, India's financial capital, can trigger anxieties, the national capital is no better. Moving to Delhi itself was a stressor for Yaruque Sadique and Nisha Moudgil, who hail from Jharkhand and Haryana respectively, and had spent their lives in vast, open spaces.

The United Nations' World Urbanization Prospects report, 2014, lists Delhi as the world's second-most populated city (nearly 25 million). Mumbai, with a population of almost 21 million, is placed fourth.

How does a claustrophobic individual cope in the meta-cities of the world's second-most populous country?

"I have chewed my knuckles in extreme situations, panicking in dimly-lit places or places where I couldn't stretch my limbs," says Sadique, 23. His last harrowing experience was being stuck in the back seat of a friend's car for hours during the recent Delhi floods. Fearing that waves of asphyxia would wash over him, he got out amidst stalled traffic and walked to his destination.

For Sadique, long distance travel is tantamount to incarceration. He has seen off a 17-hour train journey by pacing and standing near the doors for its entire duration. A day before flying to China, he overworked himself, fighting slumber just to induce sleep for the flight ahead and avoid his worst fears: being confined to a seat and having to use the very stifling plane lavatory.

"The last time I took a metro, I alighted few stations earlier because it got so crowded, I didn't think I'd make it. I vomited on the platform. And that makes you feel so self-conscious, with all the people watching," confides Nisha Moudgil, a 27-year-old food technologist based in the capital. "Air-conditioned cars and buses also make me uneasy because of closed windows and lack of ventilation. In hotels, I prefer rooms whose windows can be opened."

Moudgil prides herself on confronting, rather than avoiding situations that wrench her from her comfort zone. For instance, she travels long distances as long as she has a window seat and takes the elevator despite having had a 45-minute coughing fit due to a once-crowded office lift. Her only no-no: a washroom with a "bad latch".

"Because if the latch doesn't open easily or in a few seconds, I will faint," she underlines.

The other phobia
In 2013, The Anxious Sex study by the Scientific American Mind revealed: "The lifetime rate of diagnosis of anxiety disorders is higher in women, with 33% experiencing an anxiety disorder in their lifetime, as compared with 22% of men."

A host of other studies point to a consistent pattern: women are more susceptible to anxiety disorders such as claustrophobia and agoraphobia. But this is mostly in the US; does this hold true in India too, despite there being no official statistics?

"In my practice, yes," says psychotherapist Dr Anjali Chhabria. "Predisposition to anxiety can be traced to hormonal imbalance and family history and their coping mechanisms, but also to sociocultural influences. Gender inequality puts women on the defensive and encourages it too, making them more tuned to 'avoidance' behaviours."

This rings loud in the case of 25-year-old Nandini Khatri*, diagnosed with agoraphobia five years ago. As Anthony Vidler points out in Warped Space… agoraphobia – where one avoids unfamiliar places or situations due to a fear of helplessness or embarrassment – is the other side of the urbanisation coin.

"My greatest fear is someone embarrassing the hell out of me if I can't parallel park or drive to the basement," she says, relaying the last time she sought help to park and was ridiculed. The incident prompted complete avoidance: Khatri has not driven since 2011. Amplifying her anxiety is the general attitude towards women drivers in Delhi, she adds.

"People constantly honk at and intimidate you if you move in 5-6 seconds instead of 1-2 seconds at a signal. I'd rather not drive than be in stressful situations, sweating profusely or feeling my heart in my throat," she elaborates. "Now, I even get overwhelmed at the thought of driving my family around and fear for their safety."

Agoraphobia is difficult to box into one definition because, says Sadia Saeed Raval, its intensity differs vastly from patient to patient. "I know a 28-year-old man who didn't leave his home for 13 years, but you wouldn't know it looking at him because he ate well, exercised indoors and looked fit and healthy," shares the founder and chief psychologist at Inner Space. "Other agoraphobic people are alright in some public places and fear others. It is very subjective."

Chennai-based R Jayesh*, for one, is at ease in 'organised set-ups' such as offices and family and social functions. But crowded areas, especially in an alien city, unravel him. When he was 20, he moved to Hyderabad after graduation with a plan of staying put for a year: he lasted less than a week. "It was a nightmare. Not a second went by when I didn't feel threatened," says the 29-year-old, who works in a multinational bank. "Agoraphobia cost me my relationship. I couldn't bring myself to go to the beach or to the movies, so I'd stay home. I started drinking every day just to get over my inhibitions."

It's been a while since Jayesh overcame the alcoholism. On anti-anxiety medications until recently, he soldiers ahead now with silent affirmations, managing conversations without stammering and trembling hands.

Anxiety disorders are commonly referred to as 'irrational' fears, and therein lies one (of several) problems, feels Sadia Raval. Solutions and treatment methods should ideally be tailor-made for patients since there are no one-size-fits-all symptoms, intensity and coping mechanisms, but the prevailing attitude dictates that one "calm down and move on".

"The term 'irrational fear' in itself is judgmental and can reinforce a negative sense of self," Raval concludes. "Life in a city places so many demands on us, adding to the anxiety of those already predisposed. And most of us who are affected don't even know it – yet."

(*Names have been changed on request)