Agoraphobia: what causes it and how is it treated?

Surely each of us at least once saw a person who literally runs across the square or is afraid to leave the door open. We habitually consider such people to be eccentric, but the problem is much deeper than it might seem at first glance.

Agoraphobia is a multidimensional phobia that manifests itself in the form of fear of open spaces, large crowds... Fear of open space can manifest itself in dread at the prospect of crossing a wide street or square, or leaving an indoor door unlocked. This phobia has been known for a long time. Its name comes from the ancient Greek words, translated as "market" and "fear". Therefore, the fear of open space is often called the "market disease" or "large area disease."

Agoraphobia is a concept that includes many fears, one way or another associated with open space. Fears are unconscious and often irrational. In essence, fear is a hypertrophied manifestation of a defense mechanism - a person feels danger, and physiological, mental and biochemical processes start in his body, which include "protection", prompting him that in this situation he needs to run and be saved.

The first to describe this mental disorder with surprising accuracy was the German psychiatrist and neuropathologist Karl Westphal, who lived in the 19th century. His work on "market fear" was published in 1872 and was the first to suggest using the term agoraphobia itself.In his work, Westphal mainly described only the fear of being in an open place, but then the luminaries of science did not yet know about the crush on the metro at rush hour, did not imagine large demonstrations and rallies for several hundred thousand people.

Surely many will be surprised to learn that Sigmund Freud once suffered from agoraphobia. The disease manifested itself especially strongly in his youth, and for this reason it was very difficult for a world-renowned doctor to take independent walks in old age. He himself told about this to one of his students, Theodore Raik. Raik described this conversation in his writings, and at the same time concluded that Freud's study of human psychology and its deepest secrets was prompted by nothing more than his own mental problems. And, indeed, Freud did a lot.

Before him, psychiatrists tried to treat fears with morphines, hypnosis and electricity. In extreme cases, a patient with phobias was sent to medicinal waters or a resort. And it was Freud who was the first to suggest talking, talking with patients, discussing their problem in order to minimize the manifestations of agoraphobia. The best medical minds in the world were shocked by such a proposal, it did not fit into any reasonable framework, but they themselves could not offer anything better, and therefore in many respects it was Freud who determined the principles of psychotherapy for fear of open spaces and large crowds of people.

Medicine today looks at agoraphobia more broadly. It includes not so much the fear of open places, but also the fear of similar situations (being outside the home, the need to move somewhere outside the home, being in a crowd, public places, in transport and the subway). Agoraphobia is considered the fear of having to walk unaccompanied along a deserted street, park, fear of going on the road or traveling alone. This also includes the fear of visiting markets, large shops, restaurants, cinemas, and going to rallies. An agoraphobe is characterized by fear of any place, which, if something happens, he cannot leave, being unnoticed, without attracting the attention of others.

At the same time, people suffering from such a disorder are well aware that their fears and panic attacks have no basis and are very afraid that such attacks will occur in public, that is, become public knowledge. As a result, a person finds the only reasonable, in his opinion, way out - he closes himself in his "fortress" (house) and no force can force him to leave it.

The agoraphobe feels safe on its territory. Most can communicate well, receive guests, be hospitable hosts, work, conduct telephone conversations, solve very complex creative problems, but exclusively on their territory. As long as they understand that the space around them is under their control, they behave appropriately. They can live for years without leaving home. When trying to avoid anxiety attacks, people with this disorder deliberately limit their movements, narrow the area of ​​activity, try to avoid any situations in which they may be too far from their safe space. It is important for them to know that if necessary, they can quickly return to it.

Marilyn Monroe suffered from agoraphobia, she was very afraid of open places and large gatherings of people and visited them only when accompanied by relatives or friends whom she trusted. Actress Barbara Streisand had a similar problem.

If you ask any agoraphobe what exactly he is afraid of, why he cannot go to the middle of the square and tell everyone what he thinks about them, or simply leave the confines of his own apartment, he is unlikely to find an answer. In 95% of cases, patients with such a phobia consider their fears completely inexplicable. They see no connection between panic and previous upheavals and psychological trauma. Only about 5% of agoraphobes can, after hard thought, remember that for the very first time they experienced wild horror and panic in a situation when they felt bad in some specific circumstances: were sick with the flu, tired, it was very stuffy and hot, worried before an interview or passing the test.

The doctor, of course, will believe them. But the circumstances and situations in which fear arises cannot explain the reason for its appearance. And on this score, psychiatrists and neurophysiologists know what agoraphobes themselves do not realize - the disorder is closely related to a critically low level of a person's sense of personal safety. Quite often, it is laid down in childhood. If a person at a tender age began to perceive himself as a being vulnerable, weak and helpless, unable to withstand an evil, aggressive and vile world, then the probability that agoraphobia will manifest itself at a later age is very high.

Why can a child feel like this? For three reasons:

1. parents unnecessarily take care of him, leaving no room for their own decisions and actions, along the way instilling that the world is full of nightmares and dangers, “you need to be more careful and always on the alert”;
2. parents do not pay attention to the child, are not interested in his experiences and fears, he does not feel support and safety next to adults;
3. parents are too demanding, arbitrary, authoritarian, and the child is constantly tense in expectation that his actions, words, deeds will cause disapproval and even punishment.

In all these situations, fear becomes a habitual companion in life from childhood, to one degree or another it is constantly present. But it would be unfair to blame the parents for everything. There are also individual prerequisites for the emergence of a mental anxiety disorder. Most often, agoraphobia develops in people with a certain type of nervous system - in very sensitive, impressionable individuals, anxious, inclined to delve into their feelings, secretive, not ready to show the world their weaknesses.

But all this is only external circumstances. What happens inside a person? In fact, his own brain begins to deceive him - which is why many patients with agoraphobia develop problems with the vestibular apparatus. A healthy person manages to maintain balance due to three types of signals - proprioceptive, tactile and visual. These landmarks are quite enough to understand where you are and what your position is at a point in space in the current time.

Agoraphobes can only perceive two types of signals - tactile and visual. Due to this, pronounced disorientation arises when a person finds himself inside a swarming crowd, on inclined surfaces and large open spaces with a minimum number of visual cues. The brain sends them erroneous signals, as a result, imbalance is possible.

note that the brain is capable of such "tricks" not by itself, but with the active support of hormones. Anxiety arises as a defense mechanism, and then stress hormones (for example, adrenaline) are instantly released into the bloodstream. The hormone immediately triggers a flight-or-defense response in the brain.

In some congenital and acquired pathologies associated with hormonal imbalance, the development of agoraphobia may have precisely endocrine causes (pathological processes in the brain triggers an imbalance of hormones). This is possible with neurocirculatory dystonia, alcoholism, drug addiction, gross pathologies of the thyroid gland.

It is noteworthy that big lovers of coffee and everything that contains caffeine (strong tea and dark chocolate) also run the risk of joining the amicable ranks of agoraphobes - caffeine stimulates the production of stress hormones and, if the predisposing factors coincide, the start of the "market disease" is quite possible. According to statistics, Agoraphobia, to one degree or another, occurs in 5% of the world's population; men are less susceptible to it than women, about 2 times.

Agoraphobe is easy enough to recognize. He is afraid to leave the house, to do something outside his usual controlled territory. Going outside, crossing the road, going down the subway and getting on a crowded morning bus for the classic agoraphobe are difficult and sometimes even impossible tasks. At the same time, one is afraid to visit stores, and the second is not able to visit a hairdresser. Public transport is a common fear in this disorder, because while the bus is traveling, a person cannot get up and leave it if they feel in danger.

At the same time, accompanied by relatives or someone whom the patient fully trusts, the level of anxiety decreases, and the person is able to do what he cannot do alone. There are agoraphobes who have only one kind of fear, for example, the fear of crossing the square on foot or the fear of getting on a bus. There are people who suffer from several fears at once, up to the complete inability to leave their apartment, to move anywhere, and in the most difficult cases, they cannot remain alone in their native walls.

Usually agoraphobes act proactively - they plan their everyday life in such a way as not to face situations in which they are afraid to be at any turn of fate: looking for work within walking distance, if they are afraid of transport, start working remotely at home, if they are afraid to leave the house, order groceries at home, if they are afraid to go to the store, put door closers on the door so that they do not accidentally forget to close the door behind them. And in their measures they are very consistent, punctual and attentive to little things.

If, nevertheless, an agoraphobe, despite all the precautions, finds itself in alarming circumstances, the following signs of the disease can be noted:

• breathing quickens and becomes shallow, shallow;
• heartbeat quickens;
• the secretion of sweat increases, especially the face and hands sweat;
• dizziness occurs, loss of orientation in space, falling is possible;
• there is a feeling of "lump in the throat", it becomes difficult to swallow;
• there is a feeling of nausea and tightness in the stomach.

If a cautious and prudent agoraphobe knows that he will soon have to deal with a terrible, dangerous situation (for example, he really needs to visit the passport office and get a document, because no one will do it for him), then while waiting he begins to feel fear in a few days, anxiety builds up gradually.

True agoraphobes have low self-esteem, they are almost sure in advance that nothing good will come of their ideas and ideas. They are afraid of loneliness, because they simply do not understand how to survive without support, care, protection from the outside. They are sensitive to partings, they can become severely depressed.

The whole life of an agoraphobe - one ongoing battle for additional safe space under the sun. And it happens that patients manage to win additional land to their "fortress", they expand the space in which they feel calm. But after unforeseen traumatic circumstances arise (wife left, husband abandoned, friend betrayed, fired from work, not hired), progress usually comes to naught, and the person returns back to his "island of safety."

Psychiatrists have noticed that the first signs of the disease usually appear when a person reaches the age of 20-25 years. And this is the main difference between this fear and other phobias, which usually appear in adolescence or childhood. According to the analysis of the case histories of people with agoraphobia, experts drew attention to the fact that the first attack of terror usually occurs in certain situations - when a person stands at a stop and waits for his tram or at the moment when he walks through a shopping center or bazaar, choosing a purchase.

The disorder usually has persistent chronic character... Periods of exacerbations are replaced by remission, and then exacerbations occur again. Seven out of ten patients develop classic clinical depression, and almost half develop phobic disorders. If a person gradually develops panic syndrome, then the disease has the most severe course and is the most difficult to treat.

Unfortunately, science and medicine do not know a "magic pill" that would help a person get rid of a disease such as agoraphobia. Therefore, therapy will be long-term, complex, sometimes it continues throughout the life of the agoraphobe.

Much depends on what form of disorder is established - with or without panic disorder. If there are no panic attacks as such, it is customary to treat a person with the help of psychotherapy. This is the most effective way to deal with the fear of open space, crowds or traffic today. Medication for non-panic agoraphobia has been found to be ineffective. pills cannot be cured of this disease; you can only temporarily slightly reduce the symptoms. But in especially stubborn cases of ailment, tranquilizers are still recommended for short periods simultaneously with a psychotherapeutic course of treatment.

The main method, which in psychiatry and psychology is assessed today as the most effective, is cognitive behavioral therapy. At the very beginning, the doctor identifies the degree and frequency of anxiety and fears, the circumstances in which a person experiences them.Further, connections are established with certain memories, emotions and experiences of the patient. And then the doctor begins with the patient to change the thoughts and beliefs that provoke the emergence of fear in certain circumstances.

At the second stage, when a person begins to realize all the absurdity of his nightmares, they begin to gradually immerse him in situations that, until recently, he was most afraid of in life. First, this happens with the help of a specialist, and then independently. As a result, situations that until recently were frightening become habitual, in fact, they are not at all terrible, anxiety in a quite natural way begins to decrease.

The psychotherapist and psychiatrist do not aim to eliminate fear as such. They have a different goal - remove those psychological attitudes and prerequisites, an unhealthy perception of oneself and the world around, which lead to fear. Thus, treatment is aimed at increasing self-esteem, at establishing more friendly relations with the surrounding world and the people inhabiting it. Without this, psychotherapy will be at a minimum, and soon the phobia will return. In especially difficult cases, hypnosis is used.

Various medications are used for treatment. They can be divided into several groups.

This includes funds that, in fact, do not heal anything, but have a general strengthening effect on the body. They cannot be used separately due to the uselessness of such drugs in case of mental disorder. But in the complex treatment can be prescribed. These include Glycine, Afobazol, Fezam, Cerebrolysin, Magne B6

They mainly have a symptomatic effect, they do not treat the root cause in principle. They cause inhibition of signals in the brain, thereby reducing anxiety. Most often used benzodiazepines "Phenazepam", "Diazepam". The drugs have side effects with prolonged use, cause drug dependence, and therefore are not suitable for long-term treatment.

Drugs in this group are considered more effective in the treatment of agoraphobia than the drugs listed above. In almost 80% of patients, the level of anxiety decreases. The products are not addictive. The effect is achieved due to the normalization of the amount of neurotransmitters in the cells of the brain (the content of serotonin in particular increases). The best result can be achieved with simultaneous application antidepressants and psychotherapy. More often use Paroxetine, Sertraline, Fluoxetine.

General rules state that a person should take all medications, being absolutely sober and sane. That is, the intake of alcohol, coffee, drugs during treatment is excluded. The patient should not exceed the dosage recommended by the doctor. At the same time, refusal from psychotherapy does not guarantee any effect from the treatment at all. By themselves, the pills, if they "work", then only in relation to certain symptoms and not for long.

It is almost impossible to cope with agoraphobia on your own, since fear quickly becomes an integral part of a person's life, a part of his own personality. And the fight against it is reminiscent of the notorious fight of bees against honey. Therefore, an appeal to a specialist is a must. While undergoing treatment, the following recommendations will help speed up positive results and defeat fears:

• learn to relax - practice meditation, do yoga (this can be done using video tutorials), devote time to relaxation every day, better when it happens in the morning and in the evening;
• believe that you are on the road to recovery, you have enough strength to walk this path to the end;
• master breathing exercises - a series of inhalation and exhalation of a certain depth and intensity helps to quickly cope with panic if the attack recurs;
• keep a diary, in which every day indicate in detail what part of your fears have already been overcome, this will help you see progress and will motivate you for further treatment.

Try to enlist the support of someone you trust as much as you can. Share with him your new feelings and achievements. But gradually gain more independence: if before you could not go to the store without an accompanying person, do not be afraid to try to do it yourself, but first make half the way to the store and return, and then go all the way. In the next "approach" go to the store and stay there for a while. Gradually it will turn out and make purchases.

There is no prevention of agoraphobia, since triggers (provoking factors) are still poorly understood. And it is wiser to care about prevention for parents who want to raise mentally healthy children. To do this, moms and dads should not adhere to an authoritarian parenting style in which the child is constantly intimidated.... Hyperprotection should also be excluded - the child must have enough personal space and independence, he must have the right to choose. At first, it will be a choice of what to eat for an afternoon snack, and later - a choice of profession, university, friends.

If you are a sensitive person, anxious and very worried about what others will think of you, if you are often afraid not to cope with a task that you have to do on your own, without the help of others, if you are extremely uncomfortable on the subway or bus (but the speech is not yet is about panic), you need to seek help from a psychologist. This will help to reconsider some beliefs that, under unfavorable circumstances, may well turn into the development of agoraphobia.

For information on how to get rid of agoraphobia, see the next video.