Agoraphobia: symptoms, causes, treatment

Agoraphobia: what is it and how does it manifest?

Agoraphobia comes from two words: agora - bazaar (market, square) and phobos - fear. That is, the term literally translates as “fear of marketplaces.” In a broad sense, agoraphobia is the fear of open space.

A person is afraid of getting lost, being crushed in a crowd, getting into an unpleasant situation, or that he will become ill and no one will help. The root of agoraphobia is distrust of people, lack of self-confidence, and suspiciousness.

This is interesting! People between 20 and 30 years of age suffer most often from agoraphobia. Women are at greater risk, especially those with low social status and those who have problems in relationships with men.

General information

The fear of open space has a triple name - agoraphobia, a word of Greek origin, which is divided into two and literally translated as agora - square, market, phobos - fear. The disease is a mental disorder and is assigned an ICD-10 code F40.0 (Source: Wikipedia). Since in Ancient Greece the agora (marketplace) was a crowded place, the concept of phobia is dual in nature and also includes signs of fear of a crowd, and not just a certain open area.
Unconscious fear in agoraphobia can arise in various situations, from the need to walk through a deserted square or street to a panicky fear of traveling alone on planes, trains, buses. The patient tries to avoid phobic situations, crowded places and companies, because they may require unexpected actions. This defense mechanism is usually developed in response to severe mental shock and previous emotional trauma inflicted by people in real life. A unique difference from other phobias is the onset of the development of fear of open space; it does not arise in childhood or adolescence, but upon reaching 20-25 years of age. It affects 0.6% of humanity.

Agoraphobia was first described by the German physician Karl Westphal. He noted that most often the fear of open spaces develops with various nervous disorders and mental illnesses; it can be a consequence of anxiety or panic personality disorder , other social phobias , panic attacks , neurasthenia , hysteria , hippochondria .

Symptoms and signs of agoraphobia

Fear of open space rarely occurs in isolation; more often it is associated with other phobias and anxieties, as well as panic attacks. A panic attack can occur anywhere: in a public place, in an open deserted space, among a crowd of people, etc.

How to recognize the disease agoraphobia

Agoraphobia can be recognized by subjective and objective signs. Another feature is waiting. If a person has had a panic attack once, he will constantly wait for the next attack. The tension due to anticipation becomes the cause of a new panic attack.

It is important! Agoraphobes have low self-esteem, fear of loneliness, uncertainty, and fear of losing control. They are sure that if something happens, no one will help them.

Subjective symptoms of agoraphobia

Subjective symptoms are what the person himself feels. The main subjective symptom is fear, but its severity depends on the individual characteristics of the person. Other subjective signs include:

• desire for isolation;
• anxiety in a public place;
• fear of going outside from the house;
• fear of traveling on public transport;
• depersonalization and disorientation.

Objective symptoms of agoraphobia

Objective symptoms are autonomic nonspecific symptoms that are felt by all people with the disorder. Objective symptoms include:

• tachycardia,
• arrhythmia,
• hyperhidrosis,
• shiver,
• dizziness,
• headache,
• ringing and noise in the ears,
• bowel disorder,
• feeling of suffocation
• increased pressure,
• pain and cramps in the abdomen.

Autonomic changes are caused by the production of adrenaline - the fear hormone.

Course of agoraphobia

Fear of open space has a variable course with remissions and complications. In 50% of cases, it is not possible to achieve sustainable remission. At advanced stages of the disease, a person chooses complete isolation; he may not leave the house for months. Such an existence can hardly be called a full life; in such conditions it is impossible to fully realize oneself and open up.

In 50–70% of cases, agoraphobia is accompanied by depression. This condition is dangerous for suicide. In 20–40% new phobias develop. They make a person withdraw into himself even more.

It is important! If depression is added to the phobia, then the patient must be hospitalized urgently.

Panic attacks with agoraphobia

When agoraphobia and panic attacks are combined, a person tends to avoid public places for fear of another attack and for fear of being disgraced and being alone with his problem. A person is afraid of losing control over the situation, of not being able to cope with panic and its consequences. If a panic attack occurs several times in the same place, then when a person gets there, he will have another attack.

Signs of fear in agoraphobia

With agoraphobia, patients experience several related fears:

• fear of cardiac arrest;
• fear of the indifference of others or the absence of people;
• fear of madness;
• fear of suffocation;
• fear of open and closed doors;
• fear of leaving the house.

How to get rid of agoraphobia?

Treatment is carried out in several stages:

Stage 1. Inspection by specialists.

It is necessary to consult a therapist, cardiologist, neurologist, or psychiatrist. Each specialist must confirm or deny the presence of the disease. When examining to clarify the clinical picture, psychiatrists usually use the following tests: Beck Depression, Anxiety Scale and Sheehan Panic Attack Rating Scale.

Stage 2. Drug therapy.

Treatment is carried out for 3-6 months and consists of selecting tranquilizers and antidepressants that are suitable for the patient.

Medicines prescribed to combat the causes and manifestations of fear of crowds:

• Tranquilizers are used if urgent help is needed. Their advantage is their rapid action and pronounced anti-anxiety activity. Withdrawal syndrome is possible.
• Antidepressants mitigate the course of agoraphobia, especially in patients with concomitant depression. Helps cope with the anxiety of anticipating an attack.
• Neuroleptics are used when agoraphobia is accompanied by delusional ideas.
• Norms stabilize the emotional background.
• Beta blockers are maintenance therapy drugs with a moderate anti-anxiety effect.

Stage 3. Psychotherapy.

The methods commonly used are cognitive behavioral therapy, neurolinguistic programming, gestalt therapy, and Ericksonian hypnosis.

Stage 4. Physiotherapy.

A phobia not only has an emotional impact, but also a physical one. The disease mainly affects the patient's muscles. Therefore, it is important to do gymnastics in the morning, walk more, and take a massage course. This will help normalize sleep and stabilize the emotional background.

Causes of agoraphobia

The causes of agoraphobia can be divided into several groups. Let's take a closer look at them.

Genetic factors

In half of the cases, the phobia is inherited. Moreover, the likelihood of genetic inheritance remains even if someone in the family suffered from any anxiety disorder.

Constitutional factors

In this case, we are talking about the psychological constitution of the individual, that is, a combination of temperament, character and other characteristics. Mental characteristics explain why people react differently to the same stress. People who are prone to isolation and have increased anxiety are more susceptible to the negative effects of stress.

Stress and traumatic situations

Agoraphobia develops against a background of prolonged stress. The effect of the stimulus may be weak, but if this effect occurs systematically over a long period of time, the human psyche becomes depleted. An example of chronic stress: conflicts in the family, problems at work. This becomes the basis for the development of anxiety disorders as such.

In some cases, the cause may be an acute one-time shock that has turned into psychological trauma, for example, a real situation in which a person became ill in the square and no one could come to the rescue. In this case, the likelihood of developing agoraphobia is higher.

Having another anxiety disorder

Agoraphobia is often combined with panic disorder and social phobia (fear of public performances). Less commonly, agoraphobia is combined with logophobia (fear of talking), aquaphobia (fear of water), acrophobia (fear of heights) and other phobias.

Accented personality type

Accentuations are overly expressed character traits. Phobias develop against a background of suspiciousness, anxiety, and suspicion. Accentuations are considered a borderline state between normality and pathology; without control and correction they develop into neuroses. People with an avoidant (anxious) personality type have a higher risk of developing agoraphobia than people with other accentuations.

Psychoanalytic concept of agoraphobia

The founder of psychoanalysis, Freud, suggested that any phobia, also known as neurosis, is the result of an intrapersonal conflict. The roots of this conflict go back to childhood or adolescence. Anxiety is the result of a conflict between personal desires and inhibitions. The longer the tension persists, the stronger the severity of the conflict. Later, mental manifestations are joined by physical ones: trembling, a feeling of suffocation, shortness of breath, pain, etc.

Pathological heredity

Initially, it was believed that the main reason for the development of phobias was a hereditary factor. Studies were conducted in which it was possible to find out that the disease occurs more often in identical twins than in fraternal twins. However, later the equal influence of heredity and the influence of the social environment was recognized.

Manifestation of agoraphobia

Agoraphobia is a fear accompanied by strong somatic manifestations when a person is in certain places and situations:

• in an open space (for example: in a square),
• in public places (for example: in a cafe),
• at large public events (for example: at a stadium),
• in case of a large crowd of people (for example: in a queue or public transport),
• when a person may be under the “close attention” of others,
• with the doors and windows of the house open,
• on deserted deserted streets, where there will be no one to help him,
• when traveling alone,
• when there is no opportunity to quickly return to a safe (comfortable) place.

Sometimes agoraphobia acts as a kind of defense mechanism against the existing fear of facing aggression or accusations from others, anxiety about disgrace and being criticized by others, uncertainty about the correctness of one’s behavior and its compliance with social norms.

At the onset of the disease, in a certain situation, a person first experiences an incomprehensible and previously unexperienced attack of severe panic, accompanied by intense vegetative symptoms. These sensations are alarming, frightening and disorienting for the person. A stereotype is fixed at a subconscious level, for example: “being on the street, outside the house is dangerous.” Succumbing to his programmed attitudes, the person tries to protect himself from the effects of stressors: he stops visiting places that frighten him, or does not go out at all. A person tries not to perform any actions, avoids situations in which he could lose control of himself in the presence of other people, so as not to draw attention to his person.

Attacks of agoraphobia often do not manifest themselves when in a frightening situation, if the patient is not alone, but with a companion. Russian psychiatrists conducted an interesting experiment: they asked the patient to cross a crowded square twice. For the first time, the patient had to move with a person close to him, whom he completely trusts. He had to make the second “transition” on his own. In the first case, anxiety was minimal, and in some cases it was completely absent. The second “campaign” was accompanied by all the symptoms of panic attacks.

Diagnosis of agoraphobia

In the International Classification of Diseases (ICD), fear of open space in psychiatry is assigned code F 40.0. The diagnostic criteria for the disease are also indicated there:

1. Anxiety. Appears in any situation when a person leaves the house.
2. Autonomic manifestations: tachycardia, sweating, trembling, dry mouth, feeling of suffocation, nausea or vomiting, abdominal or chest pain. To make a diagnosis, the simultaneous presence of at least two vegetative symptoms is necessary, and one of them must be from among the first four signs.
3. Avoidance of public places and situations related to this. The patient refuses work, rest, and other things in order to avoid a traumatic situation.
4. Distress, tension in a situation that causes anxiety and at the very thought of it. The patient realizes that his anxiety and panic are irrational, but still does everything possible to avoid the situation.

Agoraphobia in combination with panic disorder is assigned code F 40.01. This type has its own diagnostic criteria:

1. A panic attack, which is manifested by the following symptoms: fear of dying, fear of going crazy during an attack, shortness of breath, pain or other discomfort in the chest, dyspepsia, dizziness and weakness, fluctuations in feelings of hot and cold. To make a diagnosis, at least 4 of these symptoms must be present.
2. Feelings of fear and anxiety when being in a public place. Fear at the thought that a person will find himself in a public place from which he cannot get out, or in which no one can help him. Such people experience fear of leaving home, crowds, bridges, public transport or the road itself.

Test for agoraphobia

Additionally, when diagnosing agoraphobia, it is suggested to take the Spielberg-Hanin test for anxiety level. The technique consists of two parts. In the first part you need to answer how you feel at the moment, in the second part - how you usually feel. In each part you need to answer 20 statements. After that, a score is calculated on two scales: personal anxiety and situational anxiety. The result is then interpreted according to the attached key.

It is important! During the diagnostic process, the doctor collects anamnesis, finds out what precedes attacks of fear and how they manifest themselves. In addition, the client’s life history is studied, with special attention paid to finding a protracted conflict.

Diagnosis of a phobia

There is no self-test to determine if you have agoraphobia. The diagnosis can only be made by a psychiatrist after differential diagnosis. Anxiety and autonomic symptoms should not be secondary to other mental disorders such as social phobia, delusions, obsessive-compulsive disorder and major depressive disorder.

To meet the ICD-10 diagnostic criteria, persistent fear of at least two of the following situations must be observed for at least six months:

• getting into a crowd;
• visiting public places,
• moving outside the home;
• traveling alone.

Avoidance behavior must be pronounced, that is, it must significantly limit social and work activity.

Methods of psychotherapy used in the treatment of agoraphobia

Several psychotherapy methods are used to treat agoraphobia. Let's look at each of them in more detail.

Behavioral psychotherapy

In the process of individual or group training, the client learns new behavior patterns. He is taught relaxation techniques, helped to relax, and then brought face to face with fear. The client first makes a list of frightening situations in order of increasing fear. Getting closer to fear occurs according to this list.

Cognitive psychotherapy in the treatment of agoraphobia

Cognitive psychotherapy involves working on the perception and thinking of an individual. Fear is caused by an inadequate perception of oneself and the situation, erroneous judgments. In 15–20 sessions, a psychologist will be able to correct this. During therapy, the client must understand that fear is caused by the costs of education, individual personality characteristics and developmental specifics, and not by real threats. This awareness helps overcome fear.

Gestalt therapy

Gestalts are human needs. An incomplete gestalt is a violation of the pattern “desire - search for ways to satisfy it - satisfaction - way out of the situation.” To get rid of agoraphobia, you need to find all unfinished gestalts and close them, that is, satisfy all suppressed desires.

Hypnotherapy

Hypnosis is one of the radical methods. The client is immersed in a trance, the specialist inspires the irrationality of his fears, and the patient is taken out of the trance state. The attitude of absence of danger is recorded on a subconscious level.

It is important! Hypnosis is not suitable for people with hysteria, delusions and low susceptibility to suggestion.

Psychodynamic psychotherapy

This method looks for the cause in old conflicts between a person and the outside world. A psychologist helps to discern the problem at the subconscious level and bring it to the conscious level. For this, the method of free association is used - a person says the first thing that comes to mind. There are no restrictions or boundaries. Spoken words and phrases help to find the hidden motives of fear.

Paradoxical intention

The psychologist creates within the individual a desire to do something that scares him. To do this, the specialist uses the method of ironic ridicule.

How to get rid of agoraphobia using paradoxical therapy:

• talk about the symptoms of the disease as vital elements;
• prohibit the client from doing what he is already afraid to do;
• exaggerate the attitude towards symptoms;
• ask the client to teach the psychologist to be afraid (teach agoraphobia).

Sometimes the methods are used in combination.

Eye movement desensitization and reprocessing (EMDR)

According to this theory, every person has a psychophysiological mechanism, the activation of which promotes forgetting and neutralization of negative information. Stress blocks this part of the brain. To unlock the mechanism, you need to make certain movements with your eyes. The exercises are carried out strictly under the supervision of a psychotherapist.

The main causes of agoraphobia

The etiology of agoraphobia is always different in each specific case.
Moreover, one event or factor cannot be said to have triggered the progression of this fear. Most often, several reasons play a role and jointly influence the formation of this disorder. An important factor is that a person with agoraphobia cannot relate his own person to society. It’s impossible to fit into society and distinguish yourself as part of something bigger. It turns out that he cannot determine his place. This may be a consequence of various psychological problems that gradually result in fear.

The most likely causes of agoraphobia:

• Evolutionary memory
  . It is believed that on a subconscious level a person takes into account and remembers the experience of past generations. That is, the protective mechanisms that helped our ancestors survive hundreds or thousands of years ago are present at some minimal level in modern humans. The fear of being in open space, of exposing oneself defenseless and weak, was the strongest for primitive man. The instinct of self-preservation did not allow him to move far from a safe place and risk his own life. Perhaps evolutionary memory works at the level of unconditioned defensive reflexes and a person will be afraid of space and crowds of people as if they threaten his life.
• Antenatal memory
  . It is known that a child in the womb perceives everything around him. He hears voices, other sounds, reacts to emotional shocks and even his mother’s mood. Threats of abortion or premature birth, as well as other antenatal complications of pregnancy, are a threat to the fetus. In this way, a fear of coming out prematurely can be subconsciously formed. The womb is the environment in which the baby feels safe. Any threat of miscarriage is, first of all, a powerful stress for the baby, which can remain for life.
• Depressive state
  . Depression is not just a bad mood. In this state, a rethinking of values ​​in life occurs, the formation of new views and fears. A person delves into himself, his own feelings, looks for the root causes of all troubles and convinces himself of his uselessness. Simply put, it artificially lowers self-esteem and belittles its importance. Therefore, it becomes quite difficult to relate oneself to society, since a person considers himself unworthy.
• Psychological trauma
  . It can cause irreparable consequences to the human psyche and create fears, including agoraphobia. Most often, there is a history of domestic or sexual violence, or a terrorist attack. In fact, any shock to a person that was life-threatening can become a trigger for the formation of a phobia. Therefore, one should study the anamnestic data in detail and determine the presence of psychotrauma, since only working with memories will help get rid of agoraphobia.
• Physical trauma
  . Much less frequently, but still, physical injuries can cause the formation of agoraphobia. This refers to a severe physical injury that has left a psychological mark, and the person is unable to get rid of obsessive experiences. For a phobia of open space to occur, the trauma must be associated with it or a crowd of people. The conditions of traumatization must coincide with those that the person subsequently fears.

How to deal with agoraphobia yourself

It is necessary to get rid of erroneous attitudes and learn psychophysiological self-regulation. The following methods are suitable for independent work.

Understanding the mechanism of agoraphobia

The fear of being alone indicates a lack of trust in people. It is necessary, with the help of auto-training, to form the attitude “I am good, people are good, the world is good” and deal with the root causes of mistrust. Most likely, the problem lies in relationships with parents or other people. We need to remember when a hostile attitude towards the world was formed.

In addition, it is necessary to analyze specific attacks. If panic overtakes you in a specific place, then this is due to the formation of a conditioned reflex: once a panic happened in this place, you remember it, returning here, you remember it and expect a new attack, because of the tension it happens. Your fixation on the problem and attempts to avoid a traumatic situation are to blame.

Stop avoiding space

How to get rid of agoraphobia on your own: break the chain of “place - bad experience - danger - avoidance.” You need to come to that place and replace the bad experience with a good one. Plan what it will be and repeat the new pattern many times.

Don't discuss your problem

Discussing the problem does not produce results. There is no need to think about how bad it is and feel sorry for yourself. You need to make an action plan and start taking action.

It is important! People with anxiety disorders tend to internalize the fears of other fearful people. When communicating with someone who has the same diagnosis, you may begin to fear places that you were not afraid of before.

Relaxation and relaxation

How to fight with relaxation, what methods to use:

• progressive relaxation (alternate tension and relaxation of individual muscle groups);
• breathing exercises;
• visualization;
• alternate concentration and relaxation.

Symptoms

The main symptom of agoraphobia is paroxysmal intense fear. It begins suddenly, usually provoked by an environment or situation that previously caused fear in a person. Agoraphobia is often accompanied by panic attacks.

Patients suffering from agoraphobia try with all their might to avoid places and situations that cause them to feel panicky, and therefore somatic symptoms do not always appear in them. But still they exist, and are quite diverse. These include increased heart rate, rapid shallow breathing, dizziness, trembling, increased sweating, a feeling of heat, ringing in the ears, and possible intestinal upset. These symptoms are caused by a significant increase in the level of adrenaline in the blood, making it difficult for a person to maintain control over himself. Symptoms are diverse and variable; they can appear, disappear, or be replaced by others.

Psychological symptoms are more pronounced. A person experiences fear because:

• his panic can be noticed by others - this causes embarrassment and even a feeling of humiliation;
• death will occur as the heart stops or the lungs stop working;
• Panic can cause loss of sanity - this fear is fueled by the symptoms of depersonalization and derealization that often accompany an attack.

On the psychological side, agoraphobia is accompanied by a person’s lack of self-confidence, low self-esteem, lack of internal control, depressive symptoms, and a persistent feeling of helplessness. Behavioral symptoms can also be identified:

1. The person avoids places and circumstances that cause anxiety. Such avoidance can have varying degrees of manifestation. For example, with a moderate degree, he will persuade himself to ride in a crowded carriage, but will not leave the door.
2. Increased confidence in the presence of another person. For example, a patient tends to go shopping only with a friend or relative. The extreme manifestation is complete intolerance of loneliness.
3. Preventive actions. A person strives to have or do something to counteract factors that cause anxiety. For example, stock up on pills or extinguish fear with alcohol.
4. The desire to escape from a place that causes anxiety or from a stressful situation, to quickly find yourself in the protection of your own home.

With agoraphobia, a person is able to show a critical attitude towards his painful anxieties, which confirms the neurotic nature of the disease. This criticality is lost only at the moment of reaching the maximum degree of anxiety during an attack. Sometimes those suffering from agoraphobia refuse to leave their home, resort to a whole range of protective actions, change jobs or quit them, move to another place, and prefer reclusion to communication.

Agoraphobia and panic attacks are unpredictable, and an attack can occur even in a place that was previously considered comfortable. The disorder is characterized by an undulating course, with remissions and exacerbations. There are also secondary symptoms in the form of anxiety, anticipation of attacks, and avoidance behavior. The presence of depressive symptoms cannot be ruled out. Concomitant depressive disorders pose a risk of suicidal behavior.

Prevention of agoraphobia

For prevention, you need to increase stress resistance: lead a healthy lifestyle, exercise, watch your diet, relax, monitor your work and rest schedule. We must strive to reduce the influence of factors that provoke the development of a phobia.

Provoking factors for agoraphobia

Negative factors include:

• childhood trauma;
• chronic stress;
• psycho-emotional instability;
• psychosomatic diseases;
• difficult life situations (job loss, divorce, accident, bankruptcy);
• alcoholism;
• hormonal changes in the body, including pregnancy and menopause in women;
• long-term use of psychoactive drugs;
• character traits.

Unfavorable character traits: suspiciousness, excessive self-criticism, hyper-responsibility, demanding of oneself, a tendency to self-examination and self-punishment, developed imagination.

How to avoid recurring attacks of agoraphobia

After achieving remission, you need to follow the doctor’s recommendations, attend maintenance courses of psychotherapy, and take pills if necessary. It is important to continue to independently work on fear, change attitudes, and master self-regulation techniques.

Causes

Scientists and psychiatrists have not agreed on what provokes the fear of open space. American luminaries claim that it begins with a panic attack, while in Europe it is generally accepted that it is agoraphobia that arises that causes the development of mental disorders and unreasonable fear, while several causes and factors are identified that can provoke it:

• previously suffered traumatic situations and emotional shocks in crowded conditions or in open areas;
• hereditary predisposition to mental illness;
• weakness of the vestibular system, impairing the ability to navigate and see visually clearly in large spaces or in crowds of people;
• developed imagination, which is why agoraphobia is more often diagnosed in women.

Thus, theoretically, the origin of agoraphobia can be biological, genetic or psychosocial.