Agoraphobia

A stepwise approach is usually recommended for treating agoraphobia and any underlying panic disorder.

The steps are as follows:

• step one – find out more about your condition, the lifestyle changes you can make, and self-help techniques to help relieve symptoms
• step two – enrol yourself on a guided self-help programme
• step three – undertake more intensive treatments, such as cognitive behavioural therapy (CBT), or see if your symptoms can be controlled using medication

The various treatments for agoraphobia are outlined below. You can also read a summary of the pros and cons of the different treatments for agoraphobia, allowing you to compare your treatment options.

Lifestyle changes and self-help techniques

Learning more about agoraphobia and its association with panic disorder and panic attacks may help you control your symptoms better.

For example, there are techniques you can use during a panic attack to bring your emotions under control. 

Having more confidence in controlling your emotions may make you more confident coping with previously uncomfortable situations and environments.

These self-help techniques are described below.

• stay where you are – try to resist the urge to run to a place of safety during a panic attack; if you're driving, pull over and park where it's safe to do so
• focus – it's important for you to focus on something non-threatening and visible, such as the time passing on your watch, or items in a supermarket; remind yourself the frightening thoughts and sensations are a sign of panic and will eventually pass
• breathe slowly and deeply – feelings of panic and anxiety can get worse if you breathe too quickly; try to focus on slow, deep breathing while counting slowly to three on each breath in and out
• challenge your fear – try to work out what it is you fear and challenge it; you can achieve this by constantly reminding yourself that what you fear isn't real and will pass
• creative visualisation – during a panic attack, try to resist the urge to think negative thoughts, such as "disaster"; instead, think of a place or situation that makes you feel peaceful, relaxed or at ease: once you have this image in your mind, try to focus your attention on it
• don't fight an attack – trying to fight the symptoms of a panic attack can often make things worse; instead, reassure yourself by accepting that although it may seem embarrassing and your symptoms may be difficult to deal with, the attack isn't life threatening

Making some lifestyle changes can also help. For example, ensure you:

• take regular exercise – exercise can help relieve stress and tension and improve your mood
• have a healthy diet – a poor diet can make the symptoms of panic and anxiety worse
• avoid using drugs and alcohol – they may provide short-term relief, but in the long term they can make symptoms worse
• avoid drinks containing caffeine, such as tea, coffee or cola – caffeine has a stimulant effect and can make your symptoms worse

Guided self-help

If your symptoms don't respond to these self-help techniques and lifestyle changes, your GP may recommend enrolling on a guided self-help programme.

This involves working through self-help manuals that cover the types of issues you might be facing, along with practical advice about how to deal with them.

A number of internet-based programmes are also available. For example, Moodjuice is an online resource designed to help you think about emotional problems and work towards resolving them.

Guided self-help for agoraphobia is based on CBT, which aims to change unhelpful and unrealistic patterns of thinking to bring about positive changes in behaviour.

In turn, CBT uses a type of therapy called exposure therapy, which involves being gradually exposed to the object or situation you fear and using relaxation techniques and breathing exercises to help reduce your anxiety.

As part of the programme, you may have brief sessions with a CBT therapist – around 20 to 30 minutes long – over the telephone or face to face. You may also be invited to take part in group work with other people with a history of agoraphobia and panic disorders.

Most self-help programmes consist of a series of goals to work towards over the course of five to six weeks.

More intensive therapies

If the self-help programme hasn't worked, you may be referred for more intensive therapies. There are three main options:

• CBT with a therapist 
• applied relaxation
• medication

Cognitive behavioural therapy (CBT)

Cognitive behavioural therapy (CBT) is based on the idea that unhelpful and unrealistic thinking leads to negative behaviour.

CBT aims to break this cycle and find new ways of thinking that can help you behave more positively. For example, many people with agoraphobia have the unrealistic thought that if they have a panic attack it will kill them.

The CBT therapist will try to encourage a more positive way of thinking – for example, although having a panic attack may be unpleasant, it isn't fatal and will pass.

This shift in thinking can lead to more positive behaviour in terms of a person being more willing to confront situations that previously scared them.

CBT is usually combined with exposure therapy. Your therapist will set relatively modest goals at the start of treatment, such as going to your local corner shop.

As you become more confident, more challenging goals can be set, such as going to a large supermarket or having a meal in a busy restaurant.

A course of CBT usually consists of 12 to 15 weekly sessions, with each session lasting about an hour.

Applied relaxation

Applied relaxation is based on the premise that people with agoraphobia and related panic disorder have lost their ability to relax. The aim of applied relaxation is therefore to teach you how to relax.

This is achieved using a series of exercises designed to teach you how to:

• spot the signs and feelings of tension
• relax your muscles to relieve tension
• use these techniques in stressful or everyday situations to prevent you feeling tense and panicky

As with CBT, a course of applied relaxation therapy consists of 12 to 15 weekly sessions, with each one lasting about an hour.

Medication

In some cases, medication can be used as a sole treatment for agoraphobia. In more severe cases, it can also be used in combination with CBT or applied relaxation therapy.

Selective serotonin reuptake inhibitors (SSRIs)

If medication is recommended for you, you'll usually be prescribed a course of selective serotonin reuptake inhibitors (SSRIs).

SSRIs were originally developed to treat depression, but they've subsequently proved effective for helping treat other mood disorders, such as anxiety, feelings of panic, and obsessional thoughts.

An SSRI called sertraline is usually recommended for people with agoraphobia. Side effects associated with sertraline include:

• feeling sick
• loss of sex drive (libido)
• blurred vision
• diarrhoea or constipation
• feeling agitated or shaky
• excessive sweating 

These side effects should improve over time, although some can occasionally persist.

If sertraline fails to improve your symptoms, you may be prescribed an alternative SSRI or a similar type of medication known as serotonin-norepinephrine reuptake inhibitors (SNRIs).

The length of time you'll have to take an SSRI or SNRI for will vary depending on your response to treatment. Some people may have to take SSRIs for 6 to 12 months or more.

When you and your GP decide it's appropriate for you to stop taking SSRIs, you'll be weaned off them by slowly reducing your dosage. You should never stop taking your medication unless your GP specifically advises you to.

Pregabalin

If you're unable to take SSRIs or SNRIs for medical reasons or you experience troublesome side effects, another medication called pregabalin may be recommended. Dizziness and drowsiness are common side effects of pregabalin.

Benzodiazepines

If you experience a particularly severe flare-up of panic-related symptoms, you may be prescribed a short course of benzodiazepines. These are tranquillisers designed to reduce anxiety and promote calmness and relaxation.

Taking benzodiazepines for longer than two weeks in a row isn't usually recommended as they can become addictive.

Antidepressants

Antidepressant medicine is used to treat depression. For example Fluoxetine, Paroxetine.

Benzodiazepines

Benzodiazepines are a group of medicines used to help sleep, reduce anxiety and as a muscle relaxant. For example, temazepam.

Panic

To panic is to be quickly overcome with a feeling of fear or worry.

Psychotherapy

Psychotherapy is the treatment of mental and emotional health conditions, using talking and listening.

Claire Ledger was diagnosed with agoraphobia after having a panic attack in the street while shopping. 

Claire, who was 26 at the time of this interview, was unable to explain the experience. She initially thought it may have had something to do with where she was, so she stopped going there and began to shop elsewhere. When she had a similar panic attack in another location, she stopped going there, too.

Within five months she'd stopped going to so many places she only felt truly safe at home. She left her job as a nurse and spent the next 2.5 years indoors. She read, watched TV, surfed the web and cared for her husband, who is in a wheelchair, and never went outside.

"When I had the first attack, I didn't know what was happening," says Claire, who lives in Bradford, West Yorkshire. "I was in a shop and felt faint all of a sudden, and had to crouch down to avoid collapsing. I was shaking and felt sick."

Claire went to her GP, who initially thought she was suffering from stress. Claire had just started a new job, recently got married, and was having IVF treatment.

"Every time I went out after that I got this feeling again," she says. "Everywhere it happened, I avoided that place. Instead of thinking it was me, I associated the panic attack with the place where it happened. I was such an outgoing person, the idea that it was all in my head never occurred to me."

Claire was eventually diagnosed with agoraphobia. "I got to a point where my stomach dropped as soon as I woke up," she says. "It's like a feeling of grief and despair. You're shaking, tired, and you don't really feel there. It's like you're watching yourself.

"I tried to get through it, but I reached a stage when even the thought of going into my own garden made me panic. It was like coming up against an invisible wall.

"It was hard on my husband. He's a big sports fan and likes going out to watch live events."

The couple's elderly neighbours would help out with getting food and household supplies. "I felt ashamed that someone in their 70s was doing my shopping," says Claire.

Claire became determined to seek treatment and went on a course of cognitive behavioural therapy (CBT). She found the treatment helpful, but it didn't change her thought process.

What made the difference was talking to other people with agoraphobia, who she contacted through online support groups. "You feel like a freak," she says. "Talking to other people in the same position was what helped me the most. We worked on breaking down our boundaries together."

She became friends with a woman in another town and they would make the same trips together in their respective neighbourhoods, slowly increasing the length of their journeys.

"We would call each other before leaving the house and would remain on the phone to each other until we got back in," says Claire. "Even though she wasn't there in person, her voice was really reassuring."

For the next two years, this was how Claire expanded her boundaries from her doorstep. "My husband changed our mobile provider when he saw the monthly bills I was running up!"

Claire has learned to cope with her moods and has now regained enough confidence to go back to work. "It's important for people to know that you can recover," she says. "You may think it's like a death sentence, but the treatments do work. I never thought I'd return to work.

"I still have my down days, but I've learned to accept that you can't feel your best every day."