A stepwise approach is usually recommended for agoraphobia (and any underlying panic disorder).
The recommended steps are usually:
- Step one: educate yourself about your condition, possible lifestyle changes you can make, and self-help techniques to help relieve symptoms.
- Step two: enrol yourself on what is known as a guided self-help programme.
- Step three: refer yourself or be referred to a more intensive type of therapy such as cognitive behavioural therapy or see if your symptoms can be controlled using medication.
Lifestyle changes and self-help techniques
Often, learning more about agoraphobia and its association with panic disorders and panic attacks can help you better control your symptoms.
For example, there are techniques you can use during a panic attack to bring your emotions better under control. Having more confidence in controlling your emotions may then make you more confident in coping with previously uncomfortable situations and environments.
These self-help techniques are described below.
- Stay where you are, and try to resist the urge to run to a place of safety during a panic attack. If driving, pull over and park where it is 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 that the frightening thoughts and sensations are a sign of panic and will eventually pass.
- Try slow, deep breathing. 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 is not 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 symptoms of a panic attack can often make it worse. Instead, reassure yourself by accepting that although it may seem embarrassing, and your symptoms may be difficult to deal with, your attack is not life-threatening.
Some lifestyle changes can also help, such as:
- taking regular exercise: exercise can relieve tension and stress while improving mood
- eating a healthy diet: a poor diet can make symptoms of panic and anxiety worse
- avoiding using drugs and alcohol: while they may provide short-term relief, in the long term they can make symptoms worse
- avoiding drinks that contain caffeine, such as tea, coffee or cola: caffeine has a stimulant effect and can make your symptoms worse
If your symptoms fail to respond to the above advice, your GP may recommend you enrol on a guided-self help programme. This involves working through self-help manuals detailing the types of issues you might be facing along with practical advice on how to deal with them.
There are also internet-based programmes you can access via a computer.
Guided self-help for agoraphobia is based on cognitive behavioural therapy (CBT), which aims to change unhelpful and unrealistic patterns of thinking to bring positive changes in behaviour (see below for more information on CBT).
In turn, CBT uses a type of therapy known as exposure therapy, which involves being gradually exposed to the feared object or situation and using relaxation techniques to help reduce anxiety.
As part of the programme you may have brief sessions with a CBT therapist (around 20 to 30 minutes) 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 contain 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:
- cognitive behavioural therapy
- applied relaxation
Cognitive behavioural therapy
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 in a more positive way.
For example, many people with agoraphobia have the unrealistic thought that if they have a panic attack it will kill them. So the therapist will try to shift to the more positive thought that having a panic attack may be unpleasant, but it is not fatal and it will pass. This shift in thinking can then 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. So your therapist will set relatively modest goals at the beginning 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 larger 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 a hour.
Applied relaxation is based on the premise that people with agoraphobia and related panic disorder have lost their ability to relax. So the purpose of applied relaxation is to re-teach you how to relax.
This is done using a series of exercises designed to teach you how:
- to spot the signs and feelings of tension
- to relax your muscles to relieve that tension
- to use these techniques in stressful or everyday situations to prevent you from feeling tense and panicky
As with CBT, a course of applied relaxation therapy consists of 12 to 15 weekly sessions lasting a hour.
In some cases, medication can be used as a sole treatment for agoraphobia. In more severe cases medication can also be used in combination with CBT or applied relaxation therapy.
Selective serotonin reuptake inhibitors
If medication is thought to be appropriate you will usually be given a course of selective serotonin reuptake inhibitors (SSRIs).
SSRIs were originally designed to treat depression but have subsequently proved to help treat other mood disorders such as anxiety, feelings of panic and obsessional thoughts.
An SSRI called sertraline is usually recommended for most people with agoraphobia.
There are several side effects of sertraline, including:
Side effects should improve over time, although some can occasionally persist.
If sertraline fails to improve your symptoms then you may be prescribed an alternative SSRI or similar type of medication known as serotonin-norepinephrine reuptake inhibitors (SNRIs).
The length of time you will have to take a SSRI (or SNRI) for will vary depending on your response to treatment. Some people may have to take SSRIs for longer than 6 to 12 months.
When you and your GP decide it is appropriate for you to stop taking SSRIs, you will be weaned off them by slowly reducing your dosage. You should never stop taking your medication unless your GP specifically advises you to.
If you are unable to take SSRIs or SNRIs for medical reasons, or you experience troublesome side effects, another medication called pregabalin may be recommended.
Common side effects of pregabalin include:
If you experience a particularly severe flare-up of feelings of panic, you may be prescribed a short course of a type of medication known as benzodiazepines.
Benzodiazepines are tranquillisers designed to reduce anxiety and promote calmness and relaxation.
However, it is not usually recommended that you take benzodiazepines for more than two weeks in a row as the medication does have the potential to become addictive if taken for longer.