What is Agoraphobia?

Agoraphobia is a very complex phobia usually manifesting itself as a collection of inter-linked conditions. For example many agoraphobics also fear being left alone (monophobia), dislike being in any situation where they feel trapped (exhibiting claustrophobia type tendencies) and fear travelling away from their ‘safe’ place, usually the home.

Signs and Symptoms:

Typical agoraphobia symptoms include fear of:

• Leaving home alone
• Crowds or waiting in line
• Enclosed spaces, such as movie theaters, elevators or small stores
• Open spaces, such as parking lots, bridges or malls
• Using public transportation, such as a bus, plane or train
• Fear or anxiety almost always results from exposure to the situation
  Your fear or anxiety is out of proportion to the actual danger of the situation
• You avoid the situation, you need a companion to go with you, or you endure the situation but are extremely distressed
• You experience significant distress or problems with social situations, work or other areas in your life because of the fear, anxiety or avoidance
• Your phobia and avoidance usually lasts six months or longer
• It usually accompanies panic disorder.

Causes:

Psychological:

• a traumatic childhood experience, such as the death of a parent or being sexually abused
• experiencing a stressful event, such as bereavement, divorce, or losing your job 
• a previous history of mental illnesses, such as depression, anorexia nervosa, or bulimia
• alcohol misuse or drug misuse
• being in an unhappy relationship, or in a relationship where your partner is very controlling.

Other causes are similar to those of panic disorder.

Treatment:

Guided self-help

With guided self-help you work through a CBT-based workbook or computer course with the support of a therapist.

The therapist works with you to understand your problems and make positive changes in your life.

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 session 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 also 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 2 weeks in a row isn’t usually recommended as they can become addictive.