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CNS Drugs. 2007;21(9):741-64.

Diagnosis and treatment of agoraphobia with panic disorder.

Perugi G, Frare F, Toni C. Department of Psychiatry, University of Pisa, Pisa, Italy. gperugi@psico.med.unipi.it

Abstract
Agoraphobia with panic disorder is a phobic-anxious syndrome where patients avoid situations or places in which they fear being embarrassed, or being unable to escape or get help if a panic attack occurs. During the last halfcentury, agoraphobia has been thought of as being closely linked to the recurring panic attack syndrome, so much so that in most cases it appears to be the typical development or complication of panic disorder. Despite the high prevalence of agoraphobia with panic disorder in patients in primary-care settings, the condition is frequently underrecognised and under-treated by medical providers. Antidepressants have been demonstrated to be effective in preventing panic attacks, and in improving anticipatory anxiety and avoidance behaviour. These drugs are also effective in the treatment of the frequently coexisting depressive symptomatology. Among antidepressant agents, SSRIs are generally well tolerated and effective for both anxious and depressive symptomatology, and these compounds should be considered the first choice for short-, medium- and long-term pharmacological treatment of agoraphobia with panic disorder. The few comparative studies conducted to date with various SSRIs reported no significant differences in terms of efficacy; however, the SSRIs that are less liable to produce withdrawal symptoms after abrupt discontinuation should be considered the treatments of first choice for long-term prophylaxis. Venlafaxine is not sufficiently studied in the long-term treatment of panic disorder, while TCAs may be considered as a second choice of treatment when patients do not seem to respond to or tolerate SSRIs. High-potency benzodiazepines have been shown to display a rapid onset of anti-anxiety effect, having beneficial effects during the first few days of treatment, and are therefore useful options for short-term treatment; however, these drugs are not first-choice medications in the medium and long term because of the frequent development of tolerance and dependence phenomena. Cognitive-behavioural therapy is the best studied non-pharmacological approach and can be applied to many patients, depending on its availability.

Treatments and drugs

By Mayo Clinic staff
As with many other mental disorders, agoraphobia treatment typically includes a combination of medication and psychotherapy. Treatment of agoraphobia is often successful, and you can overcome agoraphobia and learn to keep it under control.

Medications Antidepressant and anti-anxiety medications are commonly used to treat agoraphobia and panic symptoms. You may have to try several different medications before you find one that works best for you.

Your doctor is likely to prescribe one or both of the following:

A selective serotonin reuptake inhibitor (SSRI). Drugs in this category that are commonly used to treat agoraphobia include fluoxetine (Prozac, Prozac Weekly), paroxetine (Paxil, Paxil CR) or sertraline (Zoloft).

Another type of antidepressants, such as a tricyclic antidepressant or monoamine oxidase inhibitor. While these drugs may effectively treat agoraphobia, they're associated with more side effects than are SSRIs.

An anti-anxiety medication. Also called benzodiazepines, these drugs including alprazolam (Xanax), clonazepam (Klonopin) and others can help control symptoms of anxiety and panic attacks. However, these medications can cause dependence if taken in doses larger than prescribed or over a longer period of time than prescribed. Your doctor will weigh this risk against the potential benefit of this class of drugs. Both starting and ending a course of antidepressants can cause side effects that mimic the symptoms of a panic attack. For this reason, your doctor likely will gradually increase your dose at the beginning of your treatment, and slowly decrease your dose when he or she feels you're ready to stop taking medication often over the course of a year or more after your agoraphobia symptoms are controlled.

Psychotherapy Several types of psychotherapy or counseling can help agoraphobia. One common therapy used is cognitive behavioral therapy.

Cognitive behavioral therapy has two parts. The cognitive portion involves learning more about agoraphobia and panic attacks and how to control them. You learn what factors may trigger a panic

attack or panic-like symptoms, and what makes them worse. You also learn how to cope with these distressing symptoms, such as using breathing and relaxation techniques.

The behavioral portion of cognitive behavioral therapy involves changing unwanted or unhealthy behaviors through desensitization, sometimes called exposure therapy. This technique helps you safely confront the places and situations that cause fear and anxiety. A therapist may accompany you on excursions to help you remain safe and comfortable, such as trips to the mall or driving your car. Through gradually practicing going to feared places, people with agoraphobia learn that the fears don't come true and that their anxiety goes away with time.

If you have trouble leaving your home, you may wonder(Mayo Clinic Staff) how you can possibly venture out to a therapist's office. Therapists who treat agoraphobia will be well aware of this problem. They may offer initial appointments in your home, or they may meet you in one of your safe zones. They may also offer some sessions over the phone or through e-mail. Look for a therapist who can help you find alternatives to in-office appointments, at least in the early part of your treatment. You may also try taking a trusted relative or friend to your appointment who can offer comfort and help, if needed.

http://www(Peruji, 2007).mayoclinic.com/health/agoraphobia/DS00894/DSECTION=treatments-anddrugs

Bibliography
Mayo Clinic Staff. (n.d.). Mayo Clinic. Retrieved October 15, 2010, from Mayo Clinic Website: http://www.mayoclinic.com/health/agoraphobia/DS00894/DSECTION=treatmentsand-drugs Peruji, G. F. (2007). Diagnosis and treatment of agoraphobia with panic disorder. CNS Drugs , 21 (9), 741-764.