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Agoraphobia Treatment

When you have agoraphobia—sometimes called the “fear of fear”—you fear not being able to escape a certain place or situation, such as the subway, movie theater, a large crowd, a long line at the grocery store. Maybe you also fear not having help if you experience distressing physical sensations, which could be anything from symptoms of anxiety to incontinence. This fear leads to avoidance or engaging in safety behaviors, such as asking someone to ride the subway with you or accompany you to the grocery store.

In severe cases, individuals with agoraphobia are unable to leave their homes.

Until the DSM-5 was published in 2013, agoraphobia wasn’t considered a distinct disorder. Instead, it was believed to be part of panic disorder, such that some individuals were diagnosed with panic disorder with agoraphobia. Panic disorder involves regularly experiencing sudden, seemingly out-of-the-blue panic attacks. For instance, individuals feel out of control and experience trouble breathing, lightheadedness, sweating, and shakiness or numbness.

Agoraphobia is indeed a separate and often debilitating illness. Sometimes, it does co-occur with panic disorder. Agoraphobia also can co-occur with other conditions, including anxiety disorders and major depression.

Fortunately, individuals with agoraphobia can get better and recover. Psychotherapy is the treatment of choice for agoraphobia. Medication can be helpful, especially if you’re struggling with symptoms of panic. But, unlike medication, psychotherapy offers long-term benefits.

 

Psychotherapy

Because agoraphobia wasn’t considered a separate disorder until 2013 when the DSM-5 was published, there’s very little research that exclusively examines agoraphobia. Most of the research is on panic disorder with agoraphobia, so the recommended treatments tend to focus on that condition.

Cognitive behavioral therapy (CBT) is highly effective for individuals who have panic disorder with agoraphobia. In particular, what appears to be especially powerful is exposure-based therapy, a type of CBT.

Exposure-based therapy involves being gradually and systematically exposed to different agoraphobic situations, from the least to the most anxiety provoking. You move through this hierarchy of activities at your own pace. Once you’ve successfully completed one level, you move on to the next one until you’ve successfully completed that, and so on.

Another critical aspect is reducing your reliance on safety behaviors, which might include checking for exits, bringing others with you, and carrying a full or empty medicine bottle.

Exposure therapy also includes interoceptive exposure, which involves bringing about feared physical symptoms, such as sweating, hyperventilating, and dizziness. Eventually, when you’re ready, feared sensations are paired with feared situations. In other words, physical sensations are induced when you’re taking the subway, at the movie theater, in line at the grocery store, or anywhere else that typically sparks anxiety.

In addition, in CBT, you’ll gain an understanding of the nature of your anxiety, learn to restructure unhelpful thoughts and catastrophic beliefs that only perpetuate and deepen your anxiety, and practice relaxation techniques.

If someone doesn’t respond to exposure-based therapy, another option is panic-focused psychodynamic psychotherapy extended range (PFPP-XR). Research has found PFPP-XR to be effective for anxiety disorders, including panic disorder with agoraphobia. In 24 biweekly sessions, individuals gain a deeper understanding of their anxiety, exploring its origins along with the underlying feelings and conflicts of their symptoms. This journal article features a case example that illustrates how PFPP-XR benefits a person struggling with severe and persistent panic attacks with agoraphobia.

 

Medications

Little to no research exists on the efficacy of medication for agoraphobia on its own. Instead, again, studies have looked at the effects in individuals with panic disorder with (or without) agoraphobia.

Your doctor might prescribe medication to prevent and reduce panic symptoms, if you have them. A selective serotonin reuptake inhibitor (SSRI) is the initial treatment for panic disorder. SSRIs that have been approved by the U.S. Food and Drug Administration (FDA) for treating panic disorder are fluoxetine (Prozac), paroxetine (Paxil), and sertraline (Zoloft). Your doctor might prescribe one of these medications, or a different SSRI.

Or they might prescribe another medication that’s been FDA-approved for treating panic disorder: venlafaxine (Effexor XR), a serotonin and norepinephrine reuptake inhibitor (SNRI).

Common side effects of SSRIs and SNRIs include nausea, headache, dry mouth, dizziness, nervousness or agitation, insomnia, and sexual dysfunction (such as decreased sexual desire or delayed orgasm). In some people, venlafaxine may increase blood pressure.

Benzodiazepines, another class of medication, can reduce symptoms of anxiety right away. However, they also have an increased risk for abuse and dependence, and they can interfere with cognitive behavioral therapy (CBT). If they’re prescribed, it’s typically short term. Common side effects of benzodiazepines include dizziness, drowsiness, impaired coordination, and confusion. Because benzodiazepines are so fast acting, when you stop taking them, they can boost anxiety and trigger other adverse effects, such as insomnia and tremors.

Two other classes of medication have been found to be helpful for panic disorder: tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs). However, both are often difficult to tolerate because of their side effects. For instance, the common side effects of TCAs include fatigue, blurred vision, weakness, and sexual dysfunction. MAOIs require dietary restrictions. People must avoid foods high in tyramine, such as pepperoni, lunch meat, yogurt, aged cheeses, pizza, and avocado.

It’s important to have a thorough discussion with your doctor about potential side effects, drug interactions (if you’re currently taking medication), and any other concerns you might have about taking medication. It’s also important to take your medication as prescribed. For example, abruptly stopping an SSRI, SNRI, or TCA can trigger discontinuation syndrome (also known as withdrawal), which means you can experience flu-like symptoms, along with dizziness, anxiety, lethargy, sweating, headaches, and insomnia. If you’d like to stop taking your medication, talk to your doctor so you can do so gradually.

 

Self-Help Strategies for Agoraphobia

Avoid alcohol and other substances. Some people may turn to substances to quiet their anxiety, which can make matters worse. For instance, alcohol fractures sleep and spikes anxiety as the effects wear off.

Work through a workbook. Self-help books can help you gain a deeper, fuller understanding of agoraphobia and learn the specific tools and skills to get better. For example, Anxiety UK offers a free agoraphobia workbook that you can download at this link. You also might check out The Agoraphobia Workbook: A Comprehensive Program to End Your Fear of Symptom Attacks or Overcoming Panic and Agoraphobia: A Self-Help Guide Using Cognitive Behavioral Techniques

Turn to others. Surround yourself with supportive people. You also might find it helpful to attend an in-person support group or use an online forum to share your experiences, trade tips, and remember that you’re absolutely not alone (such as this anxiety forum on Psych Central).

Try a mental health app. You might start your search at the Anxiety and Depression Association of America, which asked mental health professionals to review and rate different anxiety-related and wellness apps.

 

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

Busch, F.N., Milrod, B.L. (2013). Panic-focused psychodynamic psychotherapy–extended range. Psychoanalytic Inquiry, 33,6, 584-594. DOI:10.1080/07351690.2013.835166.

Craske, M. (2019, March 14). Psychotherapy for panic disorder with or without agoraphobia in adults. UpToDate.com.

https://www.uptodate.com/contents/psychotherapy-for-panic-disorder-with-or-without-agoraphobia-in-adults.

Hofmann, S.G. (2017). Panic disorder and agoraphobia. Reference Module in Neuroscience and Biobehavioral Psychology, 1-5.  DOI: http://dx.doi.org/10.1016/B978-0-12-809324-5.05372-4.

Roy-Byrne, P.P. (2019, February 15). Pharmacotherapy for panic disorder with or without agoraphobia in adults. UpToDate.com. Retrieved from https://www.uptodate.com/contents/pharmacotherapy-for-panic-disorder-with-or-without-agoraphobia-in-adults.

 Schroeder, M.O. (2017, March 28). Putting agoraphobia behind you. US News and World Reports. Retrieved from https://health.usnews.com/wellness/mind/articles/2017-03-28/putting-agoraphobia-behind-you.

Yasgur, B.S. (2018, February 28). Agoraphobia: An evolving understanding of definitions and treatment. Psychiatry Advisor. Retrieved from https://www.psychiatryadvisor.com/home/topics/anxiety/agoraphobia-an-evolving-understanding-of-definitions-and-treatment.


Margarita Tartakovsky, M.S.

Margarita Tartakovsky, M.S. is an Associate Editor and regular contributor at Psych Central. Her Master's degree is in clinical psychology from Texas A&M University. In addition to writing about mental disorders, she blogs regularly about body and self-image issues on her Psych Central blog, Weightless.

APA Reference
Tartakovsky, M. (2020). Agoraphobia Treatment. Psych Central. Retrieved on October 23, 2020, from https://psychcentral.com/anxiety/agoraphobia-treatment/
Scientifically Reviewed
Last updated: 1 Jul 2020 (Originally: 3 Aug 2019)
Last reviewed: By a member of our scientific advisory board on 1 Jul 2020
Published on Psych Central.com. All rights reserved.