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

The 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 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.

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 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.
• 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 it worse. Instead, reassure yourself by accepting that although it may seem embarrassing, and your symptoms may be difficult to deal with, your attack isn't life-threatening.

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

• take regular exercise – exercise can relieve stress and tension and improve your mood
• eat 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 fail to respond to the above 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 solving 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 (see below).

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 to help reduce anxiety.

As part of the programme you may have brief sessions with a CBT therapist (around 20-30 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 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 described above 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

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 it 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 12-15 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.

Therefore, the aim of applied relaxation is 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 from feeling tense and panicky

As with CBT, a course of applied relaxation therapy consists of 12-15 weekly sessions lasting 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

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

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 six 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 symtoms, you may be prescribed a short course of benzodiazepines. These are tranquillisers that are designed to reduce anxiety and promote calmness and relaxation.

Taking benzodiazepines for longer than two weeks in a row isn't usually recommended because it can become addictive if taken for longer.

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.