As a follow up to our recent column on panic disorder, this week I would like to talk about agoraphobia - a condition that commonly co-exists with panic disorder.

Agoraphobia literally means 'fear of open or public places'. However, in a clinical setting it is defined as a fear of situations from which escape might be difficult or embarrassing or in which help may not be available in the event of a panic attack.

As mentioned in last week's column, panic attacks are brief but intense periods of fear with many associated physical symptoms. They are extremely frightening to experience and it is not surprising that many people wish to avoid situations that might trigger subsequent attacks.

Understandable though it may be, avoidance of potentially frightening situations is not appropriate and can lead to serious disability.

Frequently, this condition is portrayed in television shows and movies by showing individuals who are housebound and terrified of crowds - although agoraphobia often does exist at this level of severity, it is not always so. For some people with agoraphobia, the avoidance or fear may only exist in one or two specific situations.

Regardless of the extent of the avoidance, agoraphobia is debilitating when it makes a person unable to do things he or she enjoys or that are a necesseary part of daily living.

While agoraphobia can exist without panic disorder, it most often occurs in combination with panic disoder and roughly one third of individuals who experience panic disorder will also develop agoraphobia.

Agoraphobia tends to be a progressive condition that worsens the more it is reinforced or as panic attacks continue to occur in different places and situations. Eventually, there is no place to feel safe from anxiety.

This is why it is important to get effective treatment for both panic disorder and agoraphobia at an early stage.

Fortunately, there are several effective treatments for agoraphobia. Similar to panic disorder, agoraphobia is usually best treated with a combination of cognitive behaviour therapy and medication.

Agoraphobia therapy centres on gradually facing feared situations and increasing exposure to them until the anxiety lessens significantly or disappears. It is crucial that avoided situations are approached in a gradual manner.

Initially, this may involve using a partner, but it should progress to the individual going places and doing things alone.

Typical situations that must be practiced in therapy are things such as gradually increasing the distance away from home - either walking or driving or driving across bridges or on winding roads.

Standing in lineups, sitting in theatres with increasing distance from exits, or going into crowded places are other situations that are commonly avoided and must be approached.

If a panic attack occurs during exposure therapy, individuals are instructed to attempt remaining in the situation until the anxiety lessens rather than immediately leaving the situation and returning home.

For example, if the individual is in the mall when a panic attack occurs, he or she might sit on a bench and wait until the panic fades. Once feelings of anxiety are reduced, the individual may either leave or attempt to continue with the activity.

Progress is often rapid using this approach if the individual is willing to pursue it vigorously. Just as in most areas of life, the more practice, the better the results. Even though the person will experience anxiety in the midst of therapy, the reward is freedom and ability to function normally again.


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