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 half-century,
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 under-recognised 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.