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A 48-year-old woman presented with a two-year history of a sense of dread and nervousness about leaving home. She attributed the onset of the disorder to a period of being confined to her hotel room for three days on an overseas trip due to a bout of gastroenteritis.

On questioning she described panic attacks characterised by breathlessness, sweating, shaking, palpitations, "jelly" legs, faintness and a fear of loss of control. The attacks were experienced whenever she left the house, leading to avoidance behaviour. There was some associated depressed mood and sleep disturbance, which fluctuated. A probable family history of agoraphobia was noted in the patient's mother and in her 20-year-old daughter. The patient was not taking any drugs at the time of consultation. She reported having received relaxation training, which helped her relax but did not reduce the frequency of panic attacks. Routine biochemical investigations were normal, including thyroid function tests and electrocardiography.

A diagnosis of panic disorder with agoraphobia was made. The patient kept a diary of panic attacks over the next week and noted six attacks. She was prescribed alprazolam 1 mg at bedtime for the first two days, and the dose was titrated to 1 mg twice a day for three days, then 1 mg three times a day for three days. During this time the patient maintained her diary of panic attacks.

On reassessment after a week's treatment, the patient's panic attacks had diminished but were still present. The dose of alprazolam was increased to 4 mg/day in divided doses and the patient was reviewed at weekly intervals. By six weeks there were no further panic attacks. Medication was continued for a further eight weeks.

The patient's phobic avoidance behaviour was addressed by specifically encouraging her to confront phobic situations during drug therapy and by instituting a behavioural management plan, including homework tasks, cognitive restructuring and education about the nature of panic disorder and attacks. At the end of 14 weeks' treatment, a tapered withdrawal schedule for alprazolam was instituted.

An important element of the treatment was the recognition by the patient that the drug therapy would be for a limited time only and that the taper schedule would be flexible depending on the degree of difficulty experienced during the withdrawal process. Withdrawal was successful and the patient did not experience a return of her agoraphobia. The patient's condition over the six months after withdrawal was reviewed regularly.

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