Phobic avoidance/anxiety

Treatment options include medication, psychotherapy (e.g., CBT preferred), or a combination of both. In some cases, pharmacotherapy will follow psychotherapy treatments when full response is not realized. Patients with panic symptoms without agoraphobia may respond to pharmacotherapy alone. Agoraphobic symptoms generally take longer to respond than panic symptoms. The acute phase of PD treatment lasts about 12 weeks and should result in marked reduction in panic attacks, ideally total elimination, and minimal anticipatory anxiety and phobic avoidance. Treatment should be continued to prevent relapse for an additional 12 to 18 months before attempting discontinuation. 6 49 Patients who relapse following discontinuation of medication should have therapy resumed.49... 

Antidepressants have a delayed onset of antipanic effect, typically 4 weeks, with optimal response at 6 to 12 weeks. Reduction of anticipatory anxiety and phobic avoidance generally follows improvement in panic symptoms. PD patients are more likely to experience stimulant-like side effects than patients with depression, and they should be initiated on lower doses (Table 37-6) of antidepressant than those that are used for depression or other... 

Evaluate patients for symptom improvement frequently (e.g., weekly) during the first 4 weeks of therapy. The goal is to alleviate panic attacks and reduce anticipatory anxiety and phobic avoidance with resumption of normal activities. Alter the therapy of patients who do not achieve a significant reduction in panic symptoms after 6 to 8 weeks of an adequate dose of antidepressant or 3 weeks of a benzodiazepine. Regularly evaluate patients for adverse effects, and educate them about appropriate expectations of drug therapy. 

The efficacy of paroxetine, sertraline, and escitalopram was established in large controlled trials.58-60 SSRIs improve social anxiety and phobic avoidance and reduce overall disability. 

Benzodiazepines are used commonly in SAD however, there are limited data supporting their use. Clonazepam has been effective for social anxiety, fear, and phobic avoidance, and it reduced social and work disability during acute treatment.58 Long-term treatment is not desirable for many SAD patients owing to the risk of withdrawal and difficulty with discontinuation, cognitive side effects, and lack of effect on depressive symptoms. Benzodiazepines may be useful for acute relief of physiologic symptoms of anxiety when used concomitantly with antidepressants or psychotherapy. Benzodiazepines are contraindicated in SAD patients with alcohol or substance abuse or history of such. 

Anxiety or phobic avoidance that do not meet criteria for any of the specific anxiety disorders... 

In 1962, Klein and Fink (88) reported that imipramine blocked panic attacks but had only a minor effect on phobic avoidance or anticipatory anxiety. This clinical observation has been validated by approximately 15 double-blind studies, and TCAs have since been studied for their antipanic efficacy. Although many TCAs are effective antipanic agents, they differ in safety and efficacy, a fact that mandates fitting the drug to the individual patient based on the known advantages and potential adverse effects of each TCA (Table 13-4). 

PD and its related symptoms can be quite disabling. The recognition that specific drug therapies can effectively block the panic episodes has brought new found hope for thousands of patients. Optimal outcome, however, often requires the addition of various behavioral techniques to manage all related components of the disorder (e.g., panic attack, anticipatory anxiety, phobic avoidance). 

Diagnosis Spontaneous Panic Attacks Situational Panic Attacks Anticipatory Anxiety Symptoms of Autonomic Arousal Phobic Avoidance... 

Panic disorder is one of the most prevalent psychiatric disorders in industrialized countries. It is often associated with agoraphobia and has an estimated prevalence of between 1% and 6%. The use of imipramine in the treatment of anxiety by Klein and Fink, and the discovery by William Sargant that monoamine oxidase inhibitors (MAOIs) were effective in the treatment of "atypical depression" over 30 years ago led to the investigation of the efficacy of such treatments in patients with panic disorder. Since that time, such drugs have been shown to attenuate the symptoms of panic in addition to those of phobic avoidance and anticipatory anxiety. As both the... 

BZs should be reserved for patients at low risk of substance abuse, those who require rapid relief, or those who have not responded to other therapies. Clonazepam is the most extensively studied BZ for treatment of generalized SAD. It improved fear and phobic avoidance, interpersonal sensitivity, fears of negative evaluation, and disability measures. Adverse effects include sexual dysfunction, unsteadiness, dizziness, and poor concentration. Clonazepam should be tapered at a rate not to exceed 0.25 mg every 2 weeks. Gabapentin was effective for SAD, and onset of effect was 2 to 4 weeks. j8-Blockers blunt the peripheral autonomic symptoms of arousal (e.g., rapid heart rate, sweating, blushing, and tremor) and are often used to decrease anxiety in performance-related situations. For specific SAD, 10 to 80 mg of propranolol or 25 to 100 mg of atenolol can be taken 1 hour before the performance. A test dose should be taken at home on a day before the performance to be sure adverse effects wUl not be problematic. Incomplete response to a first-line agent may benefit from augmentation with buspirone or clonazepam. 

The first goal of treatment is to stop or reduce attacks. However, even when this is successful, anticipatory anxiety and phobias can, and often do, continue unabated. Thus, the second step is to reduce anticipatory anxiety and phobic avoidance using behavioral techniques, especially graded exposure and desensitization (see Preston 1993). These techniques are highly effective, but only after there is good containment of panic symptoms. 

The goals of therapy in the acute phase of treatment are to rednce physiological symptoms of anxiety (e.g., tachycardia, flnshing, and sweating), social anxiety, and phobic avoidance. The dnration of this phase is 4 to 12 weeks, depending on the dmg therapy. 

Phobic avoidance Attempts avoid coming into contact with a specific object or stimulus in an individual who has severe anxiety and fear in regard to the object or stimulus. It is this type of avoidance behavior that... 

CBT treatments for PTSD have been widely researched and experimentally validated (Foa et al. 1991 Follete et al. 1999 Horowitz 1986 Keane 1997 Kulka et al. 1990 Resick and Schnicke 1992 Resick et al 1981). Behavioural approaches emphasize the central role of anxious arousal and phobic avoidance in the PTSD syndrome. For example, the two-factor theory (Kilpatrick et al 1982) proposed that anxiety is conditioned to previously neutral cues at the time of the traumatic event. These cues then serve as subsequent triggers to the post-traumatic stress reaction. Avoidance develops in response to the anxiety and is reinforced by reduction in arousal associated with the avoidance. 

The key feature of specific phobia is an intense and persistent fear of circumscribed situations or specific stimuli (e.g. exposure to animals, blood). Confrontation with the situation or stimulus provokes almost invariably an immediate anxiety response. Often, the situation or stimulus is therefore avoided or endured with considerable dread. Adolescents and adults with this disorder recognize that this anxiety reaction is excessive or unreasonable, but this may not be the case in children. For a diagnosis according to DSM-IV, the avoidance, fear or anxious anticipation of the phobic stimulus must interfere with the persons daily life or the person must be markedly distressed about having the phobia. Further, the phobic reactions are not better explained by another mental disorder, such as, for example, social phobia. 

The core features of social phobia center on the intense, irrational fear of scrutiny of others and the anticipation of humiliation (Table 25-2). Individuals with this disorder avoid or endure with marked distress the phobic situations. They realize that their fear is unreasonable or excessive. The disorder has been divided into subtypes. Individuals who have anxiety in well-circumscribed situations (e.g., public speaking) have been designated as having a performance subtype those who experience anxiety in a broader spectrum of interpersonal social situations are designated as having a generalized subtype of social phobia. As social phobia has become better character-... 

Formerly called simple phobia, specific phobia is a marked, excessive, or unreasonable and persistent fear of a specific object or situation (e g., snakes, heights, thunderstorms). Exposure to the phobic stimulus provokes immediate and intense anxiety that the individual recognizes as excessive or unreasonable. The degree of impairment frequently depends on whether the feared object or situation is commonly encountered or can be easily avoided. The diagnosis should only be made if avoidant behavior interferes with the person s normal routine, social activities, or relationships, or if there is marked distress about having the fear. Differential diagnosis may include the following ... 

Utilizing behavioral therapy that involves exposure and response prevention can be particularly effective in reducing panic symptoms (O Sullivan Marks, 1990). Where systematic desensitization has been used some clients find it particularly helpful when exposure to the anxiety-producing stimuli has been long enough to allow the anxiety to be markedly reduced (Marshall, 1996). Similarly, exposure to the feared stimulus is thought to be most effective when internal and external distractions from the phobic object or situation are minimized (Foa Kozak, 1986). Treatment of this type requires that the client be systematically exposed to the object or situation that provokes the fear and the subsequent avoidance. 

A specific phobia is a circumscribed, persistent, and unreasonable fear of a particular object or situation. Exposure to the phobic stimulus is associated with an acute and severe anxiety reaction. Therefore, despite the fact that individuals with specific phobias recognize that their fear is unrealistic, most adjust their lifestyle so that they can completely avoid or at least minimize this contact. The population prevalence of specific phobias is approximately 10%, with women being two to three times as likely to be affected as men. 

Andrea, the medical consultant in the case study presented above, was determined to confront and overcome her anxiety and consequently, with a little encouragement, was able to put herself back into the situations which triggered her panic attacks in the first place. However, it is not always the case that an individual can confront their fears in this way. Frequently, once an individual has experienced a panic attack or a sequence of panic attacks in a given situation, they want to avoid that situation in case it happens to them again. Where the fear and avoidance of a specific situation becomes persistent and excessive, it is described as phobic anxiety (APA 2000). 

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