Specific phobia treatment

When is medication indicated in the treatment of psychiatric illness There is no short answer to this question. At one end of the continuum, patients with schizophrenia and other psychotic disorders, bipolar disorder, and severe major depressive disorder should always be considered candidates for pharmacotherapy, and neglecting to use medication, or at least discuss the use of medication with these patients, fails to adhere to the current standard of mental health care. Less severe depressive disorders, many anxiety disorders, and binge eating disorders can respond to psychotherapy and/or pharmacotherapy, and different therapies can target distinct symptom complexes in these situations. Finally, at the opposite end of the spectrum, adjustment disorders, specific phobias, or grief reactions should generally be treated with psychotherapy alone. 

SSRIs have been approved for the treatment of the majority of anxiety disorders, except agoraphobia and specific phobia. The mechanisms of action responsible for SSRIs anxiolytic activity remain to be fully delineated. Understanding of pre- and postsynaptic receptor regulation with chronic treatment and cross-system effects are critical in furthering our imderstanding of these drugs. Increasing specificity may improve clinical efficacy. 

A larger set of placebo-controlled studies show conclusively that imipramine is also effective for the treatment of panic disorders. Other agents shown to be effective in panic disorders include the SSRIs paroxetine, sertraline, fluvoxamine, fluoxetine and citalopram. Generally, initial treatment of moderate to severe panic disorders may require the initiation of a short course of benzodiazepines e.g. clonazepam (0.5 1 mg twice daily), and an SSRI. The patient will obtain immediate relief from panic attacks with the benzodiazepine whereas the SSRI may take 1 6 weeks to become effective. Once a patient is relieved of initial panic attacks, clonazepam should be tapered and discontinued over several weeks and SSRI therapy continued thereafter. There are no pharmacological treatments available for specific phobias, however controlled trials have shown efficacy for several agents, e.g. phenelzine, moclobemide. clonazepam, alprazolam, fluvoxamine. sertraline and paroxetine in the treatment of social phobia (Roy-Byrne and Cowlev, 2002). 

Roy-Byme, P., Cowlty, D.S. Pharmacological treatments for panic disorder, generalized anxiety disorder, specific phobia, and social anxiety disorder. In Nathan, P.E., Gorman, J.M. (eds) A Guide to Treatments that Work. Oxford University Press, Oxford, 2002, pp. 337-365. 

Available evidence indicates that systematic desensitization and in vivo exposure are the most effective treatment methods available. Pharmacological treatment has not been well investigated, but studies involving antidepressants suggest that TCAs and MAOIs are ineffective ( 85, 86 and 87). In addition, three studies suggest that sedative-hypnotic anxiolytics may undermine the behavioral treatment of specific phobias (88, 89 and 90). In another study, volunteers with animal phobias were exposed to their phobic object 1.5 hours after administration of either tolamolol, diazepam, or placebo in a double-blind crossover design. Tolamolol abolished the stress-induced tachycardia but had no beneficial behavioral or subjective effects ( 91). 

A specific phobia is a fear of a circumscribed object or situation, for instance fear of spiders, fear of flying. The diagnosis is not usually in doubt. A course of treatment by a trained therapist, involving graded exposure to the feared stimulus is the treatment of choice and can be very effective. By its nature such therapy generates severe anxiety and a benzodiazepine may permit patients fully to engage in therapy. 

Specific phobias generally are not treated with psychotropic medications. Social phobias often respond well to cognitive-behavioral treatment. When medications are used, the clinician has two main alternatives For occasional use—for example to reduce anxiety associated with theatrical performances or public speaking—the beta blocker propranolol has been shown to be quite effective. This drug does little to alter the cognitive aspects of anxiety (worry), but effectively reduces many physiological symptoms such as rapid heart rate. Anxious patients treated with propranolol take the medication only prior to the stressful event, ingesting 20-80 mg about one hour before. 

Specific phobias are perhaps the most familiar of the anxiety disorders, and are char-, acterized by a disproportionate fear of an object (e.g., spider, snake) or situation (e.g., flying, receiving an injection). When the stimulus is confronted it elicits an intense anxiety reaction, which the sufferer recognizes to be excessive but is unable to moderate. Prophylactic use of anxiolytics for predictably stressful situations is helpful, but in the longterm, medication is less successful than behavioral therapy in the treatment of specific phobias. 

United States, the 1-year prevalence rate for anxiety disorders was 13.3% in persons aged 18 to 54 years and 10.6% in those over age 55 years. Specific phobias were the most common anxiety disorder, with a 12-month prevalence of 8% however, patients were not seriously impaired in terms of daily functioning, and few persons sought treatment. The 1-year prevalence of generalized anxiety disorder (GAD) was 2.8%, that of panic disorder was 1.7%, and that of social anxiety disorder (SAD) was 3.7%. ... 

Systematic desensitization and exposure techniques are used to assist those who suffer from anxiety symptoms however, this technique is generally regarded as the treatment of choice for specific phobias (Plaud Vavrovsky, 1998). Using this in combination with in vivo techniques (real-life experiences) appears to have an even greater effect than that produced by simulating an experience in the office setting only (Marshall,... 

Treatment of specific phobia is based on cognitive-behavioral therapy (CBT) and/or pharmacotherapy, which includes principally antidepressants. ... 

A few regimens have been studied with various degrees of success in specific phobia however, to date, there is no definitive established treatment of specific phobia. 

Antidepressants are small heterocyclic molecules entering the circulation after oral administration and passing the blood-brain barrier to bind at numerous specific sites in the brain. They are used for treatment of depression, panic disorders, generalized anxiety disorder, social phobia, obsessive compulsive disorder, and other psychiatric disorders and nonpsychiatric states. 

The selective serotonin reuptake inhibitors (SSRI) have been used in adults for a wide variety of disorders, including major depression, social anxiety (social phobia), generalized anxiety disorder (GAD), eating disorders, premenstrual dysphoric disorder (PMDD), post-traumatic stress disorder (PTSD), panic, obsessive-compulsive disorder (OCD), trichotillomania, and migraine headaches. Some of the specific SSRI agents have an approved indication in adults for some of these disorders, as reviewed later in this chapter. The SSRIs have also been tried in children and in adults for symptomatic treatment of pain syndromes, aggressive or irritable ( short fuse ) behavior, and for self-injurious and repetitive behaviors. This chapter will review general aspects of the SSRIs and discuss their approved indications in children and adolescents. 

Although early anecdotal reports suggested the usefulness of this class of agents, overall studies of (3-blockers in clinical populations have not been supportive of their efficacy in social phobia. Falloon et al. [1981] compared propranolol and placebo, both used in conjunction with social skills training. This study failed to find any difference between the two treatment groups. However, the study was compromised by small sample size and failure to select subjects using specific diagnostic criteria for social phobia. 

Munjack et al. [1991] conducted a pilot study of buspirone in the treatment of social phobia. Subjects meeting DSM-lll-R criteria for social phobia were entered into an 8-week, open-label trial. Buspirone was started at 5 mg twice a day and increased by 5 mg every 2-3 days to a maximum dosage of 60 mg/day, or until side effects prevented further dose escalation. Of the 17 subjects entered in this study, 11 completed it. The 6 dropouts resulted from lack of responsiveness, adverse effects, inability to attend appointments, and a loss to follow-up. At week 6, of the 11 subjects completing the trial, 5 reported a little and 6 endorsed moderate change in their symptomatology. At the end of week 8, two subjects reported a little, 5 noted moderate, and 4 endorsed marked improvement. Although the global measures demonstrated the above results, instruments used to measure the features specific to social phobia demonstrated mixed results. 

The earliest and unfortunately still one of the commonest treatments of social phobia is self-medication with alcohol. The behaviorally disinhibiting actions of alcohol allow many social phobics to engage in social contacts that would otherwise be impossible. Legitimate therapeutic drugs for social phobia are now being discovered at a fast pace (Fig. 9—7). In fact, one of the SSRIs (paroxetine) already has been formally approved for use in the treatment of social phobia, and several other SSRIs and antidepressants are rapidly accumulating evidence of their efficacies in this condition as well. Specifically, studies of all five SSRIs (paroxetine, fluvoxamine, fluoxetine, sertraline, and citalopram) have indicated their efficacy in social phobia. Currently, SSRIs are considered first-line treatments for social phobia. 

Although the BZs show a robust anxiolytic effect, many of the clinical trials were conducted before the currently used divisions between specific anxiety disorders became available (4). As a result, knowledge of their efficacy in discrete anxiety disorders is incomplete. In clinical practice (48) BZs are widely used for GAD and as prophylactics in situational anxiety, with diazepam (l)historically being the most popular choice. Others in common use are chlordiazepoxide (2), clorazepate (3), lorazepam (4), alprazolam (5), oxazepam (6), bromazepam (7), and clonazepam (8) Response rates are high and the onset of therapeutic effect is immediate. This is an important contrast to the MAOIs, TCAs, and SSRIs, where an anxiolytic effect is not seen for several weeks. Although not specifically approved for this disorder. BZs are also effective in social phobia, with clonazepam (49) showing a superior response rate to that of alprazolam (50). Alprazolam and clonazepam are the only BZs approved for the treatment of panic disor-... 

Boerner, RJ. (2001) Kava kava in the treatment of generalized anxiety disorder, simple phobia and specific social phobia. Phytotherapy Research, 15, 646-647. 

The antihistamine hydroxyzine is an effective antianxiety agent, but only at doses (-400 mg/day) that produce marked sedation (see Chapter 24). Propranolol and metoprolol, lipophilic fi adrenergic receptor antagonists that enter the CNS, can reduce the autonomic symptoms (nervousness and muscle tremor) associated with specific situational or social phobias but do not appear to be effective in generalized anxiety or panic disorder (see Chapter 10). Similarly, other antiadrener-gic agents, including clonidine, may modify autonomic expression of anxiety but are not demonstrably usfful in the treatment of severe anxiety disorders. 

Several selective serotonin reuptake inhibitors (SSRIs), including escitalopram, fluoxetine, fluvoxamine, paroxetine, and sertraline (Fig. 22.21), are effective as first-line treatment cf seme anxiety disorders, with the purported advantage that they lack the addictive preperties cf benzediazepines (135). Specifically, the SSRIs have been shown to be effective in obsessive-ccmpulsive diserder (139), panic disorder (140), and social phobia (141). The mechanism of action of these agents in anxiety may differ with their role in the treatment of depression however,... 

Cross-situational anxiety differs from the situation-specific anxiety described in the previous chapter, in that it involves multiple anxieties and worries that affect performance across a wide range of work and non-work-related situations and tasks. Examples of cross-situational anxiety include disorders such as uncued panic attacks, agoraphobia, generalized social phobia and generalized anxiety disorder (American Psychiatric Association [APA] 2000). The treatment of panic attacks and phobias was discussed in the previous chapter. This chapter thus focuses on the formulation and treatment of generalized anxiety disorder (GAD). GAD warrants specific attention since it requires quite a different CBT treatment approach from the other forms of anxiety already mentioned. Two other anxiety syndromes which have been found to be particularly prevalent among health workers, namely post-traumatic stress disorder (PTSD) and health anxiety, are also discussed in this chapter. 

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