Patient Care Neurology & Psychiatry - November 2007 - (Page 23)

Specific phobias I phobia of bridges or heights. Depending on the phobic content, (eg, fear of the dark, assault, or driving), screen for a trauma history that could be relevant to symptom onset or perpetuation. Cognitive behavioral treatment The hallmark of CBT for specific phobias is graduated exposure to the feared situation or object. Graduated exposure may be imaginal or in vivo, self-conducted or specialist-directed, via actual or virtual reality cues, and/or interoceptive. Typically, willingness to confront a hierarchy from lesser to greater fear-arousing situations leads to gradual habituation and, often, extinction of the fear response. Animal research suggests that extinction is not the erasure of fear-conditioned memories but rather the formation of new, competing memories that dampen or eliminate the fear response.17 Recent reviews have documented the effectiveness of CBT for specific phobias in both children and adults.18,19 For example, 14 controlled studies of in vivo exposure for specific phobias have consistently demonstrated benefit. Indeed, in vivo exposure results in good treatment outcome for most types of specific phobias if it is sustained until a brief period of minimal to no anxiety.19 Although in vivo exposure is the standard, a large study of dog phobics suggested that imaginal exposure was equally effective.20 Two studies suggested no difference between in vivo and virtual reality exposure, but the latter may be helpful for phobias in which repetitive in vivo exposure is difficult (eg, flying).19 Outcomes may be comparable whether exposure treatment is self- or specialist-conducted.21 Self-help approaches yield greater benefit for specific phobias than for other anxiety disorders (see “Treatment resources for specific phobias,” page 24).22,23 Facing one’s distress may be less daunting with preparatory cognitive therapy that addresses distorted risk assessments, anxiety-escalating self-talk, feelings of being overwhelmed, and the demoralization that accompanies chronic avoidance. Anxiety management skills (eg, diaphragmatic breathing, staying in the moment, observing fluctuations in anxiety, letting go of the need to control anxiety) encourage In contrast to the other anxiety disorders, psychopharmacologic treatment rarely has a place in the treatment of specific phobias. acceptance of distress without escape or distraction in order to facilitate extinction. The emphasis in CBT has shifted to encouraging willingness to seek and accept anxiety rather than to control it through conscious effort or relaxation techniques. Both functional MRI and positron emission tomography studies suggest that exposure-based CBT modifies the dysfunctional neural circuitry that underpins specific phobias.24,25 CBT has yielded changes in brain areas associated with both automatic processing (amygdala) and evaluatory processing of fear stimuli (insula and anterior cingulate cortex).26,27 Exposure treatment may fail because of • Initial refusal • Premature dropout • Deliberate distraction or substance use during exposure • Repeated escape before arousal wanes • Sporadic rather than repetitive exposure. Relapse after successful treatment is likely if intermittent self-conducted exposure is abandoned. Blood-injury-injection phobia: A special case In contrast to the bodily arousal (eg, tachycardia) observed in response to most phobic stimuli, exposure to blood-injury-injection cues provokes the opposite bodily response: Initial hyperarousal (perhaps coupled with disgust), followed moments later by abrupt bradycardia and hypotension. This response is probably the remnant of evolutionary adaptation comparable to the reflexive immobility of a rabbit caught in the jaws of a fox (in which the absence of movement and stanched blood flow promote survival). If the vasovagal response is marked, syncope can result and may contribute to subsequent phobic conditioning. Exposure treatment is also utilized for blood- NOVEMBER 2007 PATIENT CARE NEUROLOGY & PSYCHIATRY 23

Table of Contents Feed for the Digital Edition of Patient Care Neurology & Psychiatry - November 2007

Patient Care Neurology & Psychiatry - November 2007 Contents Research Digest Medicine in the News The 15-Minute Visit Dementia workup and treatment: Do the drugs really work? Help for Your Patients Who Suffer from Specific Phobias Clinical Clips Case & Comment The Science of Healing Classified Advertising

Patient Care Neurology & Psychiatry - November 2007

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