Patient Care Neurology & Psychiatry - November 2007 - (Page 24)

I Specific phobias Treatment resources for specific phobias Self-directed or parent-directed exposure treatment Antony MM, Craske MG, Barlow DH. Mastering Your Fears and Phobias: Workbook. 2nd ed. New York, NY: Oxford University Press; 2006. Antony MM, McCabe RE. Overcoming Animal and Insect Phobias. Oakland, CA: New Harbinger; 2005. Antony MM, Watling M. Overcoming Medical Phobias. Oakland, CA: New Harbinger; 2006. Bourne EJ. Overcoming Specific Phobia: A Hierarchy and ExposureBased Protocol for the Treatment of All Specific Phobias (Client Manual). Oakland, CA: New Harbinger; 1998. Anxiety specialist referrals Anxiety Disorders Association of America: http://www.ADAA.org Association for Behavioral and Cognitive Therapies: http://www.aabt.org State Psychological Associations: http://www.apa.org/practice/refer.html to the phobic stimulus with self-talk that notices and accepts anxious thoughts and arousal may be especially helpful. Pairing desired rewards (eg, a special outing or purchase) with initial exposure can facilitate subsequent exposure through increased incentive and positive reinforcement. injury-injection phobias, often beginning with verbal descriptions or pictures, but progressing to direct exposure to the relevant cues (eg, donating blood). The unique bodily response in these phobias requires special adaptation. Patients are instructed to increase muscle tension or to stimulate memories of angry feelings that can counter the bradycardia and hypotension that occur during exposure.28 When making a referral for CBT, primary care physicians should confirm that the therapist understands this disorder and how it is usually treated. Special considerations for children Most children have normal, transient fears (darkness, intruders, water) that do not lead to the persistent avoidance and distress that characterize phobias. However, onset of most specific phobias does occur during childhood. In one study, 17.6% of children met the criteria for a specific phobia.29 The efficacy of graduated exposure treatment for childhood phobias is well established, sometimes with a single session of exposure treatment.18,30 Treatment may require specialist-directed exposure or, in some cases, facilitation by a supportive and wellinformed parent. Modeling of gradual approach Psychopharmacologic treatment In contrast to the other anxiety disorders, psychopharmacologic treatment rarely has a place in the treatment of specific phobias. Benzodiazepines may detract from exposure and inhibit extinction.31 However, pragmatism is the rule (eg, “But doctor, I have a flight next week.”) Some phobic individuals will not consider initial exposure without feeling bolstered by preemptive use of a benzodiazepine. However, habituation and extinction are context-dependent; that is, patients who attribute their success to medication are less likely to experience durable extinction of the phobia. SSRIs and other antidepressants have demonstrated anxiolytic effects for all the other anxiety disorders but are not an established treatment for specific phobias. A single, small, double-blinded, placebo-controlled study reported the effectiveness of a 4-week trial of paroxetine, 20 mg/d, for specific phobia.32 However, in the 7 years since publication, no replications or supporting data have appeared. A new approach that seeks to augment exposure treatment has received preliminary support.33 Both animal and human studies report that acute administration of D-cycloserine shortly before exposure can enhance the new learning that is necessary for extinction. Two placebo-controlled studies have reported the efficacy of D-cycloserine, 50 mg, in augmenting exposure treatment for fear of heights and for social anxiety disorder.34,35 However, other 24 PATIENT CARE NEUROLOGY & PSYCHIATRY www.patientcareonline.com http://www.ADAA.org http://www.aabt.org http://www.apa.org/practice/refer.html http://www.patientcareonline.com

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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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