Follow-up
Further Inpatient Care
Indicated only for severe cases presenting with acute suicidal ideation and/or attempt. Also, inpatient treatment including detox and/or rehab may be recommended for treatment of secondary drug and/or alcohol abuse or dependence.
Further Outpatient Care
Outpatient follow-up is usually needed through resolution of symptoms. After symptoms are resolved, physician can (1) attempt a taper of medication and therapy and (2) monitor for relapse.
Inpatient & Outpatient Medications
- Continue medication regimen for at least 6-12 months.
- If symptoms have resolved and the patient is not experiencing excessive stress, the physician can taper the patient off medication gradually.
- Psychotherapy usually helps make the transition off medication more successful.
Transfer
Physicians without expertise in conducting behavioral therapy may want to consult with a psychiatric center specializing in treatment of anxiety disorders for guidance on developing a treatment plan or for referral (for more difficult cases).
Deterrence/Prevention
Overwhelming exposure in early childhood (eg, a frightening experience with an aggressive dog) may predispose the child to the development of phobic symptoms. Intervention (psychotherapy or medication) in the early stages of symptom development may be beneficial in preventing worsening of symptoms.
Complications
- Left untreated, social phobia or agoraphobia can result in tremendous morbidity. The patient becomes restricted to the most familiar surroundings (eg, house) or most trusted people (eg, family member, spouse). Therefore, the ability to work and relate to other people is significantly impaired. Significant risk of substance abuse exists with this degree of isolation.
- Patients with specific phobia may also be limited by having to avoid buildings (in the case of acrophobia), elevators (in the case of claustrophobia), or even their own lawn (eg, fear of snakes). Usually, less impairment is observed in specific phobia than in social phobia or agoraphobia.
Prognosis
- Most patients respond to treatment, with good resolution of symptoms.
- Patients with specific phobia often recover to the highest level of functioning, while agoraphobics or social phobics either may have residual symptoms or run a greater risk of relapse even after successful treatment.
- Social phobics with extensive deficits in social skills may not respond well to treatment.
Patient Education
- The treating physician should begin a process of education, not only for the patient but also for family and friends who may be confused about the diagnosis and the need for treatment. Abilities that most people take for granted, such as socializing at gatherings or riding in a small elevator, may seem commonplace, but patients who experience phobias have tremendous difficulty in these areas and can be helped significantly by a caring support system. Family and friends can encourage the patient to confront fears, help the patient when necessary (with medication compliance or confronting fearful situations), and can also learn when to stay out of the way and allow the patient to venture forth on his own.
- Numerous books and self-help groups are available. In addition, patient advocacy groups exist nationwide to provide patients with information, presentations, and conferences. The following Web sites are helpful:
- For excellent patient education resources, visit eMedicine's Anxiety Center. Also, see eMedicine's patient education articles Anxiety, Panic Attacks, and Hyperventilation.
Miscellaneous
Medicolegal Pitfalls
- Patients with social phobia have substantial associated morbidity such as increased suicidal ideation, social isolation, and substance abuse.
- Patients with severe agoraphobia may be housebound and therefore unable to seek out medical attention when needed. Patients with concomitant panic attacks are at higher risk for substance abuse and suicide.
- Many anxiety attack symptoms resemble those found in life-threatening medical disorders, such as myocardial infarction, which must be ruled out first.
More on Phobic Disorders |
| Overview: Phobic Disorders |
| Differential Diagnoses & Workup: Phobic Disorders |
| Treatment & Medication: Phobic Disorders |
 Follow-up: Phobic Disorders |
| References |
| « Previous Page |
References
American Psychiatric Association. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). Washington, DC: American Psychiatric Association Press; 2000.
Mathew SJ, Coplan JD, Gorman JM. Neurobiological mechanisms of social anxiety disorder. Am J Psychiatry. 2001;158:1558–1567. [Full Text].
Kendler KS, Karkowski LM, Prescott CA. Fears and phobias: reliability and heritability. Psychol Med. 1999;29:539–553. [Medline].
Liebowitz MR, Klein DF. Fyer AJ, Mannuzza S, Chapman TF, A direct interview family study of social phobia. Arch Gen Psychiatry. 1993;50:286-293. [Full Text].
Magee WJ, Eaton WW, Wittchen HU, McGonagle KA, Kessler RC. Agoraphobia, simple phobia, and social phobia in the National Comorbidity Survey.Arch Gen Psychiatry. Feb 1996;53(2):159-68. [Medline].
Wittchen HU, Fehm L. Epidemiology, patterns of comorbidity, and associated disabilities of social phobia. Psychiatric Clin North Am. 2001;24:617–664. [Medline].
Stein MB, Stein DJ. Social anxiety disorder. Lancet. Mar 2008;371(9618):1115-25. [Medline].
Schneier FR, Heckelman LR, Garfinkel R, Campeas R, Fallon BA, Gitow A, et al. Functional impairment in social phobia. J Clin Psychiatry. 1994;55:322–331. [Medline].
Lochner C, Mogotsi M, du Toit PL, Kaminer D, Niehaus DJ, Stein DJ. Quality of life in anxiety disorders: a comparison of obsessive-compulsive disorder, social anxiety disorder, and panic disorder. Psychopathology. 2003;36:255–262. [Medline]. [Full Text].
Matza LS, Revicki DA, Davidson JR, Stewart JW. Depression with atypical features in the national comorbidity survey. Arch Gen Psychiatry. 2003;60:817–826. [Full Text].
Sareen J, Cox BJ, Afifi TO, de Graaf R, Asmundson GJ, ten Have M, et al. Anxiety disorders and risk for suicidal ideation and suicide attempts: a population-based longitudinal study of adults. Arch Gen Psychiatry. 62(11);2005 Nov:1249-57. [Medline]. [Full Text].
de Beurs E, van Balkom AJ, Van Dyck R. Long-term outcome of pharmacological and psychological treatment for panic disorder with agoraphobia: a 2-year naturalistic follow-up. Acta Psychiatr Scand. Jan 1999;99(1):59-67. [Medline].
Shear MK, Beidel DC. Psychotherapy in the overall management strategy for social anxiety disorder. J Clin Psychiatry. 1998;59 Suppl 17:39-46. [Medline].
Hudson C, Hudson S, MacKenzie J. Protein-source tryptophan as an efficacious treatment for social anxiety disorder: a pilot study. Can J Physiol Pharmacol. Sep 2007;85(9):928-32. [Medline].
American Psychiatric Association: Practice Guideline for the Treatment of Patients With Panic Disorder. Am J Psychiatry. May suppl, 1998;155.
Pohl RB, Wolkow RM, Clary CM. Sertraline in the treatment of panic disorder: a double-blind multicenter trial. Am J Psychiatry. Sep 1998;155(9):1189-95. [Medline]. [Full Text].
Michelson D, Lydiard RB, Pollack MH. Outcome assessment and clinical improvement in panic disorder: evidence from a randomized controlled trial of fluoxetine and placebo. The Fluoxetine Panic Disorder Study Group. Am J Psychiatry. Nov 1998;155(11):1570-7. [Medline]. [Full Text].
Uhlenhuth EH, Balter MB, Ban TA, Yang K. International study of expert judgment on therapeutic use of benzodiazepines and other psychotherapeutic medications: VI. Trends in recommendations for the pharmacotherapy of anxiety disorders, 1992-1997. Depress Anxiety. 1999;9(3):107-16. [Medline].
Lydiard RB. The role of drug therapy in social phobia. J Affect Disord. Sep 1998;50 Suppl 1:S35-9. [Medline].
Van Ameringen M, Allgulander C, Bandelow B. WCA recommendations for the long-term treatment of social phobia. CNS Spectr. Aug 2003;8(8 Suppl 1):40-52. [Medline].
Heimberg RG, Liebowitz MR, Hope DA. Cognitive behavioral group therapy vs phenelzine therapy for social phobia: 12-week outcome. Arch Gen Psychiatry. Dec 1998;55(12):1133-41. [Medline]. [Full Text].
Allgulander C. Paroxetine in social anxiety disorder: a randomized placebo-controlled study. Acta Psychiatr Scand. Sep 1999;100(3):193-8. [Medline].
Stein MB, Fyer AJ, Davidson JR. Fluvoxamine treatment of social phobia (social anxiety disorder): a double-blind, placebo-controlled study. Am J Psychiatry. May 1999;156(5):756-60. [Medline].
Further Reading
Keywords
phobic disorders, anxiety disorders, phobias, social phobia, social anxiety disorder, agoraphobia, panic, phobic neurosis, fear, mood disorders
