eMedicine Specialties > Psychiatry > Adult
Phobic Disorders: Treatment & Medication
Updated: Jul 10, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Medical Care
Treatment usually consists of a combination of pharmacotherapy (see Medication) and/or psychotherapy.12 Behavioral therapy and cognitive behavioral therapy (CBT) have demonstrated efficacy through controlled studies.13 Psychodynamic therapy (or insight-oriented therapy) is rarely indicated as an exclusive treatment for phobias and is now mostly used for cases of phobic disorders that overlap personality disorders. Deciding which treatment or combination of treatments to prescribe depends on a careful interview and assessment of the patient's goals and level of pathology.
Patient prognosis is determined by several factors, including:
- Severity of diagnosis
- level of functioning prior to onset of symptoms
- Degree of motivation for treatment
- level of support (eg, family, friends, work, school)
- Ability to comply with medication and/or psychotherapeutic regimen
Consultations
Internal medicine or neurologic consultation may be helpful to sort through the nonpsychiatric differential, especially if rare disorders, such as pheochromocytoma, are suspected.
Diet
Inquire about the amount of caffeine intake (including coffee, caffeinated teas, or sodas). Considering the overall noradrenergic hyperdrive of this group of patients, even moderate amounts of coffee might exacerbate the anxiety response and symptoms. In a small, double-blind, placebo-controlled study, a tryptophan-rich diet was shown to have a positive effect on social anxiety.14 Dietary restrictions (a tyramine-free diet) are necessary for patients taking monoamine oxidase inhibitors (MAOIs).
Activity
Activity should not be restricted. In fact, patients should be encouraged to confront anxiety-producing stimuli in the context of a behavior therapy treatment plan.
Medication
Specific phobia
Specific phobias respond best to cognitive behavioral therapy (CBT) and exposure therapy. Gradual desensitization is the most commonly used treatment. Other treatments include cognitive approaches, relaxation, and breathing control techniques. To date, no controlled studies demonstrate the efficacy of psychopharmacological intervention for specific phobias.
Agoraphobia
Agoraphobia, specifically the panic symptoms, most often responds to treatment with a selective serotonin reuptake inhibitor (SSRI).15,16,17 Treatment should be started at a low dose then titrated to the minimum effective dose for controlling the patient's panic. Benzodiazepines can be used either as an adjunct or as primary treatment; however, benzodiazepines are usually not chosen as a first-line treatment because of the potential for abuse.18 If the patient has frequent panic attacks and no history of substance abuse, a benzodiazepine can be considered until the SSRI takes effect. Long-acting benzodiazepines (eg, diazepam, clonazepam) prescribed on a standing rather than as-needed basis are preferred due to a lower addictive potential; dose can be increased every 2-3 days until panic symptoms are controlled or the maximum dose is reached.
Consider using the short-acting alprazolam for short-term use to control acute symptoms of panic. If response is minimal or nonexistent after 6 weeks, the SSRI dose can be further increased every 2 weeks until response or maximal dose is reached. Partial or no response at the highest SSRI dose warrants consideration of the following alternatives: change to a different SSRI, change to a different class (venlafaxine, duloxetine), tricyclic/tetracyclic antidepressants (TCAs) or MAOIs (both TCAs and MAOIs have demonstrated efficacy in controlled trials for agoraphobia).
For a patient with good response, treatment should be continued for 9-12 months before considering slowly tapering the medications. With symptom reoccurrence following taper, treatment should be resumed and continued indefinitely.
Social anxiety disorder (social phobia)
Both pharmacotherapy and psychotherapy are useful in treating social anxiety disorder (SAD). Social phobia typically responds to either an SSRI or an MAOI.19,20,21
Initiate treatment with an SSRI and titrate to the minimum effective dose. SSRIs approved for SAD include paroxetine22 (including SR form) and sertraline, but other SSRIs have also been shown to be effective (eg, fluvoxamine23 ). The SSRI dose can be increased if response is partial or nonexistent at 6 weeks — doses can be increased every 2 weeks until maximum dose is reached. Failing this, patients sometimes respond to high-potency benzodiazepines. Long-term treatment data from clinical studies of clonazepam are limited but support the drug's efficacy.20 Beta-blockers, clonidine, and buspirone are usually not helpful for long-term treatment, although beta-blockers (eg, atenolol, nadolol, propranolol) may be useful for the circumscribed treatment of situational/performance anxiety on an as-needed basis.
Consider tapering medications slowly after 6-12 months of full response. If symptoms reoccur following taper, restart therapy and continue indefinitely.20
5-HT1 agonist
These agents may be used to treat anxiety.
Buspirone (BuSpar)
Antianxiety agent not chemically or pharmacologically related to the benzodiazepines, barbiturates, or other sedative or anxiolytic drugs. A 5-HT1 agonist with serotonergic neurotransmission and some dopaminergic effects in CNS. Has anxiolytic effect but may take up to 2-3 wk for full efficacy.
Adult
15-60 mg PO qd/bid
Pediatric
Not established
Toxicity is increased with MAOIs, phenothiazines, and CNS depressants; increases toxicity of digoxin and haloperidol
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in hepatic or renal impairment
Benzodiazepines
This category of medication should not, in general, be prescribed to patients with a history of alcohol/drug abuse or emotional dependence. Some psychiatrists feel that the longer-acting benzodiazepines (eg, diazepam, clonazepam) have advantages such as less frequent dosing and more consistent levels throughout the day. Slowly taper benzodiazepines (usually after 6 mo) to avoid withdrawal and precipitating panic.
Alprazolam (Xanax)
Best-studied agent. Rapid (20-min) onset and short half-life can contribute to increased dependency when attempting to taper.
Adult
0.5-4 mg qd (divided bid/tid)
Pediatric
Not established
Carbamazepine and phenytoin decrease effects; toxicity increases with cimetidine, nefazodone, and CNS depressants (including alcohol)
Documented hypersensitivity; severe respiratory depression; narrow-angle glaucoma; preexisting hypotension
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Withdrawal symptoms, including seizures, may occur upon abrupt discontinuation of drug
Lorazepam (Ativan)
Sedative hypnotic with short onset of effects and relatively long half-life.
By increasing the action of GABA, which is a major inhibitory neurotransmitter in the brain, may depress all levels of CNS, including limbic and reticular formation.
When patient needs to be sedated for longer than 24 hours, this medication is excellent. Not significantly metabolized by the liver. Can be prescribed IV/IM.
Adult
2-6 mg qd PO bid/tid
0.05 mg/kg IV/IM (4 mg maximum IV dose)
Pediatric
0.02-0.1 mg/kg per dose IV/PO q4-8h; maximum 2 mg per dose
Toxicity of benzodiazepines in CNS increases when used concurrently with alcohol, phenothiazines, barbiturates, and other CNS depressants
Documented hypersensitivity; preexisting CNS depression; hypotension; narrow-angle glaucoma
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in renal or hepatic impairment, myasthenia gravis, organic brain syndrome, or Parkinson disease
Clonazepam (Klonopin)
Long-acting benzodiazepine that increases the presynaptic GABA inhibition and reduces the monosynaptic and polysynaptic reflexes. Suppresses muscle contractions by facilitating inhibitory GABA neurotransmission and other inhibitory transmitters. Has multiple indications, including suppression of myoclonic, akinetic, or petit mal seizure activity and focal or generalized dystonias (eg, tardive dystonia). Reaches peak plasma concentration at 2-4 h after oral or rectal administration.
Adult
0.5 mg PO bid/tid, titrate to 1-6 mg/d PO divided bid/tid
Pediatric
Not established
Phenytoin and barbiturates may reduce effects; coadministration of CNS depressants increase toxicity
Documented hypersensitivity; severe liver disease, and acute narrow-angle glaucoma
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in chronic respiratory disease or impaired renal function; withdrawal symptoms can result from abrupt discontinuation of the medication
Diazepam (Diastat, Diazemuls, Valium)
Modulates postsynaptic effects of GABA-A transmission, resulting in an increase in presynaptic inhibition. Appears to act on part of the limbic system, the thalamus, and hypothalamus to induce a calming effect. Also has been found to be an effective adjunct for the relief of skeletal muscle spasm caused by upper motor neuron disorders.
Rapidly distributes to other body fat stores. Serum concentration level drops to 20% of C max 20 minutes after initial IV infusion.
Individualize dosage and increase cautiously to avoid adverse effects.
Adult
2-10 mg PO/IM/IV q3-4h, repeat q2-4h prn; not to exceed 30 mg in 8 h
Pediatric
0.05-0.3 mg/kg/dose IV over 2-3 min or IM; repeat in 2-4 h prn
Alternatively, 0.12-0.8 mg/kg/d PO divided q6-8h; not to exceed 10 mg/dose
Phenothiazines, barbiturates, alcohols, and MAOIs increase CNS toxicity when administered concurrently
Documented hypersensitivity; narrow-angle glaucoma; reversal agents (eg, flumazenil) contraindicated when lorazepam used for life-threatening conditions (eg, control of intracranial pressure or status epilepticus)
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution with other CNS depressants, low albumin levels, or hepatic disease (may increase toxicity)
Antihypertensive agents
These agents are useful for the circumscribed treatment of situational/performance anxiety on an as needed basis.
Atenolol (Tenormin)
Used to treat hypertension. Selectively blocks beta1-receptors with little or no affect on beta2 types. Beta-adrenergic blocking agents affect blood pressure via multiple mechanisms. Actions include negative chronotropic effect that decreases heart rate at rest and after exercise, negative inotropic effect that decreases cardiac output, reduction of sympathetic outflow from the CNS, and suppression of renin release from the kidneys. Used to improve and preserve hemodynamic status by acting on myocardial contractility, reducing congestion, and decreasing myocardial energy expenditure.
Beta-adrenergic blockers reduce inotropic state of LV, decrease diastolic dysfunction, and increase LV compliance, thereby reducing pressure gradient across LV outflow tract. Decreases myocardial oxygen consumption, thereby reducing myocardial ischemia potential. Decreases heart rate, thus reducing myocardial oxygen consumption and reducing myocardial ischemia potential.
During IV administration, carefully monitor blood pressure, heart rate, and ECG.
Adult
50 mg PO qd; can increase to 100 mg/d, if necessary
Pediatric
Not established
Coadministration with aluminum salts, barbiturates, calcium salts, cholestyramine, NSAIDs, penicillins, and rifampin may decrease effects; haloperidol, hydralazine, loop diuretics, and MAOIs may increase toxicity of atenolol
Documented hypersensitivity; congestive heart failure, pulmonary edema, cardiogenic shock, A-V conduction abnormalities, and heart block (without a pacemaker)
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Beta-adrenergic blockade may reduce symptoms of acute hypoglycemia and mask signs of hyperthyroidism; abrupt withdrawal may exacerbate symptoms of hyperthyroidism and cause thyroid storm; monitor patients closely and withdraw drug slowly; during an IV, carefully monitor BP, heart rate, and ECG
Nadolol (Corgard)
Competitively blocks beta1- and beta2-receptors. Does not exhibit membrane stabilizing activity or intrinsic sympathomimetic activity.
Adult
40 mg/d PO initially; gradually increase dose by 40-80 mg increments at 3-7 d intervals up to 160-240 mg/d
Pediatric
Not established
Coadministration with aluminum salts, barbiturates, calcium salts, cholestyramine, NSAIDs, penicillins, and rifampin may decrease effects; haloperidol, hydralazine, loop diuretics, and MAOIs may increase toxicity of nadolol
Documented hypersensitivity; congestive heart failure, pulmonary edema, cardiogenic shock, A-V conduction abnormalities, and heart block (without a pacemaker)
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Beta-adrenergic blockade may reduce symptoms of acute hypoglycemia and mask signs of hyperthyroidism; abrupt withdrawal may exacerbate symptoms of hyperthyroidism and cause thyroid storm; monitor patients closely and withdraw drug slowly; during an IV, carefully monitor BP, heart rate, and ECG
Propranolol (Betachron E-R, Inderal, InnoPran XL)
Recommended for situational social anxiety ("stage fright").
Adult
10 to 20 mg PO prn; total dose can be up to 40-80 mg PO qd in divided doses
Pediatric
Not established
Coadministration with aluminum salts, barbiturates, NSAIDs, penicillins, calcium salts, cholestyramine, and rifampin may decrease propranolol effects; calcium channel blockers, cimetidine, loop diuretics, and MAOIs may increase toxicity of propranolol; toxicity of hydralazine, haloperidol, benzodiazepines, and phenothiazines may increase with propranolol
Documented hypersensitivity; uncompensated congestive heart failure; bradycardia, cardiogenic shock; A-V conduction abnormalities; COPD.
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Beta-adrenergic blockade may decrease signs of acute hypoglycemia and hyperthyroidism; abrupt withdrawal may exacerbate symptoms of hyperthyroidism, including thyroid storm; withdraw drug slowly and monitor closely
Antidepressants
Serotonin reuptake inhibitors may require 2-6 weeks of daily use to become effective, usually not without side effects appearing first. Shown to be effective in controlled clinical trials. As a class, it tends to have the fewest adverse effects. However, these agents can produce drug-drug interactions through their inhibition of cytochrome P450 enzymes and by displacement of other drugs from protein binding sites.
SSRIs are greatly preferred over the other classes of antidepressants. Because the adverse effect profile of SSRIs is less prominent, improved compliance is promoted. SSRIs do not have the cardiac arrhythmia risk associated with tricyclic antidepressants. Arrhythmia risk is especially pertinent in overdose, and suicide risk must always be considered, particularly when treating a child or adolescent with mood disorder.
Physicians are advised to be aware of the following information and use appropriate caution when considering treatment with SSRIs in the pediatric population.
In December 2003, the UK Medicines and Healthcare Products Regulatory Agency (MHRA) issued an advisory that most SSRIs are not suitable for use by persons younger than 18 years for treatment of "depressive illness." After review, this agency decided that the risks to pediatric patients outweigh the benefits of treatment with SSRIs, except fluoxetine (Prozac), which appears to have a positive risk-benefit ratio in the treatment of depressive illness in patients younger than 18 years.
In October 2003, the US Food and Drug Administration (FDA) issued a public health advisory regarding reports of suicidality in pediatric patients being treated with antidepressant medications for major depressive disorder. This advisory reported suicidality (both ideation and attempts) in clinical trials of various antidepressant drugs in pediatric patients. The FDA has asked that additional studies be performed because suicidality occurred in both treated and untreated patients with major depression and thus could not be definitively linked to drug treatment.
SSRIs and SNRIs can help prevent panic attacks and alleviate symptoms of anxiety and depression.Tricyclic antidepressants have long history of demonstrated efficacy and are relatively inexpensive. However, due to their broad spectrum of action and their inhibition of multiple neurotransmitter systems, they result in more side effects, such as anticholinergic and cardiovascular side effects, and therefore present problems for long-term treatment. Treatment response occurs on the same order as the SSRIs, within 2-6 weeks.
MAOIs are most commonly prescribed for patients with social phobia. Advantages of MAOIs are low risk of dependence and less anticholinergic effect than TCAs. Disadvantages are the higher number of adverse effects, including sexual difficulty, hypotension, and weight gain. A diet low in tyramine must be followed to avoid a hypertensive crisis. Over-the-counter medications should be used with great caution.
Venlafaxine (Effexor)
Reuptake inhibitor of both serotonin and norepinephrine.
Adult
Immediate release: 75 mg/d PO divided bid-tid with food; increase in 75-mg/d increments q4d to 225-375 mg/d
Extended release: 75 mg PO qd with food; increase in 75-mg/d increments q4d to 225 mg/d
Pediatric
Not established
Cimetidine, MAOIs, sertraline, fluoxetine class I-C antiarrhythmics, TCAs; phenothiazine may increase the effects
Documented hypersensitivity; patients taking MAOIs or have taken them within 14 d of initiating therapy
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Patients on this medication may experience hypertension; fatal reaction may occur if taken concurrently with an MAOI; exercise caution in patients with cardiovascular disorders
Imipramine (Tofranil)
Inhibits reuptake of norepinephrine or serotonin (5-HT) at presynaptic neuron.
Use parenteral administration for starting therapy only in patients unable or unwilling to use oral medication.
Adult
50-100 mg/d in divided doses initially, followed by a maintenance dose of 150-300 mg/d (can divide dose if needed)
Pediatric
Not established; suggested dose is 1.5 mg/kg/d (divided qd/qid) to a maximum of 5 mg/kg/d
Can cause anticholinergic symptoms with other drugs with anticholinergic properties such as H1 antagonists and antipsychotics; similarly, it can interact with quinidinelike properties and those with alpha-adrenergic properties; use it and other tricyclics with caution in elderly patients and medically ill patients; can inhibit antihypertensive effects of clonidine and cause serotonin syndrome with MAOIs
Documented hypersensitivity; narrow-angle glaucoma; in acute recovery phase following myocardial infarction; avoid in patients taking MAOIs or fluoxetine or patients who took them in the previous 2 wk
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
May impair mental or physical abilities required for performance of potentially hazardous tasks; caution in cardiovascular disease, conduction disturbances, seizure disorders, cognitive disorders, and urinary retention
Desipramine (Norpramin)
Tricyclic antidepressant that has norepinephrine and serotonin reuptake-inhibition properties. One of the oldest agents available for the treatment of depression and has established efficacy in the treatment of panic disorder. Elderly and adolescent patients may need lower dosing or slower titration.
Adult
75 mg/d PO in divided doses; increase gradually to 150-200 mg/d in divided or single dose; not to exceed 300 mg/d
Pediatric
<6 years: Not established
6-12 years: 10-30 mg/d PO or 1-5 mg/kg/d in divided doses; do not exceed 5 mg/kg/d
>12 years: 25-50 mg/d PO; gradually increase to 100 mg/d in single or divided doses; not to exceed 150 mg/d
Decreases antihypertensive effects of clonidine but increases effects of sympathomimetics and benzodiazepines; effects of desipramine increase with phenytoin, carbamazepine, and barbiturates; levels may increase with concurrent use of stimulants
Documented hypersensitivity; narrow-angle glaucoma; recent postmyocardial infarction; current administration of MAOIs or fluoxetine or administration in the previous 2 wk
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Sudden death has been associated with desipramine, do not use unless other safer antidepressants have been tried with adequate doses and treatment duration (unwise to prescribe medication without a tertiary care mental health professional consultation); cardiovascular disease, conduction disturbances, seizure disorders, urinary retention, and hyperthyroidism (patients receiving thyroid replacement) may occur
Nortriptyline (Pamelor)
Has demonstrated effectiveness in the treatment of chronic pain. By inhibiting the reuptake of serotonin and/or norepinephrine by the presynaptic neuronal membrane, this drug increases the synaptic concentration of these neurotransmitters in the central nervous system. Pharmacodynamic effects such as the desensitization of adenyl cyclase and down-regulation of beta-adrenergic receptors and serotonin receptors also appear to play a role in its mechanisms of action.
Adult
60-150 mg/d PO (can divide dose if needed)
Pediatric
Children: Not established
Adolescents: 30-50 mg/d PO (divided tid/qid); maximum 150 mg/d
Cimetidine may increase nortriptyline levels when used concurrently; nortriptyline may increase prothrombin time in patients stabilized with warfarin; while less likely than imipramine, it can still cause anticholinergic and cardiovascular drug interactions; similar risk as imipramine with MAOIs (can inhibit antihypertensive effects of clonidine and cause serotonin syndrome with MAOIs)
Documented hypersensitivity; narrow-angle glaucoma; do not administer to patients that have taken MAOIs in last 2 wk
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in cardiac conduction disturbances and history of hyperthyroidism or renal or hepatic impairment; due to pronounced effects in cardiovascular system, best to avoid in elderly patients
Duloxetine (Cymbalta)
Potent inhibitor of neuronal serotonin and norepinephrine reuptake. Indicated for generalized anxiety disorder.
Adult
30-60 mg PO qd
Pediatric
Not established
Metabolized by CYP1A2 and CYP2D6; coadministration with drugs that inhibit CYP1A2 (eg, fluvoxamine, cimetidine, ciprofloxacin, enoxacin) may increase duloxetine blood levels and toxicity; coadministration with drugs that inhibit CYP2D6 (eg, paroxetine, fluoxetine, quinidine) may increase duloxetine blood levels and toxicity; duloxetine moderately inhibits CYP2D6 and may decrease elimination of CYP2D6 substrates (eg, tricyclic antidepressants, phenothiazines [eg, thioridazine], type 1C antiarrhythmics [eg, propafenone, flecainide]); coadministration with MAOIs or triptans serotonin syndrome consisting of serious, sometimes fatal reactions that include hyperthermia, rigidity, myoclonus, autonomic instability, mental status changes including extreme agitation, delirium, and coma (see contraindications)
Documented hypersensitivity; uncontrolled narrow-angle glaucoma; within 14 d of stopping MAOIs use (do not initiate MAOIs within 5 d of stopping duloxetine)
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Observe closely for clinical worsening and suicidality when initiating treatment or following dosage change; gradually decrease dose when discontinuing, do not abruptly discontinue; caution with hepatic impairment or end-stage renal disease; recommended not to prescribe to patients with substantial alcohol use or evidence of chronic liver disease; may cause slight blood pressure increase; may activate mania or hypomania; common adverse effects include nausea, dry mouth, constipation, decreased appetite, fatigue, somnolence and increased sweating; may cause serotonin syndrome (ie, changes in mental status [agitation, hallucinations, coma], autonomic instability [tachycardia, labile blood pressure, hyperthermia], neuromuscular abnormalities [hyperreflexia, incoordination], and/or gastrointestinal tract symptoms
Clomipramine (Anafranil)
Dibenzazepine compound belonging to family of tricyclic antidepressants. Inhibits membrane pump mechanism responsible for uptake of norepinephrine and serotonin in adrenergic and serotonergic neurons. Clomipramine affects serotonin uptake while it affects norepinephrine uptake when converted into its metabolite desmethylclomipramine. Believed that these actions are responsible for preventing panic disorders.
Adult
25-100 mg/d PO
Pediatric
Not established
Barbiturates, phenytoin, and carbamazepine, decrease effects of clomipramine; clomipramine increases effects of anticholinergics, sympathomimetics, alcohol and CNS depressants; toxicity of MAOIs increases with clomipramine
Documented hypersensitivity; recent myocardial infarction; do not use within 14 d of MAOIs
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in severe cardiopulmonary or renal impairment and those unable to metabolize sorbitol; caution in seizure disorder, may lower seizure threshold; may exacerbate psychosis; patients with MDD, both adult and pediatric, may experience worsening of their depression and/or the emergence of suicidal ideation and behavior (suicidality) or unusual changes in behavior, whether or not they are taking antidepressant medications
Paroxetine (Paxil)
In addition to selective inhibition of serotonin reuptake, also has anticholinergic effect that may result in sedation or cardiovascular effects.
Adult
10-20 mg/d PO initially, followed by maintenance dose of 10-60 mg/d
Pediatric
Not established
Phenobarbital and phenytoin decrease effects of paroxetine; alcohol, cimetidine, sertraline, phenothiazines, and warfarin increase toxicity of paroxetine; a potent inhibitor of cytochrome P450 system and can cause serotonin syndrome with MAOIs
Documented hypersensitivity; concurrent administration with MAOIs or administering within 14 d of discontinuing a MAOI
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in history of seizures, mania, renal disease, and cardiac disease
Sertraline (Zoloft)
Selectively inhibits presynaptic serotonin reuptake. Shorter half-life than fluoxetine. Tends to have fewer drug-drug interactions from inhibition of the cytochrome P450 system.
Adult
50-200 mg/d PO
Pediatric
<6 years: Not established
6-12 years: 25 mg qd
>12 years: 50 mg qd
While less likely to do so compared to fluoxetine, it still increases toxicity of diazepam, tolbutamide, and warfarin; can cause a serotonin syndrome when used with MAOIs
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in preexisting seizure disorders and in those that have experienced a recent myocardial infarction, have unstable heart disease, and hepatic or renal impairment
Citalopram (Celexa)
Enhances serotonin activity due to selective reuptake inhibition at the neuronal membrane. No head-to-head comparisons of SSRIs exist, although, based on metabolism and adverse effects, citalopram is considered SSRI of choice for patients with head injury.
SSRIs are the antidepressants of choice due to minimal anticholinergic effects. All are equally efficacious. The choice depends on adverse effects and drug interactions.
Adult
20-60 mg PO qd; 10 mg/d initially, titrate by 10 mg/wk
Pediatric
Not established
May be potentiated by azole antifungals, omeprazole, macrolides; serotonin syndrome may be induced by buspirone, tramadol, MAOI, nefazodone; serotonin syndrome (ie, myoclonus, rigidity, confusion, nausea,
hyperthermia, autonomic instability, coma, eventual death) occurs with simultaneous use of other serotonergic agents (eg, anorectic agents, tramadol, buspirone, trazodone, clomipramine, nefazodone, tryptophan), discontinue other serotonergic agents at least 2 wk prior to SSRIs
Documented hypersensitivity; concurrent MAOI therapy
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in cirrhosis, suicidal tendencies, SIADH; DM, and breast-feeding; common side effects include fatigue and sexual dysfunction
Escitalopram (Lexapro)
SSRI and S-enantiomer of citalopram. Used for the treatment of depression. Mechanism of action is thought to be potentiation of serotonergic activity in central nervous system resulting from inhibition of CNS neuronal reuptake of serotonin. Onset of depression relief may be obtained after 1-2 wk, which is sooner than other antidepressants.
Adult
10 mg PO qd initially; if needed, may increase to 20 mg/d after 1 wk
Pediatric
Not established
Primarily metabolized by CYP450 3A4 and 2C19; coadministration with alcohol or other centrally acting drugs increases CNS depression; cimetidine increases AUC and maximum serum concentration; coadministration with sumatriptan and SSRIs has caused weakness and hyperreflexia
Documented hypersensitivity; administration within 14 d of receiving MAOI
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution with history of seizures, mania, suicide; common adverse effects include insomnia, ejaculation disorder (primarily ejaculatory delay), nausea, sweating, fatigue, and somnolence
Fluoxetine (Prozac)
Selectively inhibits presynaptic serotonin reuptake with minimal or no effect in the reuptake of norepinephrine or dopamine. In this patient population, initial anxiogenic effects occur, so either start with lower doses or educate patients about adverse effects. Sexual dysfunction is common, which may impact long-term compliance.
Adult
20-80 mg/d PO
Pediatric
Not established
Increases toxicity of drugs such as diazepam and trazodone by decreasing clearance through its cytochrome P450 enzyme inhibition; also increases toxicity of highly protein bound drugs; causes a serotonin syndrome with fever, muscle fasciculations, shivering, and altered mental status when used with MAOIs
Documented hypersensitivity; concurrently taking MAOIs or having taken them in the last 2 wk
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in hepatic impairment and history of seizures; MAOIs should be discontinued at least 14 d before initiating fluoxetine therapy
Fluvoxamine (Luvox)
Enhances serotonin activity due to selective reuptake inhibition at neuronal membrane. Does not significantly bind to alpha-adrenergic, histamine, or cholinergic receptors and thus has fewer side effects than tricyclic antidepressants.
FDA-approved for obsessive compulsive disorder in children (8-17 y) and adults. May be helpful for other anxiety disorders.
Adult
50 mg PO qhs initially as single dose, increase dose in 50-mg increments q4-7d as tolerated until maximum therapeutic benefit achieved; divide total daily dose into 2 doses; if doses are unequal, administer larger dose hs; not to exceed 300 mg/d
Pediatric
<8 years: Not established
>8 years: 25 mg PO qhs initially as single dose, increase dose in 25-mg increments q4-7d as tolerated until maximum therapeutic benefit achieved, divide total daily doses higher than 50 mg into 2 doses; if doses are unequal, administer larger dose hs; not to exceed 200 mg/d
Risk of a hypertensive crisis increases in coadministration with MAOIs; fluvoxamine potentiates effect of triazolam and alprazolam and thus, when taking them concurrently, dose should be reduced by at least 50%; reduce also the dose of theophylline by 1/3, and monitor plasma levels if taking it concurrently with fluvoxamine; alcohol, cimetidine, sertraline, phenothiazines, and warfarin increase toxicity of fluvoxamine; serotonin syndrome (ie, myoclonus, rigidity, confusion, nausea, hyperthermia, autonomic instability, coma, eventual death) occurs with simultaneous use of other serotonergic agents (eg, anorectic agents, tramadol, buspirone, trazodone, clomipramine, nefazodone, tryptophan), discontinue other serotonergic agents at least 2 wk prior to SSRIs
Documented hypersensitivity; patients currently taking MAOIs or have taken them in previous 2 wk; currently taking thioridazine, cisapride, or pimozide
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in liver dysfunction or cardiovascular disease and history of seizures, or suicidal tendencies
Phenelzine (Nardil)
The MAOI most commonly used for anxiety disorders. (Tranylcypromine administered at 30-60 mg/d doses is effective also.) Usually reserved for patients who do not tolerate or respond to the TCA or SSRI antidepressants.
Adult
45-90 mg/d PO divide qd/tid
Pediatric
<16 years: Not recommended
>16 years: Administer as in adults
Toxicity from phenelzine occurs due to serotonin syndrome when taken concurrently with fluoxetine or disulfiram; hypertensive crisis occurs when used with levodopa, sympathomimetics, and tyramine-containing foods
Documented hypersensitivity; pheochromocytoma; hepatic or renal disease; cardiovascular disease; cerebrovascular defect
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in hyperactive or hyperexcitable disorders and glaucoma
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References
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Further Reading
Keywords
phobic disorders, anxiety disorders, phobias, social phobia, social anxiety disorder, agoraphobia, panic, phobic neurosis, fear, mood disorders
