Phobic Disorders Treatment & Management

Anxiety is frequently a physiologic reaction that can be expected to occur under stressful life circumstances. Most times, anxiety reactions do not result in dysfunction/disability and will remit spontaneously over time. In addition, randomized clinical trials showed a high placebo response rate across a range of anxiety disorders.^[21] As such, in cases of mild anxiety disorders (not associated with disability), a wait-and-see, supportive type of intervention is recommended.

Treatment of phobic disorders usually consists of a combination of pharmacotherapy and/or psychotherapy.^[22] In general, continue a selected medication regimen for at least 6-12 months. If the symptoms have resolved and the patient is not experiencing excessive stress, the physician can gradually taper the patient off the medication. Psychotherapy usually helps make the transition off medication more successful.

Inpatient treatment is indicated only for severe cases presenting with acute suicidal ideation and/or attempt. In addition, inpatient treatment including detoxification and/or rehabilitation may be recommended for treatment of secondary drug and/or alcohol abuse or dependence.

Go to Anxiety Disorders and Generalized Anxiety Disorder for complete information on these topics.

Dietary considerations

Inquire about the amount of caffeine intake (including coffee, caffeinated teas, or sodas), as even moderate amounts 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.^[23] Dietary restrictions (a tyramine-free diet) are necessary for patients taking monoamine oxidase inhibitors (MAOIs).

Activity

Activity should not be restricted. Patients should be encouraged to confront anxiety-producing stimuli in the context of a behavior therapy treatment plan.

At this time, 3 drugs are approved by the US Food and Drug Administration (FDA) for the treatment of social anxiety disorder: 2 selective serotonin reuptake inhibitors (SSRIs) (paroxetine and sertraline) and 1 selective serotonin/norepinephrine reuptake inhibitor (SNRI) (venlafaxine). In addition, placebo-controlled, randomized controlled trials and systematic reviews show that social anxiety disorder responds to a number of other SSRIs (escitalopram, fluoxetine, fluvoxamine), the monoamine oxidase inhibitor (MAOI) phenelzine, and moclobemide, the reversible inhibitor of monoamine oxidase A (RIMA) (not approved in the United States).^[21]

SSRIs appear to be more effective than MAOIs.^[24] The beta-blocker propranolol may be useful for the circumscribed treatment of situational/performance anxiety only on an as-needed basis.^[25]

See Medications for more information on these agents.

Acute treatment

Initiate treatment for social anxiety disorder with an SSRI, and titrate to the minimum effective dose. The SSRI dose can be increased if the response is partial or nonexistent at 6 weeks—doses can be increased every 2 weeks until the maximum dose is reached.

Failing this, patients sometimes have a response to high-potency benzodiazepines (clonazepam), alpha2delta calcium channel blockers (gabapentin and pregabalin), the antiepileptic levetiracetam, and the antipsychotic olanzapine, or an SSRI/benzodiazepine combination treatment.^{[21, 25]}

Treatment with unproven efficacy includes the serotonin (5-HT) 1A partial agonist buspirone, the beta-blocker atenolol, and the tricyclic antidepressant (TCA) imipramine.^[21]

Long-term treatment

Long-term treatment data from double-blind, randomized controlled trials for social anxiety disorder show that continuing SSRI or venlafaxine treatment for up to 6 months can result in increased treatment response rates.^[21] Long-term treatment data on clonazepam are limited but support this drug's long-term efficacy.^{[21, 25, 26]}

Beta-blockers, clonidine, and buspirone are usually not helpful for the long-term treatment of social anxiety disorder. Consider tapering medications slowly after 6-12 months of full response. If symptoms reoccur following taper, restart therapy and continue indefinitely.^[26]

To date, no controlled studies demonstrate the efficacy of psychopharmacologic intervention for specific phobias. Clinical lore suggests that, as needed, use of a short-acting benzodiazepine might be useful for temporary anxiety relief in specific situations (eg, right before taking the plane for patients suffering of fear of flying) (see Medications).

Randomized, double-blind, placebo-controlled clinical trials have showed that agoraphobia, specifically the panic symptoms, responds to treatment with a selective serotonin reuptake inhibitor (SSRI) (ie, escitalopram, citalopram, fluoxetine, fluvoxamine, paroxetine, sertraline),^{[27, 28, 29]} venlafaxine and reboxetine, some tricyclic antidepressants (TCAs) (clomipramine and imipramine), and some benzodiazepines (alprazolam, lorazepam, diazepam, and clonazepam).^[21]

Based on data from comparator-controlled trials, mirtazapine and moclobemide are reasonable alternative options.^[21]

See Medications for more information on these agents.

Acute treatment

Treatment for agoraphobia should be started with an SSRI at a low dose, and 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.^[30] If the patient has frequent panic attacks and no history of substance abuse, a benzodiazepine can be considered until the SSRI takes effect.

If the response is minimal or nonexistent after 6 weeks, the SSRI dose can be further increased every 2 weeks until the 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 or change to an agent from a different drug class, including the SNRI venlafaxine, the selective noradrenaline reuptake inhibitor (SNRI) reboxetine, or TCAs.

Long-acting benzodiazepines (eg, diazepam, clonazepam) prescribed on a standing rather than as-needed basis are preferred due to a lower addictive potential; the dose can be increased every 2-3 days until the patient’s panic symptoms are controlled or the maximum dose is reached. Consider using the short-acting agent alprazolam for short-term use to control acute symptoms of panic.

Treatment with unproven efficacy includes the serotonin (5-HT) 1A partial agonist buspirone, the beta-blocker propranolol, antihistaminic drugs, and antipsychotic agents.^[21]

Long-term treatment

Double-blind studies show that continuing an SSRI or clomipramine from 12 to 52 weeks results in increased treatment response rates.^[21] 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.

Behavioral therapy and cognitive behavioral therapy (CBT) have demonstrated efficacy through controlled studies.^[31] Computerized CBT (FearFighter) has been recommended for panic and phobia by the National Institute for Health and Clinical Excellence guidelines (NICE).^[32]

Psychodynamic therapy (or insight-oriented therapy) is rarely indicated as an exclusive treatment for phobias, and this treatment 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.

The prognosis is determined by several factors, including the following:

• Severity of diagnosis
• level of functioning before 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

Self-exposure monotherapy has been shown to work as well as computerized-based exposure training, clinician-led exposure, or combination therapies of self-exposure and cognitive behavioral therapy (CBT)/self-help manual in social anxiety disorder (social phobia).^[33] In a small, 12-week randomized trial, school-based training combining exposure therapy and social skills training was highly effective for adolescents aged 14-16 years with social anxiety disorder.^[34]

A cognitive behavioral therapy (CBT)-based approach, including gradual desensitization, is the most commonly used treatment for specific phobias. Other treatments include relaxation and breathing control techniques.

Randomized controlled clinical trials indicate that specific (simple) phobias respond to exposure therapy.^[35] A small, randomized controlled clinical trial showed that virtual reality exposure therapy is as effective as standard exposure for fear of flying, with gains maintained up to 1 year following the treatment.^[36]

In one study, after the successful completion of a 4-session CBT course, the patients with specific phobias no longer showed significant functional magnetic resonance imaging (fMRI) activation in the prefrontal or parahippocampal areas, supporting the view that effective psychotherapy can normalize dysfunction in the neurocircuitry associated with anxiety and phobias.^[37]

In another study, patients with specific phobias, a 4-hour, 1-session CBT, combined in vivo exposure, and modeling resulted in increased/improved medial orbitofrontal cortex activity and decreased/improved activation in the amygdala and the insula relative to nontreated controls.^[38]

A recently published meta-analysis showed that a combination of exposure therapy, relaxation, and breathing retraining works better than other psychologic interventions for panic disorder with and without agoraphobia.^[39] Furthermore, the inclusion of homework and a follow-up program have been shown to improve outcomes. Early intervention is recommended on the basis that the shorter the duration of illness, the better the response.^[39]

Patients with social anxiety disorder (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.

Left untreated, social anxiety disorder (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. In addition, there exists a significant risk of substance abuse with this degree of isolation, and based on a prospective cohort study, social anxiety disorder has been associated with increased risk for subsequent depression.^[40]

Specific (simple) phobia has been associated with increased risk for suicide attempts and possibly suicidal ideation.^[19] These individuals 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 anxiety disorder or agoraphobia.

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.

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).

Internal medicine or neurologic consultation may be helpful to sort through the nonpsychiatric differential diagnosis, especially if rare disorders, such as pheochromocytoma, are suspected (see Differentials).

Outpatient follow-up is usually needed through the resolution of symptoms. After the patient’s symptoms are resolved, the physician can attempt to taper a medication and therapy as well as monitor for relapse.