Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Phobic Disorders Treatment & Management

  • Author: Adrian Preda, MD; Chief Editor: Iqbal Ahmed, MBBS, FRCPsych(UK)  more...
 
Updated: Jul 30, 2014
 

Approach Considerations

Anxiety often is not a significantly pathologic condition but simply a physiologic reaction that can be expected to occur under stressful life circumstances. Most anxiety reactions do not result in dysfunction or disability and will remit spontaneously over time. In addition, high placebo response rates have been documented across a range of anxiety disorders.[37] Accordingly, when an anxiety disorder is mild (ie, not associated with disability), a wait-and-see, supportive type of intervention is recommended.

Treatment of phobic disorders usually consists of pharmacotherapy, psychotherapy, or some combination thereof.[38] As a general rule, a selected medication regimen should be continued 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 away from medication more successful.

Next

Pharmacotherapy

Social anxiety disorder (social phobia)

At present, 3 drugs are approved by the US Food and Drug Administration (FDA) for the treatment of social anxiety disorder, as follows:

  • The selective serotonin reuptake inhibitors (SSRIs) paroxetine and sertraline
  • The selective serotonin/norepinephrine reuptake inhibitor (SNRI) venlafaxine

In addition, placebo-controlled, randomized controlled trials and systematic reviews show that social anxiety disorder responds to the following agents:

  • The SSRIs escitalopram, [39, 40] fluoxetine, and fluvoxamine
  • The monoamine oxidase inhibitor (MAOI) phenelzine
  • The reversible inhibitor of monoamine oxidase A (RIMA) moclobemide (not approved in the United States) [37]

Overall, SSRIs appear to be more effective than MAOIs for the treatment of social anxiety disorder.[41] SSRIs and venlafaxine are generally considered first-line agents, whereas benzodiazepines, tricyclic antidepressants (TCAs), and MAOIs are considered second-line agents.[42, 43] MAOIs and TCAs are not commonly used in this setting. Although both are effective, the former carry a risk of drug-to-drug and dietary interactions, and the latter have tolerability issues.

Antihypertensive beta-blocker therapy can be used as an augmentation strategy. Propranolol may be useful for the circumscribed treatment of situational/performance anxiety on an as-needed basis.[44]

Selected anticonvulsants (eg, gabapentin, pregabalin, valproic acid, topiramate, and tiagabine) have been shown to be effective for social anxiety disorder in mostly open-label, uncontrolled clinical trials.[43] The evidence regarding the serotonin 1 (5HT-1) agonist buspirone in this setting is conflicting.[43] A few other medications, including the second-generation antipsychotics levetiracetam and D-cycloserine, have been considered, but at present, the evidence is insufficient evidence to permit any clear recommendations.[42, 43]

Acute treatment

Treatment of social anxiety disorder should be initiated with an SSRI, titrated to the minimum effective dosage. If the response is partial or nonexistent at 6 weeks, the dosage may be increased; this may be done every 2 weeks until the maximum dose is reached.

Patients in whom SSRI therapy fails will sometimes respond to treatment with a high-potency benzodiazepine (eg, clonazepam), an alpha-2-delta calcium channel blocker (eg, gabapentin or pregabalin), the antiepileptic levetiracetam, or the antipsychotic olanzapine; they may also respond to combined SSRI-benzodiazepine therapy.[37, 44, 45]

Buspirone, the beta-blocker atenolol, and the TCA imipramine are all of unproven efficacy in this setting.[37]

Long-term treatment

Long-term treatment data from double-blind, randomized controlled trials addressing social anxiety disorder show that continuing SSRI or venlafaxine therapy for up to 6 months can result in increased treatment response rates.[37] Long-term treatment data on clonazepam are limited but support the long-term efficacy of this drug.[37, 44, 46]

Beta-blockers, clonidine, and buspirone usually are not helpful for long-term treatment of social anxiety disorder. After 6-12 months of full response, slow tapering of pharmacotherapy should be considered. If symptoms recur after tapering, therapy should be restarted and continued indefinitely.[46]

Specific phobia

To date, no controlled studies have demonstrated the efficacy of psychopharmacologic intervention for specific phobias. Clinical lore suggests that as-needed administration of a short-acting benzodiazepine might be useful for temporary anxiety relief in specific situations (eg, right before boarding a plane, for patients with a fear of flying).

Agoraphobia

Randomized, double-blind, placebo-controlled trials have shown that agoraphobia, specifically the panic symptoms, responds to treatment with SSRIs (eg, escitalopram, citalopram, fluoxetine, fluvoxamine, paroxetine, and sertraline),[47, 48, 49] venlafaxine and reboxetine, some TCAs (eg, clomipramine and imipramine), and some benzodiazepines (eg, alprazolam, lorazepam, diazepam, and clonazepam).[37] Data from comparator-controlled trials suggest that mirtazapine and moclobemide are reasonable alternatives.[37]

Acute treatment

Treatment for agoraphobia should be started with an SSRI at a low dosage, which is then titrated to the minimum dosage that effectively controls the patient’s panic. Benzodiazepines can be used either as an adjunct or as primary treatment; however, they are usually not chosen as first-line therapy because of the potential for abuse.[50] If the patient has frequent panic attacks and no history of substance abuse, a benzodiazepine may be considered until the SSRI takes effect.

If the response is minimal or nonexistent after 6 weeks, the SSRI dosage may be further increased every 2 weeks until a response is achieved or the maximal dosage reached. If the response is partial or absent at the highest SSRI dosage, the following alternatives should be considered:

  • Switch to a different SSRI
  • Switch to an agent from a different drug class (eg, venlafaxine, reboxetine, or a TCA

Long-acting benzodiazepines (eg, diazepam and clonazepam) prescribed on a standing rather than an as-needed basis are preferred because of the reduced addictive potential; the dosage can be increased every 2-3 days until either the panic symptoms are controlled or the maximum dosage is reached. The short-acting agent alprazolam may be considered for short-term use to control acute symptoms of panic.

Agents with unproven efficacy in this setting include buspirone, propranolol, antihistaminic drugs, and antipsychotic agents.[37]

Long-term treatment

Double-blind studies show that continuing an SSRI or clomipramine from 12 to 52 weeks results in increased treatment response rates.[37] For a patient with good response, treatment should be continued for 9-12 months before slow tapering of the medications is considered. If symptoms recur after tapering, treatment should be resumed and continued indefinitely.

Pediatric, adolescent, and young adult suicidality

Suicide risk must always be considered, particularly in the treatment of a child or adolescent with a mood disorder. Physicians are advised to be aware of the following information and use appropriate caution when considering treatment with SSRIs in the pediatric and geriatric populations.

In October 2003, the 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 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.

In December 2003, the UK Medicines and Healthcare Products Regulatory Agency (MHRA) issued an advisory stating that most SSRIs are not suitable for use by persons younger than 18 years for treatment of “depressive illness.” After review, the MHRA decided that the risks that SSRI therapy posed to pediatric patients outweighed the benefits, except in the case of fluoxetine, which appeared to have a positive risk-benefit ratio in the treatment of depressive illness in patients younger than 18 years.

Previous
Next

Psychotherapy

Controlled studies have found behavioral therapy and cognitive behavioral therapy (CBT) to be effective in treating phobic disorders.[51] Computerized CBT (FearFighter) has been recommended for panic and phobia by the National Institute for Health and Clinical Excellence guidelines (NICE).[52]

Psychodynamic therapy (or insight-oriented therapy) is rarely indicated as an exclusive treatment for phobias and is now mostly reserved 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.

Social anxiety disorder (social phobia)

For treatment of social anxiety disorder, self-exposure monotherapy has been shown to work as well as computer-based exposure training, clinician-led exposure, or combination therapies of self-exposure and CBT/self-help manual.[53] 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.[54, 55]

Specific phobia

A CBT-based approach, including gradual desensitization, is the most commonly used treatment for specific phobia. Other treatments include relaxation and breathing control techniques.

Randomized controlled clinical trials indicate that specific phobias respond to exposure therapy.[56] A small, randomized controlled clinical trial showed that virtual reality exposure therapy is as effective as standard exposure for treating fear of flying, with gains maintained for up to 1 year after treatment.[57]

In one study, after the successful completion of a 4-session CBT course, patients with specific phobias no longer showed significant functional magnetic resonance imaging (fMRI) activation in the prefrontal or parahippocampal areas[58] ; this finding supports the view that effective psychotherapy can normalize dysfunction in the neurocircuitry associated with anxiety and phobias.

In another study, a single 4-hour CBT session, combined in vivo exposure, and modeling resulted in increased/improved medial orbitofrontal cortex activity and decreased/improved activation in the amygdala and the insula patients with specific phobias as compared with untreated control subjects.[59]

Agoraphobia

A 2010 meta-analysis showed that a combination of exposure therapy, relaxation, and breathing retraining worked better than other psychological interventions for panic disorder with and without agoraphobia.[60] Furthermore, the inclusion of homework and a follow-up program have been shown to improve outcomes. Early intervention is recommended on the grounds that the shorter the duration of illness is, the better the response will be.[60]

Previous
Next

Diet and Activity

The patient’s intake of caffeine (eg, in coffee, caffeinated teas, or sodas) should be assessed; even moderate amounts of caffeine may 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 disorder.[61] Dietary restrictions (a tyramine-free diet) are necessary for patients taking MAOIs.

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

Previous
Next

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 (eg, psychotherapy or medication) in the early stages of symptom development may be beneficial in preventing the worsening of symptoms.

Previous
Next

Consultations

Physicians without expertise in conducting behavioral therapy may want to consult with a psychiatric center specializing in treatment of anxiety disorders, either for guidance on developing a treatment plan or, in more difficult cases, for referral.

Consultation with an internist or a neurologist may be helpful for sorting through the nonpsychiatric differential diagnosis, especially if rare disorders, such as pheochromocytoma, are suspected (see Differentials).

Previous
Next

Long-Term Monitoring

Inpatient treatment is indicated only for patients with a severe phobic disorder who presenting with acute suicidal ideation or attempts. In addition, inpatient treatment (including detoxification, rehabilitation, or both) may be recommended for treatment of secondary drug or alcohol abuse or dependence.

Outpatient follow-up is usually required until the patient’s symptoms have resolved. After the resolution of the symptoms, the physician can attempt to taper pharmacotherapy, as well as monitor for relapse.

Previous
 
 
Contributor Information and Disclosures
Author

Adrian Preda, MD Professor of Clinical Psychiatry and Human Behavior, Director of Residency Program in Psychiatry, Vice-Chair, Department of Psychiatry and Human Behavior, University of California, Irvine, School of Medicine

Adrian Preda, MD is a member of the following medical societies: American Association for the Advancement of Science, American Psychiatric Association, International College of Neuropsychopharmacology, International Congress of Schizophrenia Research, Schizophrenia International Research Society, Society of Biological Psychiatry

Disclosure: Nothing to disclose.

Chief Editor

Iqbal Ahmed, MBBS, FRCPsych(UK) Faculty, Department of Psychiatry, Tripler Army Medical Center; Clinical Professor of Psychiatry, Uniformed Services University of the Health Sciences; Clinical Professor of Psychiatry, Clinical Professor of Geriatric Medicine, University of Hawaii, John A Burns School of Medicine

Iqbal Ahmed, MBBS, FRCPsych(UK) is a member of the following medical societies: Academy of Psychosomatic Medicine, American Neuropsychiatric Association, American Society of Clinical Psychopharmacology, Royal College of Psychiatrists, American Association for Geriatric Psychiatry, American Psychiatric Association

Disclosure: Nothing to disclose.

Acknowledgements

Mohammed A Memon, MD Chairman and Attending Geriatric Psychiatrist, Department of Psychiatry, Spartanburg Regional Medical Center

Mohammed A Memon, MD is a member of the following medical societies: American Association for Geriatric Psychiatry, American Medical Association, and American Psychiatric Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

References
  1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). Washington, DC: American Psychiatric Association Press; 2000.

  2. Mathew SJ, Coplan JD, Gorman JM. Neurobiological mechanisms of social anxiety disorder. Am J Psychiatry. 2001 Oct. 158(10):1558-67. [Medline].

  3. Kendler KS, Karkowski LM, Prescott CA. Fears and phobias: reliability and heritability. Psychol Med. 1999 May. 29(3):539-53. [Medline].

  4. Fyer AJ, Mannuzza S, Chapman TF, Liebowitz MR, Klein DF. A direct interview family study of social phobia. Arch Gen Psychiatry. 1993 Apr. 50(4):286-93. [Medline].

  5. Van Houtem CM, Laine ML, Boomsma DI, Ligthart L, van Wijk AJ, De Jongh A. A review and meta-analysis of the heritability of specific phobia subtypes and corresponding fears. J Anxiety Disord. 2013 May. 27(4):379-88. [Medline].

  6. LeBeau RT, Glenn D, Liao B, et al. Specific phobia: a review of DSM-IV specific phobia and preliminary recommendations for DSM-V. Depress Anxiety. 2010 Feb. 27(2):148-67. [Medline].

  7. Linares IM, Trzesniak C, Chagas MH, Hallak JE, Nardi AE, Crippa JA. Neuroimaging in specific phobia disorder: a systematic review of the literature. Rev Bras Psiquiatr. 2012 Mar. 34(1):101-11. [Medline].

  8. Tillfors M, Furmark T, Marteinsdottir I, Fredrikson M. Cerebral blood flow during anticipation of public speaking in social phobia: a PET study. Biol Psychiatry. 2002 Dec 1. 52(11):1113-9. [Medline].

  9. Tillfors M, Furmark T, Marteinsdottir I, Fischer H, Pissiota A, Långström B, et al. Cerebral blood flow in subjects with social phobia during stressful speaking tasks: a PET study. Am J Psychiatry. 2001 Aug. 158(8):1220-6. [Medline].

  10. Lanzenberger RR, Mitterhauser M, Spindelegger C, Wadsak W, Klein N, Mien LK, et al. Reduced serotonin-1A receptor binding in social anxiety disorder. Biol Psychiatry. 2007 May 1. 61(9):1081-9. [Medline].

  11. Lanzenberger R, Wadsak W, Spindelegger C, Mitterhauser M, Akimova E, Mien LK, et al. Cortisol plasma levels in social anxiety disorder patients correlate with serotonin-1A receptor binding in limbic brain regions. Int J Neuropsychopharmacol. 2010 Oct. 13(9):1129-43. [Medline].

  12. Freitas-Ferrari MC, Hallak JE, Trzesniak C, Filho AS, Machado-de-Sousa JP, Chagas MH, et al. Neuroimaging in social anxiety disorder: a systematic review of the literature. Prog Neuropsychopharmacol Biol Psychiatry. 2010 May 30. 34(4):565-80. [Medline].

  13. Ahs F, Pissiota A, Michelgård A, Frans O, Furmark T, Appel L, et al. Disentangling the web of fear: amygdala reactivity and functional connectivity in spider and snake phobia. Psychiatry Res. 2009 May 15. 172(2):103-8. [Medline].

  14. Caseras X, Giampietro V, Lamas A, Brammer M, Vilarroya O, Carmona S, et al. The functional neuroanatomy of blood-injection-injury phobia: a comparison with spider phobics and healthy controls. Psychol Med. 2010 Jan. 40(1):125-34. [Medline].

  15. Straube T, Mentzel HJ, Miltner WH. Waiting for spiders: brain activation during anticipatory anxiety in spider phobics. Neuroimage. 2007 Oct 1. 37(4):1427-36. [Medline].

  16. Kessler RC, Petukhova M, Sampson NA, Zaslavsky AM, Wittchen HU. Twelve-month and lifetime prevalence and lifetime morbid risk of anxiety and mood disorders in the United States. Int J Methods Psychiatr Res. 2012 Sep. 21(3):169-84. [Medline]. [Full Text].

  17. Lewis-Fernández R, Hinton DE, Laria AJ, et al. Culture and the anxiety disorders: recommendations for DSM-V. Depress Anxiety. 2010 Feb. 27(2):212-29. [Medline].

  18. Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005 Jun. 62(6):593-602. [Medline].

  19. Wolitzky-Taylor KB, Castriotta N, Lenze EJ, Stanley MA, Craske MG. Anxiety disorders in older adults: a comprehensive review. Depress Anxiety. 2010 Feb. 27(2):190-211. [Medline].

  20. Ruscio AM, Brown TA, Chiu WT, Sareen J, Stein MB, Kessler RC. Social fears and social phobia in the USA: results from the National Comorbidity Survey Replication. Psychol Med. 2008 Jan. 38(1):15-28. [Medline]. [Full Text].

  21. Ollendick TH, King NJ, Muris P. Fears and phobias in children: phenomenology, epidemiology and aetiology. Child Adolesc Ment Health. 2002. 7:98–106.

  22. Wittchen HU, Jacobi F, Rehm J, et al. The size and burden of mental disorders and other disorders of the brain in Europe 2010. Eur Neuropsychopharmacol. 2011 Sep. 21(9):655-79. [Medline].

  23. Beesdo K, Knappe S, Pine DS. Anxiety and anxiety disorders in children and adolescents: developmental issues and implications for DSM-V. Psychiatr Clin North Am. 2009 Sep. 32(3):483-524. [Medline]. [Full Text].

  24. Kessler RC, Chiu WT, Jin R, Ruscio AM, Shear K, Walters EE. The epidemiology of panic attacks, panic disorder, and agoraphobia in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2006 Apr. 63(4):415-24. [Medline]. [Full Text].

  25. Fehm L, Pelissolo A, Furmark T, Wittchen HU. Size and burden of social phobia in Europe. Eur Neuropsychopharmacol. 2005 Aug. 15(4):453-62. [Medline].

  26. Wittchen HU, Stein MB, Kessler RC. Social fears and social phobia in a community sample of adolescents and young adults: prevalence, risk factors and co-morbidity. Psychol Med. 1999 Mar. 29(2):309-23. [Medline].

  27. Wittchen HU, Gloster AT, Beesdo-Baum K, Fava GA, Craske MG. Agoraphobia: a review of the diagnostic classificatory position and criteria. Depress Anxiety. 2010 Feb. 27(2):113-33. [Medline].

  28. Bruce SE, Yonkers KA, Otto MW, Eisen JL, Weisberg RB, Pagano M, et al. Influence of psychiatric comorbidity on recovery and recurrence in generalized anxiety disorder, social phobia, and panic disorder: a 12-year prospective study. Am J Psychiatry. 2005 Jun. 162(6):1179-87. [Medline].

  29. Schneier FR, Heckelman LR, Garfinkel R, Campeas R, Fallon BA, Gitow A, et al. Functional impairment in social phobia. J Clin Psychiatry. 1994 Aug. 55(8):322-31. [Medline].

  30. 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 Sep-Oct. 36(5):255-62. [Medline].

  31. Matza LS, Revicki DA, Davidson JR, Stewart JW. Depression with atypical features in the National Comorbidity Survey: classification, description, and consequences. Arch Gen Psychiatry. 2003 Aug. 60(8):817-26. [Medline].

  32. 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. 2005 Nov. 62(11):1249-57. [Medline].

  33. Stein MB, Stein DJ. Social anxiety disorder. Lancet. 2008 Mar 29. 371(9618):1115-25. [Medline].

  34. Beesdo K, Bittner A, Pine DS, Stein MB, Höfler M, Lieb R, et al. Incidence of social anxiety disorder and the consistent risk for secondary depression in the first three decades of life. Arch Gen Psychiatry. 2007 Aug. 64(8):903-12. [Medline].

  35. Magee WJ, Eaton WW, Wittchen HU, McGonagle KA, Kessler RC. Agoraphobia, simple phobia, and social phobia in the National Comorbidity Survey. Arch Gen Psychiatry. 1996 Feb. 53(2):159-68. [Medline].

  36. Liotti G. Phobias of Attachment-Related Inner States in the Psychotherapy of Adult Survivors of Childhood Complex Trauma. J Clin Psychol. 2013 Aug 28. [Medline].

  37. Baldwin DS, Anderson IM, Nutt DJ, Bandelow B, Bond A, Davidson JR, et al. Evidence-based guidelines for the pharmacological treatment of anxiety disorders: recommendations from the British Association for Psychopharmacology. J Psychopharmacol. 2005 Nov. 19(6):567-96. [Medline].

  38. de Beurs E, van Balkom AJ, Van Dyck R, Lange A. Long-term outcome of pharmacological and psychological treatment for panic disorder with agoraphobia: a 2-year naturalistic follow-up. Acta Psychiatr Scand. 1999 Jan. 99(1):59-67. [Medline].

  39. Pelissolo A. [Efficacy and tolerability of escitalopram in anxiety disorders: a review]. Encephale. 2008 Sep. 34(4):400-8. [Medline].

  40. National Prescribing Service Limited. Escitalopram (Lexapro, Esipram) for generalised anxiety disorder and social anxiety disorder (social phobia). NPS RADAR. Available at http://bit.ly/dOARMJ.

  41. Stein DJ, Ipser JC, van Balkom AJ. Pharmacotherapy for social anxiety disorder. Cochrane Review. Chichester, UK: John Wiley and Sons, Ltd; 2009.

  42. Westenberg HG. Recent advances in understanding and treating social anxiety disorder. CNS Spectr. 2009 Feb. 14(2 Suppl 3):24-33. [Medline].

  43. Ravindran LN, Stein MB. The pharmacologic treatment of anxiety disorders: a review of progress. J Clin Psychiatry. 2010 Jul. 71(7):839-54. [Medline].

  44. Davidson JR. Pharmacotherapy of social anxiety disorder: what does the evidence tell us?. J Clin Psychiatry. 2006. 67 Suppl 12:20-6. [Medline].

  45. Offidani E, Guidi J, Tomba E, Fava GA. Efficacy and Tolerability of Benzodiazepines versus Antidepressants in Anxiety Disorders: A Systematic Review and Meta-Analysis. Psychother Psychosom. 2013 Sep 20. 82(6):355-362. [Medline].

  46. Van Ameringen M, Allgulander C, Bandelow B, Greist JH, Hollander E, Montgomery SA, et al. WCA recommendations for the long-term treatment of social phobia. CNS Spectr. 2003 Aug. 8(8 Suppl 1):40-52. [Medline].

  47. Practice guideline for the treatment of patients with panic disorder. Work Group on Panic Disorder. American Psychiatric Association. Am J Psychiatry. 1998 May. 155(5 Suppl):1-34. [Medline].

  48. Pohl RB, Wolkow RM, Clary CM. Sertraline in the treatment of panic disorder: a double-blind multicenter trial. Am J Psychiatry. 1998 Sep. 155(9):1189-95. [Medline].

  49. Michelson D, Lydiard RB, Pollack MH, Tamura RN, Hoog SL, Tepner R, et al. 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. 1998 Nov. 155(11):1570-7. [Medline].

  50. 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].

  51. Shear MK, Beidel DC. Psychotherapy in the overall management strategy for social anxiety disorder. J Clin Psychiatry. 1998. 59 Suppl 17:39-46. [Medline].

  52. [Guideline] Mayor S. NICE advocates computerised CBT. BMJ. 2006 Mar 4. 332(7540):504. [Medline]. [Full Text].

  53. Barlow JH, Ellard DR, Hainsworth JM, Jones FR, Fisher A. A review of self-management interventions for panic disorders, phobias and obsessive-compulsive disorders. Acta Psychiatr Scand. 2005 Apr. 111(4):272-85. [Medline].

  54. Masia Warner C, Fisher PH, Shrout PE, Rathor S, Klein RG. Treating adolescents with social anxiety disorder in school: an attention control trial. J Child Psychol Psychiatry. 2007 Jul. 48(7):676-86. [Medline].

  55. Bunnell BE, Beidel DC, Mesa F. A Randomized Trial of Attention Training for Generalized Social Phobia: Does Attention Training Change Social Behavior?. Behav Ther. 2013 Dec. 44(4):662-673. [Medline].

  56. Ayala ES, Meuret AE, Ritz T. Treatments for blood-injury-injection phobia: a critical review of current evidence. J Psychiatr Res. 2009 Oct. 43(15):1235-42. [Medline].

  57. Rothbaum BO, Anderson P, Zimand E, Hodges L, Lang D, Wilson J. Virtual reality exposure therapy and standard (in vivo) exposure therapy in the treatment of fear of flying. Behav Ther. 2006 Mar. 37(1):80-90. [Medline].

  58. Paquette V, Lévesque J, Mensour B, Leroux JM, Beaudoin G, Bourgouin P, et al. "Change the mind and you change the brain": effects of cognitive-behavioral therapy on the neural correlates of spider phobia. Neuroimage. 2003 Feb. 18(2):401-9. [Medline].

  59. Schienle A, Schäfer A, Hermann A, Rohrmann S, Vaitl D. Symptom provocation and reduction in patients suffering from spider phobia: an fMRI study on exposure therapy. Eur Arch Psychiatry Clin Neurosci. 2007 Dec. 257(8):486-93. [Medline].

  60. Sánchez-Meca J, Rosa-Alcázar AI, Marín-Martínez F, Gómez-Conesa A. Psychological treatment of panic disorder with or without agoraphobia: a meta-analysis. Clin Psychol Rev. 2010 Feb. 30(1):37-50. [Medline].

  61. Hudson C, Hudson S, MacKenzie J. Protein-source tryptophan as an efficacious treatment for social anxiety disorder: a pilot study. Can J Physiol Pharmacol. 2007 Sep. 85(9):928-32. [Medline].

 
Previous
Next
 
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.