eMedicine Specialties > Pediatrics: Developmental and Behavioral > Medical Topics

Anxiety Disorder, Specific Phobia: Treatment & Medication

Author: Sandra L Friedman, MD, MPH, Assistant Professor of Pediatrics, Harvard University Medical School; Director of Pediatrics, LEND/UCEDD, Department of Medicine, Division of General Pediatrics, Children's Hospital of Boston
Coauthor(s): Kerim M Munir, MD, MPH, DSc, Director of Psychiatry, LEND/UCEDD, Division of General Pediatrics, Dir of Mental Health and Developmental Disabilities (MHDD) Training Prog, Children's Hospital Boston; Marilyn T Erickson, PhD, Professor Emeritus, Department of Psychology, Virginia Commonwealth University
Contributor Information and Disclosures

Updated: Dec 5, 2008

Treatment

Medical Care

  • Behavior therapy: This is the first-line treatment.
    • Exposure therapy
      • The patient is repeatedly exposed to the feared stimulus until the anxiety response it elicits is habituated. One-session treatment, as long as 3 hours, combining exposure therapy in a fear hierarchy with participant modeling, cognitive components, and reinforcement is a promising form of treatment in patients with specific phobias (SPs).5
      • Especially in children, a gradual exposure program is developed, in which the least-feared stimulus in a fear hierarchy is presented first, followed sequentially over time (in a graduated manner) by the more feared stimuli in the hierarchy. Fear hierarchies are created by the behavior therapist in collaboration with the child and parents.
      • Exposure to the feared stimulus may be conducted in real-life or imaginary contexts, in which the child is requested to visualize the feared object or situation. The longer the child is exposed to the aversive stimulus, the greater the likelihood that habituation occurs and anxiety decreases.
    • Cognitive behavioral therapy: These procedures are used when the therapist determines that the maintenance of the phobia may have a significant cognitive component. Procedures may include those in which the child is taught skills for contingency management, modeling management, and self-control. Applied tension and relaxation may be introduced, as well as improvement of specific skill deficits. No significant differences in outcome have been reported comparing individual cognitive behavioral therapy with group cognitive behavioral therapy, with improvements noted in both types of therapeutic settings.6
  • Psychotherapy: This type of therapy is not generally used to treat the specific phobia. However, the presence of an increasingly complex or disabling profile may require individual and family psychotherapy.
  • Psychopharmacology: This type of treatment is generally felt to have limited use in the treatment of specific phobia, with behavioral therapy being the main route of intervention. In some instances, selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine, sertraline, fluvoxamine, citalopram, and paroxetine, have been reported to be effective. SSRIs have been used as adjunctive therapy because patients may have coexisting anxiety disorders (See Medication).
  • Computer technology: Virtual reality exposure therapy, using a computer to provide graded exposures, has been reported. However, use of this technology has not been well studied in children.

Medication

Although behavioral therapy is the main route of intervention for specific phobias (SPs) that interferes with functioning, case reports have documented improvement of symptoms with the use of selective serotonin reuptake inhibitors (SSRIs); benzodiazepines have not been shown to be effective.

Selective serotonin reuptake inhibitors (SSRIs)

These antidepressant agents have been used as antianxiety medication to treat anxiety disorders such as panic disorders (with or without agoraphobia), generalized anxiety disorders, obsessive compulsive disorders, and specific phobias.

SSRIs are now strongly preferred over other classes of antidepressants, both in terms of their clinical efficacy and tolerability. The adverse effect profile of SSRIs is less prominent, with improved compliance. These agents also do not have the cardiac arrhythmia risk associated with tricyclic antidepressants (tertiary and secondary amine). Arrhythmia risk is especially pertinent in accidental and intentional overdose. The suicide risk must always be considered when a child or adolescent with mood disorder is treated with any psychotropic medication, including SSRIs.

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.
  • A more recent study, published in 2006, evaluated records of more than 65,000 children and adults treated for depression over a 10-year period. Results of this study did not support an increase in suicide risk or attempts after antidepressant medication was started or a higher risk with the newer types of antidepressant medication.7 However, close frequent monitoring of any patient treated with psychotropic medications remains imperative.


Fluoxetine (Prozac)

Selectively inhibits presynaptic serotonin reuptake with minimal or no effect in the reuptake of norepinephrine or dopamine.

Adult

20 mg/d PO in am and increase after several wk by 20 mg/d; not to exceed 80 mg/d
Note: If patient is taking 20 mg/d, may initiate once-weekly dosing with the 90-mg delayed-release product 7 d after the last daily dose of 20 mg

Pediatric

<8 years: Not established
>8 years: 10-20 mg PO qd

Increases toxicity of diazepam and trazodone by decreasing clearance; also increases toxicity of MAOIs and highly protein-bound drugs; 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 or recent (within 2 wk) MAOI administration; coadministration with thioridazine (both MAOIs and thioridazine are now rarely used)

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 fluoxetine therapy is initiated


Fluvoxamine (Luvox)

Potent selective inhibitor of neuronal serotonin reuptake. Does not significantly bind to alpha-adrenergic, histamine, or cholinergic receptors.

Adult

50 mg PO qhs initially; may increase gradually; not to exceed 300 mg/d
Divided daily doses bid if >100 mg/d

Pediatric

>8 years: 25 mg PO qhs initially; may increase gradually; not to exceed 200 mg/d; may be administered either qd or divided bid

CYP3A4 inhibitor; 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%; also, reduce the dose of theophylline by one third 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 before SSRI use

Documented hypersensitivity; concurrent or recent (within 2 wk) MAOI administration

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; may cause hyponatremia


Paroxetine (Paxil)

Potent selective inhibitor of neuronal serotonin reuptake. Also has a weak effect on norepinephrine and dopamine neuronal reuptake.

Adult

20 mg/d PO initially; may increase gradually prn; not to exceed 60 mg/d
Use lower starting dose (ie, 10 mg) for elderly persons or in patients with renal or hepatic dysfunction

Pediatric

>8 years: 5-10 mg PO qd initially; may increase by 5 mg/wk; not to exceed 30 mg/d

CYP2D6 inhibitor; phenobarbital and phenytoin decrease effects of paroxetine; alcohol, cimetidine, sertraline, phenothiazines, and warfarin increase toxicity of paroxetine; 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 before SSRI use

Documented hypersensitivity; concurrent or recent (within 2 wk) MAOI administration

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, or suicide attempt; caution in cardiac, hepatic, or renal disease; may cause hyponatremia

More on Anxiety Disorder, Specific Phobia

Overview: Anxiety Disorder, Specific Phobia
Differential Diagnoses & Workup: Anxiety Disorder, Specific Phobia
Treatment & Medication: Anxiety Disorder, Specific Phobia
Follow-up: Anxiety Disorder, Specific Phobia
References
[ CLOSE WINDOW ]

References

  1. American Psychiatric Association. Anxiety disorders. In: Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: APA; 1994:393-444.

  2. NIMH. Anxiety disorders. National institutes of Mental Health. Available at http://www.nimh.nih.gov/publicat/anxiety.cfm. Accessed Last accessed January 13, 2006.

  3. Biel MG, Klein RG, Mannuzza S, et al. Does major depressive disorder in parents predict specific fears and phobias in offspring?. Depress Anxiety. 2008;25(5):379-82. [Medline].

  4. Cooke LJ, Haworth CM, Wardle J. Genetic and environmental influences on children's food neophobia. Am J Clin Nutr. Aug 2007;86(2):428-33. [Medline].

  5. Zlomke K, Davis TE 3rd. One-session treatment of specific phobias: a detailed description and review of treatment efficacy. Behav Ther. Sep 2008;39(3):207-23. [Medline].

  6. Liber JM, Van Widenfelt BM, Utens EM, et al. No differences between group versus individual treatment of childhood anxiety disorders in a randomised clinical trial. J Child Psychol Psychiatry. Aug 2008;49(8):886-93. [Medline].

  7. Simon GE, Savarino J, Operskalski B, Wang PS. Suicide risk during antidepressant treatment. Am J Psychiatry. Jan 2006;163(1):41-7. [Medline].

  8. Robinson J, Sareen J, Cox BJ, Bolton J. Self-medication of anxiety disorders with alcohol and drugs: Results from a nationally representative sample. J Anxiety Disord. Mar 22 2008;[Medline].

  9. Abene MV, Hamilton JD. Resolution of fear of flying with fluoxetine treatment. J Anxiety Disord. Nov-Dec 1998;12(6):599-603. [Medline].

  10. Albano AM, Chorpita BF. Treatment of anxiety disorders of childhood. Psychiatr Clin North Am. Dec 1995;18(4):767-84. [Medline].

  11. Antony MM, Barlow DH. Social and specific phobias. In: Tasman A, Kay J, Lieberman JA, eds. Psychiatry. Philadelphia, PA: WB Saunders; 1997:1037-59.

  12. Balon R. Fluvoxamine for phobia of storms. Acta Psychiatr Scand. Sep 1999;100(3):244-5; discussion 245-6. [Medline].

  13. Benjamin J, Ben-Zion IZ, Karbofsky E, et al. Double-blind placebo-controlled pilot study of paroxetine for specific phobia. Psychopharmacology (Berl). Apr 2000;149(2):194-6. [Medline].

  14. Bernstein GA, Shaw K. Practice parameters for the assessment and treatment of children and adolescents with anxiety disorders. American Academy of Child and Adolescent Psychiatry. J Am Acad Child Adolesc Psychiatry. Oct 1997;36(10 Suppl):69S-84S. [Medline].

  15. Bolton D, Eley TC, O'Connor TG, et al. Prevalence and genetic and environmental influences on anxiety disorders in 6-year-old twins. Psychol Med. Mar 2006;36(3):335-44. [Medline].

  16. Craske MC, Waters AM. Panic disorder, phobias, and generalized anxiety disorder. Annu Rev Clin Psychol. 2005;1:197-225.

  17. Emmelkamp PM. Technological innovations in clinical assessment and psychotherapy. Psychother Psychosom. 2005;74(6):336-43. [Medline].

  18. Erickson MT. Behavior Disorders of Children and Adolescents: Assessment, Etiology, and Intervention. 3rd ed. Prentice-Hall; 1998:251-9.

  19. Essau CA, Conradt J, Petermann F. Frequency, comorbidity, and psychosocial impairment of specific phobia in adolescents. J Clin Child Psychol. Jun 2000;29(2):221-31. [Medline].

  20. Fairbanks JM, Pine DS, Tancer NK, et al. Open fluoxetine treatment of mixed anxiety disorders in children and adolescents. J Child Adolesc Psychopharmacol. Spring 1997;7(1):17-29. [Medline].

  21. Goodwin RD, Gotlib IH. Panic attacks and psychopathology among youth. Acta Psychiatr Scand. Mar 2004;109(3):216-21. [Medline].

  22. Ollendick TH, Hersen M, Cllendick TH, eds. Handbook of Child Psychopathology. 3rd ed. Plenum; 1998:243-60.

  23. Kendall PC, Howard BL, Epps J. The anxious child. Cognitive-behavioral treatment strategies. Behav Modif. Apr 1988;12(2):281-310. [Medline].

  24. Muris P, Schmidt H, Merckelbach H. The structure of specific phobia symptoms among children and adolescents. Behav Res Ther. Sep 1999;37(9):863-8. [Medline].

  25. Reinblatt SP, Walkup JT. Psychopharmacologic treatment of pediatric anxiety disorders. Child Adolesc Psychiatr Clin N Am. Oct 2005;14(4):877-908, x. [Medline].

  26. Silverman WK, Ginsburg GS. Specific phobia and generalized anxiety disorder. In: March JS, ed. Anxiety Disorders in Children and Adolescents. New York, NY: Guilford Press; 1995:151-80.

  27. Silverman WK, Kearney CA. Listening to our clinical partners: informing researchers about children's fears and phobias. J Behav Ther Exp Psychiatry. Jun 1992;23(2):71-6. [Medline].

  28. Silverman WK, Moreno J. Specific phobia. Child Adolesc Psychiatr Clin N Am. Oct 2005;14(4):819-43, ix-x. [Medline].

  29. Straube T, Mentzel HJ, Glauer M, Miltner WH. Brain activation to phobia-related words in phobic subjects. Neurosci Lett. Dec 6 2004;372(3):204-8. [Medline].

  30. Strauss CC, Last CG. Social and simple phobias in children. J Anxiety Disorders. 1993;2:141-52.

  31. Wilhelm K, Boyce P, Brownhill S. The relationship between interpersonal sensitivity, anxiety disorders and major depression. J Affect Disord. Apr 2004;79(1-3):33-41. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

anxiety disorder, specific phobia, SP, simple phobia, fears, fear, morbid dread, panic, animal phobia, zoophobia, blood-injection-injury phobia, environmental phobia, situational phobia, environmental-situational phobia, phobic avoidance, persistent fear, irrational fear, tremor, fainting, shaking, tantrums, behavioral inhibition, unreasonable fear, excessive fear, height phobia, fear of heights, claustrophobia, social phobia, major depressive disorder

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Sandra L Friedman, MD, MPH, Assistant Professor of Pediatrics, Harvard University Medical School; Director of Pediatrics, LEND/UCEDD, Department of Medicine, Division of General Pediatrics, Children's Hospital of Boston
Sandra L Friedman, MD, MPH is a member of the following medical societies: American Academy of Pediatrics and American Medical Directors Association
Disclosure: Nothing to disclose.

Coauthor(s)

Kerim M Munir, MD, MPH, DSc, Director of Psychiatry, LEND/UCEDD, Division of General Pediatrics, Dir of Mental Health and Developmental Disabilities (MHDD) Training Prog, Children's Hospital Boston
Kerim M Munir, MD, MPH, DSc is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry and American Psychiatric Association
Disclosure: Nothing to disclose.

Marilyn T Erickson, PhD, Professor Emeritus, Department of Psychology, Virginia Commonwealth University
Disclosure: Nothing to disclose.

Medical Editor

Chet Johnson, MD, Medical Director, Child Development Unit, Department of Pediatrics, Professor, University of Kansas Medical Center
Chet Johnson, MD is a member of the following medical societies: American Academy of Pediatrics
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

CME Editor

Daniel Rauch, MD, FAAP, Director, Pediatric Hospitalist Program, Associate Professor, Department of Pediatrics, New York University School of Medicine
Daniel Rauch, MD, FAAP is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, and Society of Hospital Medicine
Disclosure: Baxter Honoraria Consulting

Chief Editor

Caroly Pataki, MD, Professor of Clinical Psychiatry and Behavioral Sciences, Department of Psychiatry, Division Chair, Child and Adolescent Psychiatry, Director of Training, Child and Adolescent Psychiatry Residency Program, University of Southern California Keck School of Medicine
Caroly Pataki, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, New York Academy of Sciences, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.