Anxiety Disorders Treatment - Phobias

Most anxiety disorders are readily treatable with a combination of psychotherapy and medication. Learn the details of these treatments and other treatment options for generalized anxiety disorder, panic disorder, agoraphobia, social phobia, specific phobia, and post-traumatic stress disorder/acute stress disorder. Treatments for anxiety depend upon the specific disorder diagnosed by a trained mental health professional. Below you will find some general treatment guidelines for different Anxiety Disorders.

This document deals with the treatment of Phobias (fears). Other available documents deal with the treatment of Panic-Related Anxiety (including Agoraphobia), Trauma and Generalized Anxiety

Social Phobia

Introduction

Social phobia is the most common anxiety disorder in the population. Both men and women experience it equally. The greatest single fear that exists for people is the fear of giving a public presentation or talk, which is a symptom of social phobia. This is because at the root of social phobia is the excessive fear of either being scrutinized by others or of performing a behavior out of anxiety in front of others that might be embarrassing or humiliating, such as speaking unclearly, trembling, or even blushing.

For those suffering from social phobia it can greatly affect the quality of their lives. Oftentimes, because of the extreme anxiety those with social phobia experience during interactions with others, they avoid many social opportunities. Some have had their career potential significantly thwarted if their career advancement has rested upon giving public presentations or developing career networking relationships. Others with social phobia struggle with feelings of loneliness because their social anxiety gets in the way of pursuing dating opportunities or they may avoid social gatherings such as parties.

Social phobia can often be confused with shyness. However, for the majority of those suffering with social phobia they tend not to be shy around those they are familiar with; they can even be quite outgoing when there is not the fear of making an impression on someone whose opinion of them is unknown. Also, those with social phobia experience an extremely high level of anxiety in social situations that far exceeds the discomfort that shy people experience in social situations.

Up until recently, not much was known or understood about social phobia, especially in terms of how to treat it. We now know that people who suffer from social phobia tend to misinterpret neutral social clues so that they think others are negatively evaluating them. They are also very concerned with making a positive impression on people because they greatly desire approval from others. They often doubt their own abilities to be able to be successful in making a good impression. Fortunately, we now have effective therapy interventions to treat those with social phobia.

Psychotherapy

The treatment of choice for social phobia is cognitive behavioral therapy within a group setting called CBGT (cognitive behavioral group therapy). The ideal treatment group size for CBGT includes six patients and two therapists. This treatment relies on a triad of cognitive behavioral interventions, which include: simulated exposures to feared situations through role-plays, cognitive restructuring, and homework assignments done in in vivo exposure.

Before group treatment begins, the patient meets with the therapist and a rank-ordered hierarchy of the patient's most to least feared social situations is constructed. The group creates simulated scenarios in which the patient is exposed to his/her least feared social situations and as the patient is able to conquer these scenarios, moves up on his/her hierarchy list. If the patient begins to feel anxious or increased physiological arousal during a simulated situation, the patient is taught to use a variety of relaxation techniques, such as deep breathing to reduce the anxiety. It is through these simulated exposures that patients are able to face their fears and work through them in a monitored, safe setting.

The second component of CBGT is cognitive therapy. This is very effective since researchers have discovered that social phobia is largely born out of irrational beliefs that people develop over time. The cognitive beliefs of someone with social phobia are based upon the possibility of being negatively evaluated by others, which leads to strong feelings of vulnerability. Also, because those with social phobia tend to have a strong need for approval from others, they fear that they lack the self-esteem, social skills, or ability to make a good social impression on people.

During the first few sessions of CBGT the therapist educates the patients about cognitive therapy and how they can learn to replace their irrational beliefs that lead to anxiety or fear with healthy beliefs. Throughout the simulated scenarios, the group members can then challenge each other's irrational beliefs. By being able to point out to a group member during a simulated exposure that the member's self-perception about how they are coming across in a social situation is distorted, it offers important cognitive restructuring in the moment. CBGT is a careful balancing act between exposure and periods of cognitive restructuring.

The third component of CBGT is having the patients carry out in vivo homework assignments. This means that once the patient has mastered a feared scenario in the group setting, that the patient then goes and exposes himself/herself to a real-life similarly feared scenario, such as giving a presentation or going to a party. This allows for the skills that the patient learns in the group to be transferred to real-life situations.

There are many advantages that the group setting offers to those suffering from social phobia as compared to receiving individual therapy. First, those with various degrees of social phobia can learn vicariously through each other how to effectively handle their fears in social situations. Second, it helps group participants to realize that there are other people with similar fears and problems. This realization helps to reduce participants' fears that their problems are unique and mysterious. Third, by participating in a group treatment it helps to strengthen the patient's public commitment to change. Fourth, a group offers multiple partners with whom role-plays can be practiced. Fifth, a group offers a range of participants who can provide invaluable feedback to each other to help challenge the participant's irrational beliefs underlying their anxiety.

Since a person with social phobia has usually been struggling with the disorder for many years, 3 months of CBGT is not going to completely rid a person of social phobia; however, a reduction in the patient's symptoms should be evident. If after the twelve weeks of CBGT the patient's social phobia has not improved, then it is recommended that the patient continue either in another CBGT group and/or receive individualized psychotherapy treatment. If the person's anxiety within the feared social situations is severe enough to produce panic attacks, then panic control techniques and education about panic attacks should supplement the person's treatment. (See treatment for panic disorder). If the person really does have weak social skills, then social skills training as a supplemental treatment intervention would be quite helpful. Another treatment alternative to try after engaging in CBGT is psychotropic medication.

Medication

Medication for social phobia should be considered as a second line treatment after effective cognitive behavioral treatment has been attempted. Some medications can be helpful in the treatment of someone with social phobia in which cognitive behavioral therapy has been unsuccessful. The medications that have proven to be most successful in treating social phobia are the antidepressant medications called MAOIs (monoamine oxidase inhibitors), such as phenelzine (Nardil). The MAOIs seem to work best for generalized social fears. However, taking MAOIs requires many dietary restrictions because certain foods containing the pressor amine, Tyramine, such as the majority of cheeses, alcoholic beverages, and yeast products can produce an adverse reaction with the medication causing dangerously high blood pressure.

For more specific forms of social phobia such as public speaking and performance anxiety the beta-blockers, such as atenolol have been successful. These provide the convenience of only having to take them just a few hours before the specific anxiety provoking event. However, these medications have not proven to be very successful for severe generalized social phobia.

Recently, the SSRI anti-depressant medication called Paroxetine (Paxil) has received attention for reducing the symptoms of social phobia. This medication generally has few side effects and can be taken for more severe generalized forms of social phobia.

Reference:
Summarized from "Social Phobia and Social Anxiety", by Heimberg, Richard and Hope, Debra. In Clinical Handbook of Psychological Disorders. Barlow, David. The Guilford Press, 1993.

Specific Phobia

Introduction

Specific phobias are the most prevalent anxiety disorders within the population. They occur when a person develops an irrational fear to a specified object or situation and feels a great degree of anxiety or even has a panic attack when exposed to that feared object or situation. Approximately five to twelve percent of the population has a specific phobia with slightly more women than men being affected by a phobia. Phobias that develop during childhood are usually outgrown by adolescence. Most specific phobias develop during adolescence or adulthood in a person's mid-twenties.

A phobia can develop in a person at anytime as a reaction to a traumatic incident. For example, if a person is in an accident that occurs on a bridge the experience may create a phobia of bridges. Sometimes people can develop a phobia by witnessing something bad happening to another person. For example, witnessing a person being bitten by a snake might create a phobia of snakes in the person who witnessed the incident. People can also develop phobias from hearing about information that might frighten them, such as a person who hears an in-depth story about a plane crash on the news might then develop a phobia of flying. People who have a specific phobia are aware that their level of fear and anxiety about the feared object or situation is unreasonable.

The most common subtypes of specific phobias are: animal, including animals and insects; natural environment, including bad weather, water, and heights; blood-injection-injury, including seeing blood from an injury, injection, or medical procedure; situational, including bridges, flying, using public transportation, and tunnels.

The most common situation that people fear most is actually public speaking. However a fear of public speaking is categorized under social phobia. This is because the primary feature of social phobia is a fear of being in a situation in which a person will be evaluated by others or somehow do something that will cause humiliation and/or embarrassment to oneself in public. Public speaking is more about the fear of being under public scrutiny, than fearing a specific situation based solely on irrational fears of that situation. To learn more about the fear of public speaking, go to our section on Social Phobia (link to Social Phobia).

Specific phobias usually tend not to cause much disruption in a person's life. Most people are able to lead normal lives easily able to avoid whatever specific situation or object the person fears. For example, if a person has a phobia of snakes it is unlikely that being afraid of snakes will disrupt the person's life, unless the person is a forest ranger or works in the snake collection at a zoo. However, a specific phobia can become a problem for people who have to travel by plane regularly for business and have a fear of flying, or are afraid of elevators and have to use an elevator on a daily basis either for professional or personal reasons.

Fortunately, specific phobias are very treatable. The treatment of choice consists of cognitive behavioral interventions. Medication may be used in an adjunctive manner depending upon the severity of the phobia.

Psychotherapy

Psychotherapy is the treatment of choice for specific phobias. Cognitive behavioral treatment interventions including exposure, systematic desensitization, cognitive re-structuring, and relaxation techniques include the best approach to treat specific phobia.

Exposure therapy is the most effective therapy treatment technique for specific phobia. This intervention entails exposing the patient to the feared situations or objects for continuous periods of time. This way the patient is forced to confront his/her fears within the context of therapeutic management. The patient starts with situations that are the least anxiety provoking, such as seeing pictures of snakes, and works up through a hierarchy of gradually more difficult scenarios to most anxiety producing, such as holding a snake. The patient is taught a variety of relaxation techniques such as progressive muscle relaxation and deep breathing so that the patient can control anxiety levels during exposure to the feared object or situation.

Systematic desensitization is another widely used intervention for specific phobia. It involves having the patient imagine being exposed to the feared object or situation. Again, the patient begins with the least anxiety producing scenarios and works up to the most anxiety producing scenarios. The patient is encouraged to imagine very specific details associated with the feared object or situation such as smells, tastes, sounds, visual cues, and touch in order to make it as real as possible. Relaxation techniques are used to moderate anxiety levels. Studies have indicated that exposure to the feared scenarios in a person's imagination is an effective technique for conquering specific phobias.

Cognitive therapy is also helpful to people with specific phobia since their fears about a particular object or situation are based on irrational beliefs. Using cognitive therapy, the therapist helps the patient to identify what the irrational beliefs are that the person holds to be true about the feared object or situation. Then the therapist helps the patient replace the irrational beliefs with more realistic or adaptive beliefs about the feared object or place. Sometimes this may also require educating the patient with correct information about whatever it is the patient fears. For example, a person's phobia of flying may be fueled by not understanding how an airplane works and the extensive training that airline pilots have. By educating the patient with this information it can help the patient form more realistic beliefs that help reduce the patient's fear.

Medications

There are not currently any psychotropic medications used just to treat specific phobia. Medications should only be used as an adjunctive treatment approach if the person is experiencing moderate to severe anxiety or panic when in the presence of the feared object or situation. Another factor to consider is how often the person is confronted with the feared object or situation. For instance, if the person is phobic of elevators and must use an elevator every day for work then medication is more strongly indicated. Also, the use of medication will depend on whether or not the person is effectively able to reduce their anxiety with relaxation techniques.

If medication is indicated for a specific phobia than the anti-anxiety benzodiazepine agents such as Alprazolam (Xanax) or Clonazepam (Klonopin) would be the drug of choice. This is because they are short acting, which means they work quickly to relieve anxiety, so they do not have to build up in a person's body over time to be effective. Also, since they are short acting they leave a person's system quickly so that the person does not have to deal with ongoing negative side effects of being on a continuous medication.

It is important to use benzodiazepines carefully, however, because they are highly physically and psychologically addictive. They should not be prescribed to anyone who has any prior history of addictions and/or substance abuse. These medications need to be prescribed and used with caution.

Comments
  • Sandy

    I really need help for my anxiety and don't know where to turn to anymore. My Dr (MD) said they don't know that much about it. I can't seem to take the antidepressants. I have been on Klonipin for awhile now but I think it's also making me a zombie or sick. I also take Ambien because I could not sleep on the Klonipin.

    I can't have a life because of this. I try so hard to conquer this but can't. Can someone please help me.