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The causes of social phobia and its treatment are similar to those of agoraphobia and simple phobia. Medications for this and other phobic disorders have been useful in two contexts. First, the minor tranquilizers or anxiolytics are excellent means of treating anxiety symptoms. However, they do not appear to block the actual process of panic attacks. Second, certain of the tricyclic antidepressants have been used in some patients, often in doses well below those used for the Affective Disorders.
Considerable success in controlling panic attacks, with and without agoraphobia, has been reported in recent years through the use of tricyclic antidepressants, especially imipramine (Tofranil, Geigy), and monoamine oxidase inhibitors (MAOI's), such as phenelzine (Nardil, Parke-Davis). The dramatic reduction in panic attacks that follows such medication is the central factor in recovery from agoraphobic disorders. Sometimes the mere control of the panic is sufficient to allow patients to resume their customary activities. If anticipatory anxiety persists despite the disappearance of the acute panic attacks, benzodiazepines or behavioral desensitization or both are required to combat this more chronic form of anxiety. In addition, insight psychotherapy should be considered for those patients who fulfill the criteria for this form of treatment; with the acute, disabling symptoms under pharmacological control, such patients may be helped to resolve the psychological conflicts that frequently play a significant role in producing the surface symptoms.
Imipramine will block some panic attacks and clomipramine (not yet available in the United States) is a promising drug; however, the latter appears of more use in Obsessive Compulsive Disorder and both have significant side effects. The MAO inhibitors are helpful for some patients.
Antianxiety Drugs The minor tranquilizers have a particularly important place in the treatment of the phobic disorders. Chlordiazepoxide (Librium) and diazepam (Valium) are both effective aids to the patient in his struggle with the phobic situation if they are taken in sufficient doses to produce a relaxation of tension and musculature.
In the case of an agoraphobic patient, the clinician might have the patient imagine (perhaps in hypnotic trance, but this does not seem to add to the effectiveness of treatment) taking a fearful trip, remaining in the anxiety-producing fantasy as long as possible, then "returning" to the therapist's office. This is repeated a number of times, and the patient is instructed to perform the same exercise as often as possible between sessions. Family members are frequently engaged to assist in the process and monitor the "homework." Written journals and diaries may also be used.
In most patients, panic attacks can be treated at the same time, in the same way. Sometimes attention to the physiologic cues of panic or mounting anxiety helps the patient to recognize and control panic symptoms.
Psychotherapy can be a useful part of the treatment of the anxious or phobic patient. The term "psychotherapy" implies a wide variety of kinds of therapist-patient interaction, overlapping considerably with the behavioral treatments. It is almost impossible to work with a patient in any context without providing considerable interest, support, and understanding. Beyond this, the patient who has given up a symptom may suffer feelings of loss for the symptom itself, for the "equilibrium" of life-style which has existed surrounding the symptom, or both. The opportunity for continuing counselling may be valuable.
Those patients who do not respond to the briefer treatments often benefit from more in depth psychodynamic psychotherapy. The typical patient after such treatment was in better condition than 77% of untreated controls evaluated at the same time. The various modes examined included psychodynamic, cognitive, and humanistic, as well as behavioral and social, therapies.
The behavioral technique of "exposure" is an effective treatment, both short- and long-term, for agoraphobics and many other phobia patients. The use of exposure in fantasy, presenting increasingly anxiety-producing situations as discomfort dissipates at each level, is a form of systematic desensitization. Exposure in vivo also involves gradual adaptation to anxiety-producing objects or situations, but the objects or situations are actually present during the treatment. Flooding, rapid exposure to almost overwhelming volumes of phobic material, also known as implosion, may be used either in fantasy or in vivo.
In general, the behavioral treatments, perhaps coupled with appropriate psychotherapy, have the greatest likelihood of effectiveness, and should be tried before medication is prescribed on any chronic basis.
Internet Mental Health
Reprinted from Internet Mental Health, Copyright © 1995 by Phillip W. Long, M.D.