Pharmacotherapy for specific phobia in adults

http://www.uptodate.com/contents/pharmacotherapy-for-specific-phobia...

Official reprint from UpToDate www.uptodate.com 2013 UpToDate

Pharmacotherapy for specific phobia in adults Authors Richard Swinson, MD Randi E. McCabe, PhD Disclosures All topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: Oct 2013. | This topic last updated: Abr 12, 2012. INTRODUCTION Specific phobia is an anxiety disorder characterized by clinically-significant fear of a particular object or situation that typically leads to avoidance behavior. Phobic fears include animals, insects, heights, water, enclosed places, driving, flying, seeing blood, getting an injection, and choking or vomiting. Specific phobias are among the most common mental disorders and can be highly disabling [1,2]. However, they are also among the most treatable mental disorders [3-6]. Despite availability of efficacious treatments, the majority of individuals with specific phobias are hesitant to seek treatment [7]. This may be due to lack of knowledge that the phobia is treatable, embarrassment to disclose the phobia to a health professional, accommodation of the phobia through avoidance, or fear of increased anxiety or discomfort in the course of treatment [5]. Pharmacotherapy for specific phobia in adults is discussed here. The epidemiology, pathogenesis, clinical manifestations, course, and diagnosis of specific phobia in adults are discussed separately. Psychotherapy for specific phobia in adults is discussed separately. Specific phobias relating to clinical procedures (eg, bloodinjection-injury phobia) and other manifestations of acute procedural anxiety are discussed separately. Specific phobia and other fears in children are also discussed separately. (See "Specific phobia in adults: Epidemiology, clinical manifestations, course and diagnosis" and "Psychotherapy for specific phobia in adults" and "Acute procedure anxiety in adults: Epidemiology and clinical presentation" and "Treatment of acute procedure anxiety in adults" and "Overview of fears and specific phobias in children".). TREATMENT OVERVIEW First-line treatment for specific phobia is cognitive-behavior therapy (CBT) that includes exposure treatment [8]. (See "Psychotherapy for specific phobia in adults".) Pharmacotherapy, including benzodiazepines and serotonergic reuptake inhibitors, has a limited role in treatment of specific phobia. Medications are used when CBT is not available or when patients prefer medication to CBT despite the lack of comparably robust supporting evidence from clinical trials. Benzodiazepines Indications Among medications, benzodiazepines are most often used in the treatment of specific phobia when the phobic stimulus is infrequently encountered and unavoidable, such as in the treatment of a flying phobia or blood-injection-injury phobia. Patients who have experienced intense fear on previous occasions when undertaking these activities may wish to have a reasonable certainty that their anxiety can be lessened if they were to experience the feared stimulus again. (See "Treatment for specific phobias of medical and dental procedures", section on 'Blood-injection-injury phobia'.) Efficacy There are no rigorous data from clinical trials suggesting that benzodiazepines are effective for specific phobia [9]. A randomized trial of 28 women with flying phobia who traveled on two flights over a one week period found that alprazolam led to reduced anxiety but a greater physiologic response on the first flight, compared to placebo, and increased anxiety, physiologic response, and panic on the second flight [10]. Section Editor Murray B Stein, MD, MPH Deputy Editor Richard Hermann, MD

1 de 4

02/12/2013 05:08

Pharmacotherapy for specific phobia in adults

http://www.uptodate.com/contents/pharmacotherapy-for-specific-phobia...

A non-randomized trial of 91 patients with dental phobia allowed participants to select whether to receive pretreatment with midazolam, a one-session stress management training, or no intervention prior to a surgical dental procedure [11]. In an analysis of only the 50 patients completing the procedure and subsequent assessment, both interventions led to reduced fear at the time of the procedure compared to the control group. The effects of the stress management training, but not the medication, were sustained at two-month follow-up. Substantial clinical experience suggests that flying phobia can be effectively treated with benzodiazepines. However, well-designed randomized trials are needed to determine efficacy [12]. Other trials of sedative medications have suggested that generalized anesthesia and nitrous oxide are effective treatments for dental phobia, though evidence comparing these agents to cognitive and behavioral therapies is mixed [13-15]. Sedating medications are most useful for treating phobias that do not involve performance that could be adversely affected by the medication. (See "Treatment for specific phobias of medical and dental procedures", section on 'Dental phobia'.) Administration A benzodiazepine with a relatively short onset (eg, lorazepam 0.5 to 2 mg) can be taken 30 minutes before the stimulus is encountered. Patients should be advised to take a test dose prior to using it for the phobic situation to ensure it does not lead to oversedation. Patients should be warned not to consume alcohol and the drug together due to the risk of additive side effects such as sedation, confusion, and impaired coordination. The risk of abuse of benzodiazepines is largely confined to individuals with a substance abuse history or problem, though a family history of substance abuse may be a risk factor for some individuals [16]. Treating patients who are no longer currently abusing substances with benzodiazepines is not absolutely contraindicated, but would require closer monitoring and, in some cases, the use of longer-acting benzodiazepines with slower onset of action (eg, clonazepam) that may reduce abuse liability. Dose escalation can be discouraged by prescribing a minimal supply of pills for infrequent use. Selective serotonin reuptake inhibitors Indications In cases where medications have been selected for treatment of specific phobia and a benzodiazepine is ineffective, a serotonin reuptake inhibiting antidepressant can be used. Given the time course of response to a serotonin reuptake inhibiting antidepressant (ie, weeks to months), an SRI is indicated only when there is sufficient time to attain therapeutic benefit and only in instances where repeated exposure to the phobic stimulus is anticipated over a prolonged time period. A serotoninergic agent may be more suitable than a benzodiazepine when the patient is repeatedly exposed to the phobic stimulus (eg, an individual with claustrophobia whose job requires him or her to ride as a passenger in a car). Efficacy Two very small trials and some case reports suggest that selective serotonin reuptake inhibitors (SSRIs) may be effective for specific phobia, though larger trials of these agents are needed. A randomized trial compared 12 weeks of treatment with escitalopram (5 to 20 mg/day) to placebo in 12 patients with specific phobia (types included enclosed spaces, flying, heights, dentist, and animals) [17]. A statistically-significant difference was not seen between the two groups, though a trend in favor of medication was observed in this small trial. A randomized trial compared four weeks of treatment with paroxetine (20 mg/day) to placebo in 11 patients with specific phobia (types included confined spaces, storms, flying, animals, heights, driving) [18]. Patients treated with paroxetine showed greater reductions in fear and avoidance compared to the placebo group. Two case reports described the resolution of a pre-existing flight phobia associated with treatment of a co-occurring mood disorder with fluoxetine [19]. A third case report described remission of a storm phobia associated with fluvoxamine treatment [20]. Administration SSRIs are typically started at the low end of their therapeutic range and titrated up gradually until response is achieved. As examples, the starting dose of escitalopram in specific phobia is as low as 5 mg daily with upward titration over two to three weeks to 20 mg daily. Sertraline starting dose is 50 mg daily and increasing to 200 mg daily in the same time period. The duration of a therapeutic trial of an SSRI should be a

2 de 4

02/12/2013 05:08

Pharmacotherapy for specific phobia in adults

http://www.uptodate.com/contents/pharmacotherapy-for-specific-phobia...

minimum of six to eight weeks before concluding that the medication has failed. (See "Selective serotonin reuptake inhibitors: Pharmacology, administration, and side effects".) COMPARING CBT AND MEDICATION There are no clinical trials comparing the efficacy of cognitive-behavioral therapy (CBT) to benzodiazepines or serotonin reuptake inhibitors for specific phobia. However, multiple trials show CBT to be effective versus placebo, while studies of SSRIs and benzodiazepines are of insufficient number and quality to clearly determine benefit over placebo. (See "Psychotherapy for specific phobia in adults".) COMBINING CBT AND MEDICATION There are no clinical trials comparing combinations of SSRIs or benzodiazepines with CBT in specific phobia to either medications or CBT as monotherapy. If an SSRI is used to treat specific phobia, it should ideally be paired with exposure therapy and then gradually withdrawn as the fear and avoidance are reduced. Augmentation of cognitive-behavioral therapy (CBT) with cycloserine and hydrocortisone has shown promise in the treatment of specific phobia. However, the use of these medications for specific phobia is still experimental and cannot be recommended at present. Cycloserine Cycloserine, a partial N-methyl-d-aspartate (NMDA) receptor agonist, has been found to effectively augment CBT in the treatment of specific phobia [21] and other anxiety disorders [22,23]. The medications hypothesized mechanism of action is through facilitation of extinction learning. In a randomized trial, 28 subjects with a height phobia were randomly assigned to receive cycloserine or placebo in augmentation of virtual reality exposure [21]. A single dose of the medication (either 50 mg or 500 mg) or placebo was administered 30 to 60 minutes prior the exposure session. Patients who received either dosage of cycloserine plus exposure experienced greater reduction in anxiety symptoms of height phobia than patients who received placebo plus exposure; the difference between groups was seen following each treatment session and on assessment three months following treatment. Hydrocortisone Two trials have found hydrocortisone, a glucocorticoid, to effectively augment CBT in the treatment of specific phobia [24,25]. While the mechanism of action is not known, endogenous glucocorticoids have been found to be released in persons experiencing fearful situations. Forty patients with a height phobia were randomly assigned to receive hydrocortisone 20 mg taken orally or placebo one hour before each of two sessions of virtual reality exposure-based CBT [24]. Exposure therapy augmented by hydrocortisone led to a greater reduction in fear of heights compared to placebo-augmented exposure, as assessed following treatment and at a one-month post-treatment. The reduction in anxiety was accompanied by lowered physiological arousal measured by skin conductance (sweating) during the exposure task. Twenty patients with a spider phobia were randomly assigned to receive hydrocortisone 10 mg taken orally or placebo one hour prior to exposure to a picture of a spider [25]. Patients receiving hydrocortisone experienced a greater reduction in stimulus-induced fear compared to placebo. SUMMARY AND RECOMMENDATIONS For most presentations of specific phobia, we recommend first-line treatment with a cognitive-behavioral therapy (CBT) that includes exposure treatment over other psychotherapeutic or pharmacologic interventions (Grade 1B). (See "Psychotherapy for specific phobia in adults".) When CBT/exposure is unavailable or when patients prefer medication to psychotherapy, we suggest treatment of specific phobia with an infrequently encountered phobic stimulus with a benzodiazepine. (Grade 2C). Benzodiazepine are best suited for patients who lack a history of a substance-use disorder and for situations where the drugs sedating effects do not interfere with functioning (eg, as a passenger on a plane flight). A benzodiazepine such as lorazepam 0.5 to 2 mg can be taken 30 minutes before encountering the situation. The patient should take a test dose prior to using the medication for the phobic situation to ensure it does not lead to oversedation. Patients should be warned not to consume alcohol and the drug together due to the risk of additive side effects such as sedation, confusion, and impaired coordination.

3 de 4

02/12/2013 05:08

Pharmacotherapy for specific phobia in adults

http://www.uptodate.com/contents/pharmacotherapy-for-specific-phobia...

(See 'Benzodiazepines' above.) When CBT/exposure is unavailable or when patients prefer medication to psychotherapy, we suggest treatment of specific phobia with a frequently encountered phobic stimulus with a selective serotonin reuptake inhibitor (SSRI) (Grade 2C). As an example, sertraline can be started at 50 mg/day and titrated up to a therapeutic dose over two to three weeks. (See 'Selective serotonin reuptake inhibitors' above.) Use of UpToDate is subject to the Subscription and License Agreement. Topic 14640 Version 2.0

4 de 4

02/12/2013 05:08