Current Therapy Trends for Specific Phobias and Their Long-term Effectiveness - Essay Example

Current Therapy Trends for Specific Phobias and Their Long-term Effectiveness Introduction: Anxiety is a part of the normal response of an individual to situations that are challenging or threatening. Anxiety thus is an advantageous mechanism of the human body. However, the presence of either severe, or persistent, or inappropriate anxiety can hinder the normal everyday functioning of an individual in all aspects of life including occupational and social functioning. Specific phobia is one such common anxiety disorder and is easily treatable among the many mental disorders (Gros & Antony, 2006). Specific Phobias: Shear (2006), defines specific phobia as “irrational fears, usually accompanied by avoidance of the feared stimulus”. A simple phobia, which was earlier known as simple phobia is thus a lingering and unreasonable fear that is caused by the presence or thought of a specific object or situation that normally poses little or no real danger. Faced by such an object or situation the response is an immediate reaction that causes the individual to feel severe anxiety that. The consequence is that the individual avoids the specific object or situation. The severe distress caused to the individual interferes with the ability of the individual to function normally. Though adults with specific phobia recognize and understand that the fear they feel is excessive or not given to reason, they find themselves unable to overcome such fears (Specific Phobias). The DSM – IV criteria for specific phobias are: “Persistent fear of a circumscribed stimulus (object or situation), other than fear of having a panic attack (as in panic disorder) or of humiliation, or embarrassment in certain social situations (as in social phobia). During some phase of the disturbance, exposure to the stimulus almost invariably provokes an intense anxiety response. The stimulus is avoided or endured with intense anxiety. The fear or associated avoidance behavior significantly interferes with the person’s normal routine or with usual social activities or relationships with others, or there is marked distress about having the fear. The stimulus is unrelated to the content of the obsessions of obsessive-compulsive disorder or post traumatic stress disorder”. (Lader & Uhde, 2000). Specific phobias are of different types and are classified based on the object or situation that causes it. Specific phobias include animal phobias like fear of dogs, snakes, insects, or mice; situational phobias like flying, riding a car, driving, going over bridges or tunnels, or of being in an enclosed space; natural environment phobias like fear of storms, heights, or water; blood-injection-injury phobias like, fear of seeing blood or of invasive medical procedures, such as blood tests or injections, or fear of being injured; other phobias like fear of falling down, fear of loud sounds, or fear of costumed characters, such as clowns. An individual could be affected by one or more specific phobias (Specific Phobias). The U.S. National Comorbidity Survey (NCS) has ranked the prevalence of specific phobias among anxiety disorders after social phobias at a lifetime prevalence of 11.3% (Lader & Uhde, 2000). In the United States of America the estimated number of people affected by specific phobias is estimated at more than six million adults (Specific Phobias). Cause of Specific Phobias: There is no proper understanding of the cause of specific phobias. However, many of the specific phobias seem to have an association with a traumatic experience or a learned reaction. For example an individual having an experience of having been stuck in a lift, may develop a fear of enclosed spaces. Individual experiences are not necessary in the development of specific phobias. Seeing a traumatic event in which others are caused harm or experience fear could cause a specific phobia. Even listening to repeated dramatic warnings of potentially dangerous situations or animals could bring about a specific phobia in an individual. Fear could also be a learned action. Children exposed to parental reaction of fear and anxiety to certain objects or situations could also learn to fear and be anxious about the same objects or situations (Friedman, Munir & Erickson, 2006). These differences in the development of specific phobias have given rise to several theories as to the etiology of specific phobias. The learning theories are two namely classic conditioning and operant conditioning. In classic conditioning a previous neutral stimulus gets paired with an aversive stimulus such that the result is a strong fear or emotional response. This learning is believed to be the result of witnessing an event that involved someone else and elicits fear. Operant conditioning is involved where parents, without noticing it, reinforce the phobic behavior through their actions in providing children with large amounts of social attention surrounding a particular avoidant behavior (Friedman, Munir & Erickson, 2006). These learning theories by themselves do not explain the development and persistence of specific phobias with sufficient strength, which has led to the cognitive learning theories in specific phobias. These theories stipulate that distorted and maladaptive thoughts lie behind the development and persistence of specific phobias, but there is a lack of clarity in as to the impact of these negative thoughts on the causes and consequences of these fears (Friedman, Munir & Erickson, 2006). The final set of theories on the cause of specific phobias is in direct contrast to the earlier theories. These theories are the genetic, familial and constitutional theories. Personality is inheritable, and so the genetic and familial theories suggest that specific phobias are inheritable too. Their hypothesis is based on the observations of genetic and familial links to specific phobias. The constitutional theory suggests that constitutional factors have a role to play in increase in risk for harsh individual experiences leading to the development of specific phobias (Friedman, Munir & Erickson, 2006). Many of the specific phobias develop in childhood or adolescence. In comparison to specific phobias that develop later in life, specific phobias developed in childhood or adolescence demonstrates the possibility of resolving themselves over time (Lader & Uhde, 2000). Diagnosing Specific Phobias: Based on the presence of symptoms an evaluation that consists of a complete medical history and physical examination is done. There are no laboratory tests that enable a diagnosis of specific phobias yet, several tests may be employed to rule out any underlying physical illness that may be responsible for the symptoms demonstrated by the individual, before a psychiatrist or psychologist continues with the diagnostic procedures. Specially designed interview and assessment tools are employed by the psychiatrists and psychologists in the evaluation and diagnosis of an individual for specific phobias (Specific Phobias). Differential diagnosis forms an essential part of the diagnosis of specific phobias from two factors. The first is to distinguish these anxiety disorders from the other anxiety disorders with which there is a similarity in symptoms. For instance specific phobias may present with similar symptoms as panic attacks. The differential diagnosis is made on the basis of the difference that specific phobias have a specific relationship with the phobic stimulus, while panic attacks can arise even in the absence of a specific stimulus, even though particular stimuli may be associated with the fear and arousal through conditioning (Lader & Uhde, 2000). Treatment of Specific Phobias: The rationale in the treatment of anxiety disorders, of which specific phobias are a part of, is after the identification of the type of disorder to utilize the minimal of intervention to the maximum and long lasting benefit to the client in the form of the removal of the disorder on a permanent basis. As there is no clarity to the cause of specific phobias, an individualized approach in the treatment is the accepted current mode of treatment of specific phobias (Lader & Uhde, 2000). The traditional approach to treating specific phobias is after the identification of the anxiety disorder through an evaluation of the patient to use psychological management strategies like counseling, behavioral therapy or cognitive therapy. Medication in the treatment strategy is in the event of inadequate success in the management or as an adjunct to the psychological management. Medication as a sole treatment strategy is not a commonly utilized strategy. The reason behind this that has particular import in the treatment of specific phobias is that pharmacological approaches to the treatment of psychiatric disorders targets biochemical disorders. With specific phobias the emotional learning component has greater impact in the disorders, the treatment of which is better facilitated through psychological approaches than pharmacological approaches. Managing the emotional learning component in specific phobias reduces the intensity in the disorder and the biochemical element of the disorder gets removed through this. Pharmacological approaches become useful only when there is a total failure in the psychological approaches (Ressler, et al, 2004). Although specific phobias are considered to be the simplest of the anxiety disorders, there are several issues that impinge on the efficient use of psychological approaches in its treatment and the long term results. Specific phobias come in different forms and more than one may be present in an individual. Different forms of psychological approaches are employed in the treatment of specific phobias, but the efficacy of the treatment in the different sub-types of specific phobia is not equal. For instance there are indications that virtual reality is more effective in flying and height phobia, while cognitive therapy is more useful in claustrophobia. This evidence is however limited and more studies are required to confirm the unequal efficiency of the different modes of psychological approaches in the treatment of the different specific phobia subtypes. If this is true, then there is the requirement for further studies and evidence as to which mode of psychological approaches has proven efficacy in the different subtypes of specific phobias (Choy, Fyer & Lipsitz, 2007). There is another issue with regard to psychological approaches in the treatment of specific phobias. Most of the phobias demonstrate a robust response to psychological approaches in vivo exposure, but along with that are the high dropout rates and low acceptance of treatment that are associated with psychotherapy. Treatment gains are essentially seen in the first year of treatment. There is a dearth of evidence to establish the efficiency of psychological approaches in long term positive effects in the treatment of specific phobias and hence the need for such studies. Till there is such clear evidence, an essential strategy in the use of any psychological approaches in the treatment of specific phobias is to devout enough attention towards treatment acceptance and retention to avoid relapse (Choy, Fyer & Lipsitz, 2007). Available data suggests that pharmacological approaches alone in the treatment of specific phobias have not delivered promising results, and the pharmacological approaches are used in combination with psychological approaches in the treatment of specific phobias. However, emerging evidence suggests that there is little benefit in the use of the combination of pharmacological approaches and psychological approaches over the use of either alone as a treatment option. In the light of the uncertainty that exists in the benefit of combination therapies over mono-therapies in the treatment of specific phobias, it would be useful to try and examine more efficient means of combining pharmacological approaches and psychological approaches in the treatment of specific phobias (Pull, 2007). Psychological Approaches in the Treatment of Specific Phobias: Treatment of any disease or condition is based on the cause. There are many possible causes for specific phobias and so too the psychotherapies. Behavior therapy has been the first line of treatment in specific phobias. In behavior therapy the patient is repeatedly exposed to the feared stimulus till the anxiety response it causes is habituated. This repeated exposure to the feared stimulus could be affected either in real-life situations or in imaginary. The focus is on generating the feared stimulus for habituation or rather systematic desensitizing. The greater the exposure to the feared stimulus the greater is the likelihood that habituation occurs leading to diminishing in the anxiety that it elicits (Friedman, Munir & Erickson, 2006). Cognitive behavior is best employed when the persistence of the specific phobia appears to have a cognitive component. In cognitive behavior in the treatment of specific phobias, the individual is taught skills for the contingency management, modeling management and self control. Specific skill deficits are identified and measures to identify these skill deficits have an added impact (Friedman, Munir & Erickson, 2006). Behavior therapy while being the mainstay in the treatment of specific phobias has not proved to be a total solution in the treatment of specific phobias. Advances in technology are being used to assist in removing the difficulties experienced in behavior therapy. The availability of computers has made it possible to use virtual reality in behavior therapy. Pull (2005), points out that there is growing evidence to suggest that virtual reality exposure therapy holds out promise in the treatment of several anxiety disorders including specific phobias. Behavioral therapy techniques in treating specific employs graded exposure to the anxiety producing stimuli. The problem faced here is many patients find it difficult to use their imagination to create such stimuli. It is here that virtual reality therapy provides the solution in the use of computers to generate the required stimuli. Virtual reality therapy has been found to be useful in treatment of specific phobias like fear of flying, fear of heights, and fear of public speaking (North, North & Coble, 1998). Pharmacological Approaches in the Treatment of Specific Phobias: Though pharmacological approaches have been frequently employed in the treatment of several anxiety disorders, the evidence of their utility in specific phobias is conflicting. Selective serotonin reuptake inhibitors and ant-depressants are the chosen pharmacological approaches in the treatment of several anxiety disorders. Besides the inconclusive evidence of utility, there are other problems associated with these pharmacological approaches like lack of speedy action, side effects, and distressing symptoms on discontinuation. This leads to non-compliance. Long-term pharmacological treatment is quite often associated with remission. This has caused Pollock and Kuo (2004), to suggest that there is the requirement for the development of new pharmaceutical agents that are more efficacious, quicker acting, and have lesser side effects. Combination Therapies: The lack of sufficient evidence or success in the use of either psychological or pharmacological approaches in the treatment of specific phobias has led to the use of combining these approaches. Cognitive behavior treatment has been employed in combination with drugs like flouxetine. A new approach that holds out promise is the combination of D-cycloserine with cognitive behavior therapy. D-cycloserine acts as a partial agonist at the N-methyl-D-aspartate glutamatergic receptor and through this action increases the extinction of fear (Starcevic, 2006). Though further studies are needed to confirm the efficiency of this novel combination, there is emerging evidence from studies to its efficiency in treating specific phobias, as seen in its efficiency in treating acrophobia (Ressler, et al, 2004). Conclusion: Efficient treatment of diseases and conditions require a sound understanding of the causes. In the case of specific phobias there is lack of clarity on the causes, and in addition there is the added factor that it exists as various subtypes. Based on the available information treatments for specific phobias have developed on the form of psychological approaches, pharmacological approaches, and a combination of both. In spite of several approaches there is no conclusive evidence as to their efficacy. On the other hand there has emerged more information that these approaches are not being as efficient as was expected. This has led to use of technology and the search for new combination therapies. The jury is still out as far as these emerging adjuncts to psychological and pharmacological approaches are concerned. However, the emerging evidence suggests that these new and novel additions to the armory of treatments against specific phobias do hold out promise. Literary References Choy, Y., Fyer, A.J. & Lipsitz, J. D. (2007). Treatment of specific phobia in adults. Clinical psychology review, 27 (3), 266-286. Friedman, S. L., Munir, K. M., & Erickson, M. T. (2006). Anxiety Disorder: Specific Phobia. Retrieved Oct. 8, 2007, from, eMedicine, from WebMD Web site: http://www.emedicine.com/ped/topic2659.htm Gros, D. F. & Antony, M. M. (2006). The assessment and treatment of specific phobias: a review. Current psychiatry reports, 8 (4), 298-303. Lader, M. H. & Uhde, T. W. (2000). Anxiety, Panic and Phobias. Health Press Ltd: Oxford. North, M. M., North, S. M. & Coble, J. R. (1998). Virtual reality therapy: an effective treatment for phobias. Studies in health technology and informatics, 58, 112-119. Pollock, R. & Kuo, I. (2004). Advances in the Treatment of Anxiety Disorders. Retrieved Oct. 8, 2007, from, WebMD, Medscape Today Web site: http://www.medscape.com/viewarticle/471569 Pull, C. B. (2005). Current status of virtual reality exposure therapy in anxiety disorders: editorial review. Current Opinion in Psychiatry, 18(1), 7-14. Pull, C. B. (2007). Combined Pharmacotherapy and Cognitive-Behavioral Therapy for Anxiety Disorders. Current Opinion in Psychiatry, 20 (1), 30-35. Ressler, K. J., Rothbaum, B. O., Tannenbaum, L., Anderson, P., Graap, P., Zimand, E., Hodges, L. & Davis, M. (2004). Cognitive enhancers as adjuncts to psychotherapy: use of D-cycloserine in phobic individuals to facilitate extinction of fear. Archives of general psychiatry, 61 (11), 1136-1144. Shear, K. (2006). Anxiety Disorders: Specific Phobia in Medical Settings. Retrieved Oct. 9, 2007, from, ACP Medicine Online, WebMD, Medscape Today Web site: http://www.medscape.com/viewarticle/534477. Specific Phobias. Retrieved Oct. 9, 2007, from, WebMDHealth, Medscape Today. Web site: http://www.medscape.com/viewarticle/472334 Starcevic, V. (2006). Anxiety States: A Review of Conceptual and Treatment Issues. Current Opinion in Psychiatry, 19 (1), 79-83. Read More