Panic Attacks and Phobias

Part 2

EARLY BEHAVIORAL TECHNIQUES

A landmark event in the development of treatment for phobias occurred with the publication of a book in 1958. In the book, Joseph Wolpe, a learning theorist, reported excellent results from treating adult phobic patients with a procedure called “systematic desensitization,” which he had adapted from a technique developed in the 1920’s for helping children overcome animal phobias. Systematic desensitization requires the client to learn formal, deep-muscle relaxation. It is up to the client also to rank situations related to the phobia that cause anxiety. An individual who fears snakes, for example, might place “holding a snake” at the top of the list of things that make him anxious and “viewing a caged snake from across the room” at the bottom of the list.

The client is then asked to imagine, in as much detail as possible, the least fear-provoking scene from his list. At the same time he is asked to relax as previously taught. By remaining comfortable while imagining the feared situation, the client may weaken the association between the situation and feelings of anxiety. Once the client has become comfortable imagining the least threatening situation, he moves up the list and masters each in turn.

Proponents of this method have claimed that facing a feared situation in imagination is as effective as confronting it in reality. But most therapists have found that there is a gap between fantasy and reality. In other words, once the client has completed desensitization treatment and undertakes to face the real object or situation, he is likely to have to move part of the way back down his list. For example, while holding an imaginary snake, he may at first be able to touch, but not to hold, a real snake. By practicing further in the real situation, however, he may eventually be able to fully master his fear.

Systematic desensitization was the first form of behavior therapy used to treat phobias. The late 1960’s witnessed development of another, named “implosion,” which soon came to be widely used in a modified form termed “imaginal flooding.”

Flooding, like desensitization, involves the client’s experiencing fear-provoking situations in his imagination. In other ways, flooding and desensitization are quite different. In flooding, the therapist, rather than the client, controls the timing and content of the scenes to be imagined. He describes the scenes with great vividness, in a deliberate effort to make them as disturbing as possible. Also, the client is not instructed to relax; rather, the aim is for him to experience his fears and anxieties with maximum intensity, in the hope that by surviving “the worst,” he can loosen the phobia’s grip on him. The prolonged experience with these feared images is thought to help the client get used to them, so that they gradually lose their power to cause anxiety.

In the early days of implosive therapy and flooding, therapists included scenes referring to guessed-at unconscious conflicts believed to underlie the patient’s phobias. But studies showed that not only were the horrifying scenes of implosion very disturbing to patients (sometimes causing nightmares), but also they did not make treatment any more effective than flooding alone. Thus, implosive techniques are no longer used.

A number of researchers have compared desensitization and flooding. They have found that the two forms of treatment are about equally effective: Both reduce phobic anxiety and behavior in people with simple phobias, but desensitization is not as effective as flooding for agoraphobia. Although not well studied, neither method appears to be very effective for social phobics.

EXPOSURE THERAPY

When behavior therapists observed that the exposure to the feared situation was the common ingredient in desensitization and flooding, they began to develop other techniques they hoped would be even more effective. While earlier methods were aimed at reducing anxiety so that clients could change their behavior (e.g. enter feared situations), the new techniques focused instead on altering behavior. Once behavior changed, the reasoning went, anxiety would diminish.

The underlying assumption is that phobic anxiety is maintained - it continues and may get more intense - when the person repeatedly avoids the object or situation that elicits the anxiety. Avoidance prevents him from “unlearning” the association between an object or situation and anxiety. Exposure to such situations, by contrast, gradually habituates the person to it - that is, he learns that no real danger is present. Gradually, the anxiety is extinguished. Some therapists believe that the more rapidly such exposure takes place, the more rapidly the phobia will be eliminated.

In treatment, the therapist explains this rationale to the client, outlines the procedure that will be followed, and helps him anticipate what his reactions are likely to be. The therapist assures the client that he will always be available to help the client cope with the sense of danger, and will be ready to stop the procedure at any time the client seems unable to tolerate the danger.

The client is then exposed to the object or situation he fears. Techniques differ on how gradually the person is made to encounter fearful objects and how long the exposure continues. In general, clients are asked to stay in the situation until their anxiety begins to diminish. With each session, they tolerate closer and longer confrontations with the threatening object or circumstance.

Such in vivo (in life) exposure has replaced methods that rely upon imagined danger. It is considered the treatment of choice for simple phobias. Most investigators also believe that it is the best available treatment for agoraphobia when accompanied by drug treatment (see below). Some therapists use exposure in imagination as a means of helping their clients confront feared situations in real life. There is some evidence that the effects of treatment may be more long-lasting when imagination-based exposure is used along with in vivo exposure, although not everyone needs both. Programs using in vivo exposure techniques have become the mainstay in the treatment of simple phobias and agoraphobia. Exposure does not seem to be as effective in treating social phobias, unless it is accompanied by training in specific social skills.

COGNITIVE THERAPIES

Several recently developed techniques that try to change the phobic’s thought patterns may be used along with exposure. Most of these techniques have grown out of behavioral therapists’ attempts to account for and change the persistent habits of thought that seem to bind people to their fears. One form of cognitive-behavioral treatment - “self-statement training” - teaches clients to become aware of such negative thought statements as, “I’ll faint if I touch that,” or “I can’t do it,” and to replace them with positive coping statements like, “Of course, I can do it.” Once the client has become familiar with this approach, he can use it to help himself progress through a behavioral treatment program.

Taking a completely different tack, therapists using “paradoxical intention” encourage clients to try to feel as anxious and panicky as possible. Clients are urged to exaggerate their symptoms, often with a note of humor injected. For example, a woman who is afraid she may faint or fall down might be instructed to “faint” on purpose and to warn those around her: “Stay out of my way. When I fall, I fall hard. I bet I’m the best fainter you’ve ever seen.” Frequently, taking charge of symptoms in this way diminishes their force. In fact, a client who is “trying” to faint, sweat, or tremble may find himself unable to do so.

DRUG THERAPY

Over the years, many drugs have been tried by phobic patients. Barbituates provided little benefit. The newer class of drugs used to treat generalized anxiety, the benzodiazepines (such as Valium or Librium), do lessen the anticipatory anxiety that accompanies phobias, but do not generally block panic attacks. The exception is alprazolam, a modified benzodiazepine, which appears to be effective in moderate to high doses, although dependency is often an unavoidable side effect when the drug is taken for long periods of time.

Beginning in the early 1960s, however, it was discovered that certain antidepressants could prevent the unpredictable panic attacks characteristic of agoraphobia. The assumption is that once panic attacks no longer threaten the patient, the anxiety that accompanies anticipation of future panic attacks and the avoidance of future panic attacks and the avoidance of behavior will also diminish. The two types of drugs that have been most extensively tested and shown to be effective are the MAO inhibitors (for example, phenelzine) and tricyclic antidepressants (for example, imipramine). Although usually used to relieve depression, these drugs also produce antianxiety actions that are independent of their antidepressant effects. Anticipatory anxiety sometimes diminishes once panic attacks have stopped. Some patients respond at low dosages, but most appear to require amounts equal to that needed to reduce depression.

MAO inhibitors and tricyclic antidepressants do produce some unwanted side effects. Most of these side effects, such as drowsiness, gradually subside after the drug is taken for several weeks. MAO inhibitors require special caution, however. Patients taking these drugs must restrict their intake of certain foods, such as aged cheese, red wine, and other medications. Reactions between these substances and the MAO inhibitors can produce high blood pressure, severe headaches, and other side effects that in rare cases can be life-threatening. Despite these possible complications, the MAO inhibitors, when used judiciously, can produce remarkable improvements in patients subject to panic attacks.

Drug therapy for panic attacks is generally given for periods of 6 months to 1 year. Many patients can then manage well without drugs, although relapses requiring resumption of medication are common. The relative duration of success of various therapies is still a matter of controversy.

As noted, most antianxiety drugs are not thought to be effective in stopping panic attacks, although recent research suggests that in very high amounts they may be. The common tranquilizers, such as Valium and Librium, are sometimes also used to treat the generalized anxiety that accompanies phobias.

As noted earlier, a relatively new drug, alprazolam (Xanax), a type of benzodiazepine, has been found to block panic attacks quite dramatically within days after patients start taking it. This rapid response, along with many other positive features, may make alprazolam a useful drug for treating panic, although this use has not yet been approved by the U.S. Food and Drug Administration. Alprazolam has the disadvantage, however, of producing physical dependence and drowsiness in some patients. Seizures have also been reported when the drug is abruptly discontinued.

Another class of drugs, beta adrenergic blockers, has been found useful in treating some phobias, especially specific types of social phobias, such as public speaking phobia. These drugs, usually used to treat high blood pressure, may be used in patients who do not respond to other forms of treatment. There is some suggestion that they may be especially appropriate for patients who have such physical symptoms as trembling and heart palpitations. MAO inhibitors have also been demonstrated to be effective in the treatment of social phobias.

NUTRITION

Solutions to the problem of phobias have also been sought in the realm of nutrition. Certainly, severely malnourished individuals are less able than others to cope with stress. And, patients who are subject to panic attacks have been found to be unusually sensitive to caffeine and may wish to gradually eliminate it from their diets. Otherwise, there is no reliable evidence that any special diet is likely to benefit most phobic patients.

PHOBIA TREATMENT PROGRAMS

Phobia treatment programs now exist in many parts of the United States. These programs use a variety of behavioral therapy techniques to help clients confront and overcome their fears. In addition, through these programs drugs may be recommended and prescribed for individuals likely to benefit from them.

In a typical program, phobic individuals work together in groups with a trained group leader. In some programs, family members and friends are also invited to attend the weekly meetings. Group sessions are used to teach attitudes and skills that are helpful in overcoming phobias. The client also has weekly practice sessions, either alone or in a group, with a therapist who is a mental health professional or a recovered phobic. During these sessions, the client uses his new coping skills in situations he would previously have avoided. With the therapist at his side, he gradually takes progressively more difficult steps toward his final goal. Setbacks are expected and viewed as opportunities for further practice and gain. Agoraphobic clients who are housebound sometimes begin their treatment in their own homes.

Although organized phobia treatment programs offer many advantages, they do not exist in all areas. Many individual therapists are experienced at working with phobic patients, and some will accompany their patients in fear-producing situations.

Referrals to treatment programs and therapists can be obtained by calling or writing to the local, regional, or State chapters of the American Psychological Association, the American Psychiatric Association, the National Association of Social Workers, the American Nurses Association, the National Mental Health Association, the American Association for Counseling and Development, and the Phobia Society of America. In addition, several books and tape cassettes offer self-treatment programs. Since the effectiveness of these programs has not been evaluated, referral to them in this pamphlet does not imply an endorsement by the National Institute of Mental Health.

A word of caution: Not every form of treatment is appropriate for every patient or client. Nor does every therapist or phobia program offer all forms of treatment - psychotherapy, behavior therapy, and medications. Often, a combination of these treatments is necessary. If you feel that you are not being helped by one clinic, program, or therapist, you may wish to seek help elsewhere.

OUTCOMES AND OUTLOOK

The outlook for people with phobias has improved greatly in the last two decades. People with simple phobias can often be relieved of their fears in a matter of weeks. People subject to panic attacks can usually find relief with antidepressant medication. Through the use of these drugs and exposure treatment, people with agoraphobia can be helped to venture out and face the threatening situations they have been avoiding. People with social phobias can be taught social skills and helped somewhat with exposure therapy and medication. All can learn to understand their fears, and possibly solidify their progress, with the help of other therapies - group or individual psychotherapy or family therapy.

If you or someone you know has a phobia, don’t bypass the chance for help. Because physical diseases sometimes mimic phobias, it is a good idea to consult a physician to make certain that symptoms don’t mask a serious physical illness. Then find someone who is skilled in treating phobias. The odds are three to one that the treatment will succeed.

PHOBIAS

Technophobia - Fear of technology Sciophobia - Fear of shadows Decidophobia - Fear of making decisions Nyctophobia - Fear of night Electrophobia - Fear of electricity Topophobia - Fear of performing (Stage Fright) Tropophobia - Fear of moving or making changes Triskaidekaphobia - Fear of the number 13 Gephyrophobia - Fear of crossing bridges Ophidiophobia - Fear of snakes Gatophobia - Fear of cats Hydrophobia - Fear of water Batrachophobia - Fear of reptiles Pyrophobia - Fear of fire Astrapophobia - Fear of lightning Spermophobia - Fear of germs Pnigerophobia - Fear of smothering Cynophobia - Fear of dogs Aerophobia - Fear of flying Ochlophobia - Fear of crowds Blennophobia - Fear of slime Katagelophobia - Fear of ridicule Spheksophobia - Fear of wasps Thalassophobia - Fear of the ocean Kakorraphiaphobia - Fear of failure Gynophobia - Fear of women Agoraphobia - Fear of open spaces Claustrophobia - Fear of enclosed spaces Eremophobia - Fear of being alone Acrophobia - Fear of heights Musophobia - Fear of mice Apiphobia - Fear of bees Gamophobia - Fear of marriageScholionophobia - Fear of school Odynephobia - Fear of pain Keraunophobia - Fear of thunder Amathophobia - Fear of dust

FOR FURTHER INFORMATION

Beck, A.T.; Emery, G.; and Greenberg, R.L. ANXIETY DISORDERS AND PHOBIAS - A COGNITIVE PERSPECTIVE, New York: Basic Books, 1985.

DuPont, R.L., ed. PHOBIA: A COMPREHENSIVE SUMMARY OF MODERN TREATMENTS, New York: Brunner/Mazel, 1982.

Ferber L. Phobias and their vicissitudes. JOURNAL OF THE AMERICAN PSYCHOANALYTIC ASSOCIATION 7:182, 1959.

Klein, D.F., and Rabkin, J.G., eds. ANXIETY: NEW RESEARCH AND CHANGING CONCEPTS. New York: Raven Press, 1981.

Marks, I.M. CURE AND CARE OF NEUROSES. New York: Wiley, 1981.

Mavissakalian, M., and Barlow, D.H., eds. PHOBIA: PSYCHOLOGICAL AND PHARMACOLOGICAL TREATMENT. New York: The Guilford Press, 1981.

Sheehan, D.V. THE ANXIETY DISEASE. New York: Charles Scribner’s Sons, 1983.

Tuma, A.H., and Maser, J., eds. ANXIETY AND THE ANXIETY DISORDERS. Hillsdale, N.J.: Erlbaum, 1985.

Uhde, T.W., and Nemiah, J.C. Panic and generalized anxiety disorders. IN COMPREHENSIVE TEXTBOOK OF PSYCHIATRY, 5^th ed. eds. H.I. Kaplan and B.J. Sadock, Baltimore: Williams and Wilkins 1988.

Van Praag, H.M., ed. RESEARCH IN NEUROSIS. New York: SP Medical and Scientific Books, 1978.

Weiss, E., ed. AGORAPHOBIA IN THE LIGHT OF EGO PSYCHOLOGY. New York: Grune and Stratton, 1964.

Zitrin, C.M.; Klein, D.F.; Woerner, M.G.; and Ross, D.C. Treatment of Phobias. I. Comparison of imipramine hydrochloride and placebo. ARCHIVES OF GENERAL PSYCHIATRY, 40:125, 1983.

This booklet was written by Bette Runck, science writer in the Science Communication Branch. Office of Scientific Information, National Institute of Mental Health (NIMH). An earlier version was done on contract for NIMH by Washington, D.C. science writer Elaine Blume. Drafts were reviewed, sometimes repeatedly, by many experts on phobia. The assistance of the following is gratefully acknowledged: Jack D. Maser, Ph.D., Barry Wolfe, Ph.D., Jack Blaine, M.D., Robert Prien, Ph.D., Barbara Scupi, M.S., Thomas W. Uhde, M.D., Robert M. Post, M.D., Jack D. Burke Jr., M.D., and Jeffrey H. Boyd, M.D., all NIMH staff members; Donald F. Klein, M.D., and Michael R. Liebowitz, M.D., New York State Psychiatric Institute, New York City; Robert Michels, M.D., AND Katherine Shear, M.D., the New York Hospital-Cornell University Medical Center, New York City; Peter A. Di Nardo, Ph.D., State University of New York, Oneonta, N.Y.; Michael J. Kozak, Ph.D., Temple University School of Medicine, Philadelphia; and Bruce N. Cuthbert, Ph.D., Temple University School of Medicine, Philadelphia; and Bruce N. Cuthbert, Ph.D., University of Florida, Gainesville. Editorial assistance was provided by NIMH staff members Anne Cooley, Marilyn Sargent, Myrle Kahn, and Sherry Prestwich.

Department of Health & Human Services Public Health Service Alcohol, Drug Abuse, and Mental Health Administration Rockville, MD 20857

DHHS Publication No. (ADM) 88-1472 Printed 1986 Reprinted 1988