Treatment of phobias

Summary of treatment options
The most proven treatment for phobias is psychological, and in most cases, the success rate is very high.

Psychosocial treatments

Psychological therapies (often referred to as therapy or psychotherapy) involve a trained professional who uses clinically researched techniques, usually talking therapies, to assess and help people make positive changes in their lives. Two treatments - exposure therapy and flooding - both derived from behavioural theory, are the most successful psychological methods of treatment for phobias.

People with social phobias may benefit from specific training in social skills or assertiveness techniques. These may be taught either individually by a therapist or counsellor or in a group. Counselling may include some techniques used in psychological therapies, but is mainly based on supportive listening, practical problem-solving and information giving.

All therapy should be provided to people and their families and whanau in a manner which is respectful of them and with which they feel comfortable and free to ask questions. It should be consistent with and incorporate their cultural beliefs and practices.

Medication

Medication may be used according to individual need and symptoms. It is sometimes used in addition to psychological therapy. Antidepressants can be effective for severe social phobia. Antidepressants or tranquillisers (benzodiazepines) may be recommended for agoraphobia, especially if it is associated with panic attacks.

If you are prescribed medication you are entitled to know the names of the medicines, what symptoms they are supposed to treat, how long it will be before they take effect, how long you will have to take them for and what their side effects (short and long-term) are.

If you are pregnant or breast-feeding no medication is entirely safe. Before making any decisions about taking medication in pregnancy you should talk with you doctor about the potential benefits and problems associated with each particular type of medication.

Complementary therapies

Complementary therapies which enhance the person's life may be used in addition to psychological treatments and prescription medicines.

Treatment of specific phobias & blood, injury, injection phobias

Psychosocial treatments: exposure therapy /systematic desensitisation
The psychological treatment of choice is called exposure. This simply means carefully exposing yourself to the phobic object or situation in a gradual and stepwise way so you can ease yourself into the frightening situation. For example, if spider phobia is your problem you might start off by thinking about spiders, then looking at pictures of spiders, then looking at real dead spiders, then live ones, then handling live spiders.

As you proceed, it is likely you will gradually gain confidence and your anxiety will become less. This technique, preceded by training in deep muscle relaxation, is called systematic desensitisation - systematically making you less sensitive to the thing you fear.

The amount of exposure therapy needed depends on how frightened you are to start with and how often you can practise. Exposure therapy requires you to tolerate some anxiety. If you can only tolerate a little, it takes longer. Typically it takes six to eight sessions, every one or two weeks. It is likely that you will be asked to keep a diary of your anxiety levels as you carry on with the exposure programme from your home.

There is a faster type of exposure called flooding. This is like learning to swim by jumping in at the deep end. Obviously this can be very frightening. Flooding means exposing yourself to the situation that makes you very anxious and staying there until your anxiety starts to drop. This may take a couple of hours. Although this technique brings fast results, it can be very unpleasant and is not used very often.

Unfortunately most general practitioners do not have the time or the training to do exposure therapy themselves, and most specialist community mental health services run by hospitals deal with only the most severe cases. Treatment there is free of charge.

At a number of community service agencies, charges are based on your ability to pay. Private therapists' fees may range from $60 to $200 per session, although some operate on a sliding scale. Fees for group therapy (where such groups are available), are cheaper.

Medication
Medications are rarely, if ever, useful in treating these phobias. They could, however, be used to get you through a phobic situation which was very important to you. For example, if you have a fear of flying that you usually just cope with by avoiding flying, and then had to fly to your son's wedding, you could probably cope by taking tranquillisers (benzodiazepines) to get you through the flight.

Treatment of social phobia

Psychosocial treatments - psychological therapy
Most people with phobias can be greatly helped by therapy. But even after treatment, a number of people will remain a little anxious in some social situations. They are much better but not totally cured.

The same sort of exposure therapy as is used in treating specific phobias is often useful for social phobias. In this case people would be encouraged to gradually expose themselves to social situations, progressing from mildly worrying encounters to social events that are more bothersome. In this way they learn to become more confident as their anxiety fades away.

Usually people with phobias also have interfering thoughts about themselves, such as thinking all the time about how much they are shaking or thinking other people are looking at them and judging them negatively because of it. Ways to challenge or replace these unhelpful thoughts are often taught so that more realistic and helpful thoughts can take their place.
 
Some people with social phobia may not be sure how good they are at talking to other people and may benefit from practical training in social skills or assertion. Social skills training involves learning specific skills for relating to other people in social situations, and gaining confidence in such situations.

Assertion training teaches techniques for asserting one's views and needs in a way which is acceptable and respectful to others. This training is often done in groups as it gives the opportunity for feedback from other people in the group. Single-sex groups can be more useful or more acceptable to some people.

In some cities there may be specific groups for people overcoming flying phobia, water phobia or those who find speaking in public difficult. Fees for these are as for treatment for specific phobias and blood, injury, injection phobias quoted in the above section.

Medication - antidepressants
If social phobia is severe and difficult to change with psychological therapy, then medications can be used. Antidepressants have an effect on social phobia even if you are not depressed. They are effective for about 70 per cent of people with social phobia.

A major problem with using medication to treat social phobia is relapse. If you are using medication as the only form of treatment, there is a high risk that the problem will flare up again when you stop taking the tablets. This highlights the importance of using additional treatments such as psychological therapy.

Antidepressants have no immediate effect and start working after two to three weeks. Their effect can increase over several more weeks. They are usually taken for three to 12 months to block the anxiety associated with social phobia. This time can be used to try to build up your confidence. Almost all are tablets or capsules taken once a day. They are not addictive, but there may be a small rebound effect of anxiety and insomnia if you stop very suddenly.
 
Antidepressants have a number of side effects depending on which type of antidepressant it is. These side effects differ from person to person and, although they can be quite severe for some people, they usually fade away after two to three weeks. You may need to try different antidepressants before you find one which suits you.

Antidepressants affect brain chemicals, mainly noradrenaline and serotonin. The Tricyclic Antidepressants (tricyclics/TCAs) and the Monoamine Oxidase Inhibitors (MAOIs) are the oldest antidepressants and have been useful in the treatment of social phobia.

However, the antidepressants generally prescribed first these days are newer Selective Serotonin Re-uptake Inhibitors (SSRIs) and occasionally Reversible Inhibitor of Monoamine Oxiadase A (RIMA) which is a safer version of the old MAOIs.

These newer antidepressants have been shown to be effective in treating social phobia for many people and have fewer side effects than the older antidepressants.

Selective serotonin re-uptake inhibitors (SSRIs)
Over the past decade the Selective Serotonin Re-uptake Inhibitors (SSRI) antidepressants have become available. SSRIs have their effect specifically on serotonin, and can often be started at the usual effective dose from day one, although the therapeutic effect may take some weeks to occur.

As some people experience a slight increase in anxiety when starting at the full dose it is often useful to start at a smaller dose and build up gradually.

Side effects of SSRIs can include:

• nausea and weight loss or weight gain
• headache
• trouble sleeping
• agitated or jittery feelings, (occur less if the starting dose is low and increased gradually)
• rash (not common, but means the drug should be stopped)
• sexual problems.

SSRI-like antidepressants
The newest 'SSRI-like' generations of antidepressants target serotonin and noradrenaline neurotransmitter systems with less effect on other neurotransmitter systems, therefore fewer side effects.

Overseas studies have found they are also useful in treating social phobia. These newer antidepressants may not be subsidised, and, depending on dose, may cost up to $400 per month. Although more expensive, these newer types of medications are equal in effectiveness to the tricyclics and have less troublesome side effects.

Reversible inhibitors of monoamine oxidase A (RIMAs)
MAOIs are an older group of antidepressants which have been shown to be effective in the treatment of social phobia, however, due to potentially dangerous interactions with some foods and medicines they are rarely used nowadays.

A safer form has been developed called a Reversible Inhibitor of Monoamine oxidase A (RIMA). The effective dose of moclobemide is usually reached over two weeks or more.

Tricyclic antidepressants (tricyclics/TCAs)
Tricyclics can be very effective at treating social phobia and may be useful for those who have found little benefit from SSRIs or have been unable to tolerate that type of medication.

Each TCA has a different pattern of side effects, so when one is not tolerated there is likely to be another that causes less of that side effect. Because of these side effects, it is necessary to start on a low dose and increase slowly over two weeks or more to reach the effective dose (usually about 150mg per day).

The tricyclic antidepressants work by increasing amounts of noradrenaline and serotonin.

This group of medicines includes: amitryptiline; amoxapine; clomipramine; desipramine; dothiepin; doxepin; imipramine; maprotiline; mianserin; nortryptiline; trimipramine.

 Common side effects of tricyclics include:

• drowsiness (this is can be beneficial if sleep problems exist)
• blurred vision
• dry mouth
• constipation
• dizziness
• trouble urinating (mostly a problem for older men)
• increased sweating
• weight gain
• problems with sexual function, such as impotence, reduced sex drive, or lack of orgasm
• heart problems, but only in people who already have heart problems or are elderly (some of this group of drugs are safer for people with heart problems).

Because of their effects on the heart these drugs are very dangerous in overdose.

Treatment of agoraphobia

Psychosocial treatments - exposure therapy / systematic desensitisation
Exposure therapy is the main therapy used for treating agoraphobia. As agoraphobic problems tend to be more widespread, treatment can take longer - from three to six months.

Panic and agoraphobia make each other worse. If you can overcome your phobic avoidance through exposure, then panic attacks tend to become less of a problem. If you reduce panic attacks then agoraphobia lessens.

Because people with agoraphobia feel more secure with company, family or whanau and friends can play a bigger role in treatment. With your agreement, these people can help you with some of the therapeutic tasks you may need to perform from home.

Fees for therapy are in the same range as those for the treatment of specific phobias and social phobias (see above).

Medication
If the agoraphobia is severe or if depression is a problem, medication may be advised. The same antidepressant medications that are useful in social phobia are helpful in agoraphobia (see section above on antidepressants). About 70 per cent of people do well with the first medication they try.

Some people may need to try more than one to see which suits them best. Your doctor may wish to give you a physical check-up to make sure the medication will not cause you health problems.

Benzodiazepines (tranquillisers)
Benzodiazepines (the Valium type of medicines) are sometimes used in the treatment of agoraphobia. They increase the activity of a chemical in the brain called GABA (gamma amino butyric acid) which regulates alertness. This lessens anxiety, induces sleepiness, and makes the muscles relax.

A major problem with using benzodiazepines to treat agoraphobia is the risk of relapse. If you are using medication as the only form of treatment there is a very high risk that your problems will flare up again when you stop taking the medication. This highlights the importance of using additional treatments such as psychological therapies.

There are two ways of taking benzodiazepines. One is to take them for very short periods to relieve great distress or allow you to cope with some important event you cannot avoid. The other, less common way, is to take them regularly for weeks or months to prevent panic occurring.

If you take them regularly you are likely to develop some dependency which is why they are usually only prescribed for short periods (up to two weeks). If you have trouble with addictions they are best avoided.
 
Stopping them needs to be done gradually and under medical supervision. Sudden stopping may produce withdrawal symptoms such as anxiety, insomnia, nausea, headaches and dizziness and, occasionally, may induce seizures.

People with epilepsy must be careful as withdrawal can also make seizures more likely. The effects of sudden stopping may be similar to your original symptoms of anxiety, so it is hard to tell if you have withdrawal or not.

Benzodiazepines work almost immediately and have few side effects. The main side effect of drowsiness or fatigue usually wears off.

People taking benzodiazepines need to be aware they may become too drowsy or relaxed to drive or operate machinery. Muscle relaxation can be a risk for older people whose muscles may be weak, and increase their risk of falling by taking benzodiazepines. Older people may also become confused. Those with severe breathing problems need to be careful as benzodiazepines can reduce breathing a little.

Benzodiazepines are not advised in pregnancy, especially near birth, as they can affect the baby and some of them get into breast milk.

Benzodiazepines are safe with almost all other medicines. The effects of alcohol are magnified by them, so it should be avoided.

Medicine interactions

Most psychiatric medicines tend to react with each other when taken in combination. Their sedative effect in particular may make you feel sleepy. Your doctor will, where possible, limit the number of medications prescribed. You should be told what effects you may notice from the medication, receive clear instructions about how you should take it and what precautions are necessary.

You should not mix different types of antidepressants unless instructed by your doctor as this could be very dangerous.

The effects of alcohol and many illegal drugs will also be heightened, so they should be avoided. It is important the doctor knows all the medications (including any herbal medicines such as St John's Wort) you are taking, as some taken together can be dangerous.

Complementary therapies

The term complementary therapy is generally used to indicate therapies and treatments which differ from conventional Western medicine and which may be used to complement, support or sometimes replace it. There is an ever-growing awareness that it is vital to treat the whole person and assist them to find ways to address the causes of mental health problems rather than merely alleviating the symptoms. 

This is often referred to as an holistic approach. Complementary therapies often support an holistic approach and are seen as a way to address physical, nutritional, environmental, emotional, social, spiritual and lifestyle needs. 

Many cultures have their own treatment and care practices which many people find helpful and which can often provide additional benefits to health and wellbeing.  Rongoa Maori is the indigenous health and healing practice of New Zealand. Tohunga Puna Ora is a traditional healing practitioner. Traditional healing for many Pacific Islands' people involves massage, herbal remedies and spiritual healers.

In general, meditation, hypnotherapy, yoga, exercise, relaxation, massage, mirimiri and aromatherapy have all been shown to have some effect in alleviating mental distress. Complementary therapies can include using a number of herbal and other medicinal preparations to treat particular conditions. It is recommended that care is taken as prescription medicines, herbal and medicinal preparations can interact with each other.

When considering taking any supplement, herbal or medicinal preparation we recommend that you consult a doctor to make sure it is safe and will not harm your health.

Women who may be pregnant or breastfeeding are advised to take extra care and to consult a doctor about any supplements, herbal or medicinal preparations they are considering using, to make sure they are safe and that they will not harm their own or their baby's health.

See also: Phobias; phobias - living with

Support groups

See the support organisations (which include helplines) under Further information and support below.

Original material provided by the Mental Health Foundation of New Zealand, 2002. Edited by everybody, May 2005.