Social and Specific Phobias: Pharmacotherapy

Pharmacotherapy

Specific Phobia

Pharmacotherapy is generally thought to be ineffective for specific phobias. However, little research has been conducted to assess the utility of medications for specific phobias, and it is not uncommon for phobic patients occasionally to be prescribed low dosages of benzodiazepines to be taken in the phobic situation (e.g., while flying). The few relevant studies that have been conducted have examined the use of benzodiazepines and beta-blockers alone or in combination with behavioral treatments for specific phobias and in general have found that drugs do not contribute much to the treatment of specific phobias. However, one problem with the research to date is that it has not taken into account differences among specific phobia types. For example, claustrophobia and other phobias of the situational type appear to share more features with panic disorder than with the other specific phobia types. Therefore, medications that are effective for panic disorder (e.g., imipramine, alprazolam) may prove to be effective for situational phobias. Although there are few studies examining this hypothe-sis, preliminary data suggest that benzodiazepines may be helpful in the short term but lead to greater relapse in the long term and possibly interfere with the therapeutic effects of exposure across sessions. There have been very few controlled studies to date ex-amining the effectiveness of antidepressants for specific phobia.

Social Phobia

In contrast to specific phobias, social phobia has been treated successfully with a variety of pharmacological interventions including SSRIs such as sertraline, fluvoxamine and paroxetine, benzodiazepines such as alprazolam, traditional monoamine oxidase inhibitors (MAOIs) such as phenelzine and reversible in-hibitors of monoamine oxidase A (RIMA), such as moclobemide and brofaromine.

Numerous controlled trials across a range of SSRIs includ-ing sertraline, fluvoxamine and paroxetine have demonstrated their effectiveness in the treatment of social phobia, such that the SSRIs are currently considered the first-line medication treat-ment. Due to their tolerability and efficacy, the SSRIs have been referred to as “the new gold standard” in pharmacological treat-ment for social phobia. Uncontrolled open trials and case series studies with citalopram and fluoxetine suggest that these SSRIs may also be beneficial in the treatment of social phobia. Another benefit of SSRIs is their broad spectrum efficacy for common comorbid disorders such as depression and panic disorder.

Research on the use of anxiolytics for the treatment of so-cial phobia have focused on high potency benzodiazepines (e.g., clonazepam, alprazolam) and the nonbenzodiazepine buspirone. Several studies have examined the significant utility of clon-azepam for treating social phobia. Alprazolam may also be effec-tive but there are too few studies to establish this. The findings on buspirone are mixed.

Due to the potentially severe side effects of MAOIs as well as the necessity for certain dietary restrictions, they are notrecommended as a first-line treatment. The findings from more recent trials involving RIMAs have been less encouraging than initial studies suggested. Discontinuation of MAOIs and RIMAs have been associated with a tendency to relapse.

Research on beta-blockers indicates that they are no bet-ter than placebo for most patients with generalized social pho-bia. Although beta-blockers have been used to treat individuals from nonpatient samples with heightened performance anxiety (e.g., people with public speaking anxiety, musicians with stage fright), their efficacy for treating individuals with discrete social phobia has not been established. Nevertheless, beta-blockers are often prescribed for discrete performance-related social phobias. Preliminary findings suggest that gabapentin, a medication typi-cally used in the treatment of partial seizures, may be effective in the treatment of social phobia, but more research is needed to confirm this finding.