BEHAVIORAL HEALTH CONSULT

David V. Mandich, PsyD; A practical guide to Scott A. Fields, PhD Cabin Creek Health Systems: Riverside the management of Health Center, Belle, WV (Dr. Mandich); West Virginia University School When a patient reports symptoms suggestive of , of Medicine,­ Charleston Division (Dr. Fields) ask questions designed to clarify thoughts and behaviors. [email protected] A 4-step plan can also help. The authors reported no potential conflict of interest relevant to this article.

THE CASE Joe S* is a 25-year-old white man who lives with his mother and has a 5-year history of worsening hypertension. He recently presented to the clinic with heart palpitations, , abdominal distress, and dizziness. He said that it was difficult for him to leave his home due to the intense he experiences. He said that these symptoms did not occur at home, nor when he visited specific “safe” locations, such as his girlfriend’s apartment. He reported that his fear had increased over the previous 2 years, and that he had progressively limited the distance he traveled from home. He also reported difficulty being in crowds and said, “The idea of going to the movies is torture.”

● HOW WOULD YOU PROCEED WITH THIS PATIENT?

*The patient’s name has been changed to protect his identity.

he most prevalent psychiatric maladies differences being the specific phobic situa- in primary care are and mood tions or stimuli. T disorders.1,2 Anxiety disorders are pat- Unfortunately, these phobias are likely to terns of maladaptive behaviors in conjunction be undiagnosed and untreated in primary care with or response to excessive fear or anxiety.3 partly because patients may not seek treat- The most prevalent in the ment.4-6 The ease of avoiding some phobic United States is specific phobia, the fear of a situations contributes to a lack of treatment particular object or situation, with a 12-month seeking.5 Furthermore, commonly used brief prevalence rate of 12.1%.2 measures for psychiatric conditions generally Other phobias diagnosed separately in identify and anxiety but not pho- the Diagnostic and Statistical Manual of Men- bias. However, family physicians do have re- tal Disorders, Fifth Edition (DSM-5), include sources not only to diagnose these disorders, social phobia and , which are, but also to work with patients to ameliorate respectively, the fear of being negatively evalu- them. Collaboration with behavioral health ated in social situations and the fear of being providers is key, as patients with phobias trapped in public/open spaces. Social pho- generally benefit from cognitive behavioral bia and agoraphobia have diagnostic criteria therapy (CBT), while those with comorbid psy- nearly identical to those of simple phobias chiatric conditions may benefit from a combi- regarding the fear response, with the primary nation of CBT and medication. CONTINUED

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Phobic response vs TABLE 1 adaptive fear and anxiety Summary of DSM-5 The terms anxiety and fear often overlap when diagnostic features used to describe a negative emotional state of 3 arousal. However, fear is a response to an ac- for specific phobia tual (or perceived) imminent threat, whereas Criteria for specific phobiaa anxiety is the response to a perceived future The following symptoms must be present for at 3 threat. Fear, although unpleasant, serves an least 6 months: adaptive function in responding to immedi- • Marked anxiety or fear about a stimulus that 7 ate danger. Anxiety, in turn, may represent is greater than would be expected given the an adaptive function for future activities as- danger or risk. (In children this may mani- sociated with fear. For example, a cave dweller fest by crying, clinging, refusal to physically having seen a bear enter a cave in the past move, or tantrums.) (fear-evoking stimulus) may experience anxi- • An immediate anxiety or fearful response ety when exploring a different cave (anxiety occurs nearly every time. that a bear may be present). In this situation, • The stimulus is endured with a great deal of the cave dweller’s fear and anxiety responses anxiety/fear or is completely avoided. are important for survival. • The impairment caused by the fear or anxiety With phobias, the fear and anxiety respons- affects the ability to function socially or at work. Ask specific es become maladaptive.3 Specifically, they in- Specific phobias include, but are not limited to, volve inaccurate beliefs about a specific type of questions the following types: ­designed to elicit stimulus that could be an object (snake), envi- Animal (eg, snakes, spiders, dogs) the patient’s ronment (ocean), or situation (crowded room). , cognitions, Accompanying the maladaptive thoughts are Natural environment (eg, ocean, snowstorm, forest) and physiologic correspondingly exaggerated emotions, physi- and behavioral ologic effects, and behavioral responses in Blood, injection, injury (eg, blood draw, shots, specific illness) responses. alignment with one another.8 The development of this response and the etiology of phobias is Situational (eg, enclosed areas, airplanes) complex and is still being debated.7,9,10 Research Other (eg, vomiting, clowns) points to 4 primary pathways: direct psycholog- aAgoraphobia and social phobia are not considered one of the specific phobias, but they are diagnosed with similar ical conditioning, modeling (watching others), criteria and patients exhibit the same phobic reactions. instruction/information, and nonassociative Their ­differentiation exists in the specific stimuli evoking the (innate) acquisition.7,10 While the first 3 path- phobic response. ways involve learned responses, the last results from biological predispositions. • Physiologic responses: changes in heart rate, respiration, blood ­pressure, and other sympathetic nervous system DIAGNOSING PHOBIAS: responses with exposure to stimuli. WHAT TO ZERO IN ON • Behavioral responses: the most DSM-5 provides diagnostic criteria for specific common response is avoidance, phobia, agoraphobia, and social phobia, with with displays of anger, irritability, or each diagnosis requiring that symptoms be ­apprehension when avoidance of the present for at least 6 months (TABLE 1).3 Diag- stimulus is impossible. nosis of phobias should include evaluation of 4 components of a patient’s functioning: sub- Evaluating these 4 components can be jective fears, cognitions, physiologic respons- accomplished with structured interviews, es, and behaviors.8 behavioral observations, or collateral re- • Subjective fears: the patient’s de- ports from family members or the patient’s scribed level of distress/agitation to a peers.8 Thorough questioning and evaluation specific stimulus. (TABLE 28) can enable accurate differentiation • Cognitions: the patient’s thoughts/ between phobias unique to specific stimuli beliefs regarding the stimulus. and other DSM-5 disorders that might cause

34 THE JOURNAL OF FAMILY PRACTICE | JANUARY/FEBRUARY 2020 | VOL 69, NO 1 TABLE 2 ety of psychotherapeutic and pharmacologic Questions to ask patients who treatments are efficacious for phobias, in may have a specific phobia8 some instances the true utility of an interven- tion to meaningfully improve a patient’s life Subjective fears is questionable. The issue is that the research Are there specific things, places, or situations evaluating treatment often evaluates only one that cause you to be very nervous, scared, or component of a phobic response (eg, subjec- agitated? tive fear or cognitions), which may not ade- Cognitions quately represent an overall adaptive change.8 Do you find yourself thinking about specific Additionally, the long-term and sustained ef- feared things, places, or situations for a great ficacy of pharmacologic treatments, particu- portion of the day? larly post-discontinuation, can vary according Physiologic responses to the treatment or type of phobia.5,6,11 Do specific things, places, or situations cause Psychotherapeutic interventions for pho- an automatic change in your heart rate or how bias have shown substantial benefit. CBT is you breathe? helpful, with the most efficacious technique Behavioral responses being exposure therapy.5,6,8,11,12 CBT can begin When you cannot avoid a specific thing, place, during the initial primary care visit with the or situation, do you find yourself getting angry family physician educating the patient about or wanting to leave? phobias and available treatments. Evidence Note: Questions can also be asked of family members, ­provided the patient gives permission. With exposure therapy, patients are in- indicates­ that troduced to the source of anxiety over time, CBT is helpful whereby they learn to manage the distress for phobias, similar symptoms. For example, a patient di- (TABLE 3). Even a single extended session of with exposure­ agnosed with post-traumatic disorder exposure treatment, to a maximum of 3 hours, therapy­ being­ (PTSD) might have a fear response even when can be effective.13 In contrast to research in- the most triggering stimuli are not present. Identifica- volving pharmacologic interventions, studies efficacious­ tion of a clear, life-threatening incident could of psychotherapeutic interventions for treat- technique.­ help with a differential between phobias and ment of social phobias have demonstrated PTSD. However, a patient could be diagnosed sustained positive effects.11 Sustained effects with both disorders, as the 2 conditions are not from exposure therapy last for 6 months to mutually exclusive. 1 year and can even be extended with self-­ The physiologic and behavioral response directed exposure.5 symptoms of phobia can also mimic purely Pharmacologic interventions—specifically medical conditions. Hypertension or tachycar- selective serotonin reuptake inhibitors ­(SSRIs) dia observed during a medical visit could be and selective serotonin norepinephrine reup- due to the fear associated with agoraphobia or take inhibitors (SNRIs)—have been effective with a medically related specific phobia. Blood in treating social phobia and agoraphobia.6 pressure elevated during testing at the medical However, treatment of specific phobias via appointment could be normal with at-home pharmacologic interventions is not support- monitoring by the patient. Thus, blood pressure ed due to limited efficacy and few studies for and heart rate screenings performed at home ­SSRIs and SNRIs.5,6 instead of in public places may help to rule out , although effective in whether potentially elevated numbers are re- alleviating some phobic symptoms, are not lated to a fear response. Fear and avoidance-like recommended per current guidelines due to symptoms can also be due to , adverse effects and potential exacerbation of the and appropriate drug screening can provide in- phobic response once discontinued.5,6 This poor formation for an accurate diagnosis. result with benzodiazepines may be due to the absence of simultaneous emotional exposure to the feared stimuli. Unfortunately, little research HOW BEST TO TREAT PHOBIAS has been done on the long-term effects of phar- Although research demonstrates that a vari- macologic intervention once the treatment has

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TABLE 3 to overcome the agoraphobia and took an Exposure therapy: “awesome” vacation. He also reported a sig- nificant decrease in panic symptoms. JFP

A simplified example CORRESPONDENCE Exposure therapy helps reverse maladaptive­ Scott A. Fields, PhD, 3200 MacCorkle Avenue Southeast, 5th Floor, Robert C. Byrd Clinical Teaching Center, Department of avoidance to a feared stimulus. Gradual Family Medicine, Charleston, WV 25304; [email protected]. exposure helps patients experience success in managing their fear.

Step 1: Identify different methods of exposure References to the fear-evoking stimulus (eg, with height 1. Simon G, Ormel J, VonKorff M, et al. Health care costs associated phobia: climbing a stepladder, looking over a with depressive and anxiety disorders in primary care. Am J Psy- chiatry. 1995; 152:352-357. balcony, riding in a glass elevator). 2. Kessler RC, Petukhova M, Sampson NA, et al. Twelve‐month and Step 2: Rank the methods from least to most lifetime prevalence and lifetime morbid risk of anxiety and mood disorders in the United States. Int J Methods Psychiatr Res. 2012; fear evoking. 21:169-184. Step 3: Have the patient engage in each 3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth edition (DSM-5). Arlington, VA: ­method of exposure, starting with the least American Psychiatric Association; 2013:189-233. fearful method and moving to the next 4. Bandelow B, Michaelis S. Epidemiology of anxiety disorders in method only when the lesser method no longer the 21st century. Dialogues Clin Neurosci. 2015; 17:327-335. ­produces a phobic response. 5. Choy Y, Fyer AJ, Lipsitz JD. Treatment of specific phobia in adults. Clin Psychol Rev. 2007; 27:266-286. Step 4: Have the patient continue regular in 6. Bandelow B, Michaelis S, Wedekind D. Treatment of anxiety dis- vivo exposure for maintenance of recovery. orders. Dialogues Clin Neurosci. 2017; 19:93-107. 7. Poulton R, Menzies RG. Non-associative fear acquisition: a review of the evidence from retrospective and longitudinal re- search. Behav Res Ther. 2002; 40:127-149. 11 been discontinued. So, for medication, the 8. Davis III TE, Ollendick TH. Empirically supported treatments for question of how long treatment effect lasts af- specific phobia in children: Do efficacious treatments address the components of a phobic response? Clin Psychol Sci Pract. ter discontinuation remains unanswered. 2005; 12:144-160. 9. Field AP. Is conditioning a useful framework for understand- ing the development and treatment of phobias? Clin Psychol THE CASE Rev. 2006; 26:857-875. Mr. S’s family physician diagnosed his condi- 10. King NJ, Eleonora G, Ollendick TH. Etiology of childhood pho- bias: current status of Rachman’s three pathways theory. Behav tion as agoraphobia with panic attacks. He Res Ther. 1998; 36:297-309. was prescribed sertraline for his panic attacks 11. Fedoroff IC, Taylor S. Psychological and pharmacological treat- ments of social phobia: a meta-analysis. J Clin Psychopharmacol. and referred for CBT with a psychologist. CBT 2001; 21:311-324. focused on cognitive restructuring as well as 12. Wolitzky-Taylor KB, Horowitz JD, Powers MB, et al. Psycho- logical approaches in the treatment of specific phobias: a meta-­ gradual exposure where he would travel with analysis. Clin Psychol Rev. 2008; 28:1021-1037. increasing distances to various locations. Af- 13. Zlomke K, Davis III TE. One-session treatment of specific phobias: a detailed description and review of treatment ter 10 months of treatment, Mr. S was able ­efficacy. ­Behav Ther. 2008; 39:207-223.

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