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By Root 953 0

locked in a closet; a cat phobic will sit in a room full of cats; the agoraphobe is dropped off, in the company of the therapist, at a shopping center. In each case, the patient waits an agreed-upon length of time—it may seem an eternity, but it is actually usually around four hours—without leaving. At first the patient is terrified, but inevitably, after an hour or so, the fear starts to dissipate when she sees that no harm comes to her. After about four hours the patient is not in a state of fear anymore. She now is in the presence of the CS, but in the absence of the UR. She is exhausted and drained, but the phobic fear has extinguished.

The opposite of relaxation is used for blood phobias with marked success. In this common phobia (about 3 percent of the population has it), the victim’s heart rate and blood pressure drop sharply, and she faints at the sight of blood. Applied tension is taught to blood phobics. They learn to tense the muscles of the arms, legs, and chest until a feeling of warmth suffuses the face. This counterconditions the blood-pressure drop and fainting, just as relaxation counterconditions anxious tension.7

These therapies work at least 70 percent of the time. After a brief course of such therapy, usually about ten sessions, most patients can face the phobic object. Applied tension with blood phobia works even better: Remission is lasting; former phobics rarely come to like the object, but they no longer fear it.

Unsuccessful therapy. After extinction therapy, symptoms do not manifest themselves elsewhere. This lack of symptom substitution is important, since both psychoanalytic and biomedical theories claim that eliminating the phobia directly is merely cosmetic. The underlying conflict or the underlying biochemical disorder still exists untouched, these schools of thought have it, and symptoms must appear elsewhere. But, in fact, they do not.

Psychoanalysis does not work on phobias. Cognitive therapy, in which patients look at the irrationality of their phobias (“What really is the probability of an airplane crash?” or “Look here—no adult in Philadelphia has ever been mauled by a cat”) and learn to dispute these irrational thoughts, does not seem to be of much use for specific phobias.8 Cognitive therapy for panic may be useful in agoraphobia, however, when panic is a central problem.9

The Right Treatment

PHOBIA SUMMARY TABLE

Drugs are not very useful with object phobias. The anti-anxiety drugs produce calm when taken in high doses in the phobic situation itself, though the calm is accompanied by drowsiness and lethargy. So for an airplane phobic who must suddenly fly, a minor tranquilizer will help, but only temporarily. The calm is cosmetic: Once the drug wears off, the phobia is intact.

The combination of drugs and extinction therapy for object phobias is also probably not useful. For extinction to work, it seems necessary to experience anxiety and then have it wane. Anti-anxiety drugs block the experience of anxiety and so block extinction of anxiety. The phobia therefore remains intact.

Drugs do not seem very useful with social phobia. MAO inhibitors (strong antidepressants) have been used with some success. About 60 percent of patients improve while on these drugs. But the success is temporary and the relapse rate high once the drugs are discontinued. Remember also that MAO inhibitors have dangerous side effects (see chapter 3). Somewhat lower improvement (around 50 percent) occurs with the strong anti-anxiety agents, like Xanax, and with beta-blockers. But, again, the relapse rate is very high and the drugs have marked side effects. A high relapse rate upon drug discontinuation suggests only a cosmetic effect on phobic anxiety.10

Agoraphobia, in contrast, is helped by antidepressant drugs, and in a noncosmetic way. Antidepressants seem to work to almost the same extent as extinction therapies, and they are particularly useful in combination with extinction therapies.11 What is probably crucial is that agoraphobia, unlike most other phobias, typically involves panic attacks.