London, Robert, T., Clinical Psychiatry News
"I can't go into the elevator; I won't be able to breathe. I'm scared. My heart is going to explode."
This kind of utter desperation that we hear from some patients makes one thing clear: Phobias and anxiety disorders present tremendous therapeutic challenges.
They also appear to be quite common. In fact, phobias are the most common mental disorders in the United States ("Concise Textbook of Clinical Psychiatry" [Baltimore: Williams & Wilkins, 1996, p. 201]). They afflict 5%-10% of the population, and at one time or another, as many as 25 percent of the population suffer from a phobic disorder, some researchers say. These phobic disorders are often of the specific phobia type.
When phobias go untreated, the resulting stress and anxiety can be so severe that additional psychiatric disorders can occur, such as major depressive disorders, anxiety disorders, and, of course, substance abuse disorders.
Many of these specific phobia disorders respond well to cognitive-behavioral therapy, traditional behavioral therapy techniques, and strategies using hypnosis. Pharmacologic treatments have also been shown to be effective.
The long-term explorative psychotherapies in the treatment of phobias--unfortunately still used by some psychotherapists--are essentially ineffective. They may enhance understanding of the phobic response but do not bring resolution.
In treating specific phobias, I prefer a combination therapy involving systematic desensitization and gradual, guided exposure. One successful approach involves systematic desensitization with visualization techniques for short periods of time, coupled with reciprocal inhibitions, in which pleasant visualizations counter the anxiety and stress of the phobic thoughts.
In my experience, when you combine this in vitro technique of systematic desensitization and reciprocal inhibition with the in vivo technique of gradual exposure, patients markedly improve.
I once treated an advertising executive for severe phobic response to elevators by combining the in vitro and in vivo techniques. This 42-year-old gentleman had just about stopped using elevators. Although not a fitness enthusiast, the patient had gotten into the habit of walking up and down as many as 15 flights of stairs two to three times a day to get in and out of his office.
Getting around at home was not a problem, since he lived in a single-story ranch house. But his business trips, which he took two to three times a month, were nightmares, and high-rise office buildings caused him severe anxiety and stress. Sometimes he was able to find a stairwell, but its door was frequently locked. When the only alternative was using an elevator, he overcame his avoidance and fear, which are consistent with phobic disorders. He was able to get on the elevator with other people by sheer force of will--but in terror.
He made sure that someone was going to a floor beyond the one he needed to reach. But even so, he experienced tachycardia, sweating, and severe gastrocolic reflex causing an intense need to go to the bathroom.
The patient's life was paralyzed by phobic fear. He was ready to make a change.
The program I designed for him was a 10-session combination of 1 office visit lasting 90 minutes and 9 subsequent field trips to elevator banks in high-rise office buildings. A 10-session fee was established at the time the patient made the appointment. All of the visits occurred within a 3-week period, and the program incorporated in vitro and in vivo techniques.
The patient is taught relaxation exercises on the first office visit, and then proceeds to use a systematic densensitization technique to see the phobic situation without experiencing a full exposure to it. The patient practices the desensitization technique until it is perfected.
In this case, the executive used the split movie screen technique of projecting the phobic situation into the left side of an imaginary screen. …