Benzodiazepines and Behavioural Treatment of Phobic Anxiety

Social phobia: an update on treatment

Social phobia is a prevalent anxiety disorder that may be treated with pharmacotherapy, psychotherapy, or both. This article reviews the empirical evidence for these interventions and discusses new treatment developments. Active ingredients and mechanisms involved in the effectiveness of treatment are discussed. In addition, the elements of social phobia and its treatment that are similar to other anxiety and non-anxiety disorders are considered. Finally, it discusses future efforts to improve diagnosis and treatment for social phobia, including possible revisions to the diagnostic criteria that might be considered in the forthcoming fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, as well as routine care and obstacles for dissemination.

Benzodiazepines and the Behaviour Therapist: Managing Withdrawal and the Problems of Concurrent Treatment with these Drugs

Many of the clients being treated by behaviour therapists will also be taking benzodiazepines. The use of these drugs may interact with the problems presented to the behaviour therapist and complicate treatment. In addition the behaviour therapist may be asked to help in managing withdrawal in those who have become dependent on benzodiazepines. The evidence relating to the effects of these drugs and their withdrawal reactions is discussed and suggestions made as to how withdrawal might best be managed.

Combining alprazolam with systematic desensitization therapy for dental injection phobia

To determine whether a benzodiazepine facilitates systematic desensitization, 144 subjects with dental injection phobia received systematic desensitization in combination with placebo or one of two doses of alprazolam (0.5mg or 0.75mg). Systematic desensitization therapy included computer-controlled presentation of digitized video segments followed by in vivo exposure segments, culminating in an actual dental injection. Subjects advanced to the next hierarchy segment when low anxiety was reported during a segment. Alprazolam and placebo groups progressed at the same rate. The 0.75mg group had elevated heart rates while watching video segments compared with placebo. In a subsequent behavioral avoidance test (during which subjects were randomized to a new drug condition), there was no indication that state-dependent learning had occurred. Dental fear was reduced similarly in all groups for 1 year after study completion. No advantage was found to combining alprazolam with systematic desensitization for dental injection phobia.

Cognitive-behavioral therapy for social anxiety disorder: current status and future directions

Cognitive-behavioral therapy (CBT) is the most thoroughly studied nonpharmacologic approach to the treatment of social anxiety disorder, and its efficacy has been demonstrated in a large number of investigations. This article summarizes the data on the efficacy of CBT for the treatment of the symptoms of social anxiety disorder and impaired quality of life. The relative efficacy of various CBT approaches, both in the short-term and over extended follow-up periods, is reviewed. Factors associated with more or less positive response to CBT among patients with social anxiety disorder are examined. Special attention is given to the comparison of CBT with pharmacologic approaches to the treatment of social anxiety disorder and the potential utility of combining these approaches. Future directions in the application of combinations of CBT and pharmacotherapy to the treatment of social anxiety disorder are discussed.

Comparison between one-session psychological treatment and benzodiazepine in dental phobia

To compare the effects of a single session of psychological treatment and acute administration of benzodiazepine, 50 dental phobic patients were allocated either to psychological treatment, benzodiazepine, or no treatment for anxiety. Psychological treatment consisted of stress management training and imaginal exposure to phobic stimuli with homework assignments. Benzodiazepine was administered 30 min before dental treatment. Both treatment conditions led to less anxiety during dental surgery than did the control condition. Phobic patients in the benzodiazepine condition showed a relapse after dental treatment, whereas those in the psychological treatment condition showed further improvement until the follow-up 2 months later. Of the latter group, 70% continued dental treatment; only 20% and 10% returned in the benzodiazepine and control conditions, respectively.

Acute and delayed effects of alprazolam on flight phobics during exposure

In order to test if a benzodiazepine would enhance or hinder the therapeutic effects of exposure, immediate and delayed effects of alprazolam on flight phobics were assessed by questionnaires and ambulatory physiological recording. Physiological measures included heart rate, skin conductance level and fluctuations, finger temperature, respiratory sinus arrhythmia, and various respiratory measures derived from two bands calibrated for each subject. Twenty-eight women with flying phobia flew twice at a 1-week interval. One and a half hours before flight 1, 14 randomly assigned phobics received double-blind 1 mg of alprazolam and 14 received placebo. On flight 1, alprazolam reduced self-reported anxiety (5.0 vs 7.4) and symptoms (5.3 vs 3.6) more than placebo, but induced an increase in heart rate (114 vs 105 bpm) and respiratory rate (22.7 vs 18.3 breaths/min). Before flight 2, the alprazolam group did not expect to be more anxious than the placebo group (6.7 vs 6.5), but in fact indicated more anxiety during flight (8.5 vs 5.6), and a substantial increase in panic attacks from flight 1 to flight 2 (7% vs 71%). Heart rates in the alprazolam group increased further (123 bpm). Results indicate that alprazolam increases physiological activation under acute stress conditions and hinders therapeutic effects of exposure in flying phobia.

Behaviour therapy and benzodiazepines: allies or antagonists?

Behaviour therapy and benzodiazepines are directed towards common problems and are often used in combination. At present we know little about the beneficial or adverse interactions of these two treatments. This paper reviews the available literature and suggests that there are important theoretical and clinical issues to be resolved.

Effects of diazepam on approach, self-reported fear and psychophysiological responses in snake phobics

The effects of diazepam was assessed on a number of measures of phobic anxiety. Snake-phobic subjects underwent two sessions on either diazepam or placebo in a crossover design. In addition to a habituation series, a slide with the phobic object was displayed as well as a live snake which subjects were asked to approach. The anxiolytic effect of diazepam was manifest in only one measure of fear, namely self-rated fear at the point of closest approach when it also attained the highest level. The result would indicate that diazepam has an anxiolytic only on high levels of subjective anxiety. The magnitude of the phasic cardiac reaction to the slide was highly and positively correlated with self-rated fear of the slide.

Conditioned emotional responding under diazepam: a psychophysiological study of state dependent learning

An experimental study on 34 healthy male volunteers demonstrated that a therapeutic dose of diazepam (15 mg PO) influenced the reproduction of a conditioned emotional response (skin conductance activity) on subsequent test days. This effect depended upon the pharmacological state present at acquisition, and was in accordance with a drug-dissociation interpretation of diazepam's amnesic effect. The results are interpreted as an example of diazepam state-dependency effects upon development of behavioral tolerance to stress. The clinical consequence of the results indicates that patients under diazepam medication will to a certain degree be deprived of the ability to develop appropriate coping strategies. It is concluded that combining psychotherapy with diazepam treatment may have the opposite effects to those intended.

Alcohol, other drugs and tobacco use and anxiolytic effectiveness. A comparison of anxious patients and psychiatric nurses

Recent studies raise questions regarding use or abuse of alcohol by phobics, and about compatibility of behaviour therapy and benzodiazepine use. In this study 40 patients, referred with mainly anxiety-related problems to a nurse behaviour therapist, and a comparison group of 40 psychiatric nurses completed a self-administered questionnaire assessing use of alcohol, sedative drugs and tobacco, and their perceived anxiolytic effectiveness. The paper confirms earlier findings that the patients, in general, drank less than the general public. They also drank less than the nurses, but used more sedative drugs and were heavier smokers. Alcohol was an unreliable anxiolytic. A few patients, including two agoraphobics, drank heavily and did not enter treatment made conditional on stopping drinking. Implications for case management are discussed.

How nurse therapists assess and contribute to the management of alcohol and sedative drug use among anxious patients

Fourteen nurse therapists completed self-administered questionnaires on their assessment of and input to management of alcohol and sedative drug use among 110 anxious patients referred to them for behaviour therapy. Information on use and on case management is summarized. The therapists play an active, extended role in assessing, communicating about and in some cases advising on reduction of these substances. Policies on use in the context of behaviour therapy are formed in training, and implications for training and the need for awareness of the relevant literature are discussed.

Applied relaxation training for generalised anxiety and panic attacks: the efficacy of a learnt coping strategy on subjective reports

The results of applied relaxation training in patients with generalised anxiety and panic attacks are reported. ART was taught during one session, by means of participant demonstration, written instructions, taped instructions, or a combination of all three, with instructions to practice at home. All four methods proved superior to a waiting list control, but there were no differences between the treatment groups. There was some evidence for the non-specific effect of expectancy, but this did not completely explain the treatment effect.