A 28-year-old man comes to the office due to anxiety. The patient was recently promoted at work, requiring a move from the 2nd to the 15th floor of his office building. He says, "Every time I have to take the elevator to my new office, my heart starts pounding and I can't catch my breath. I am having panic attacks on a daily basis." The patient is distracted at work, spending at least an hour worrying about leaving the building. At night he needs 2-3 hours to fall asleep due to worries about his work performance. The patient has had similar episodes in the past and notes that he has been fearful of heights since adolescence, when he learned that his cousin suffered severe injuries from a fall. He has no other medical or psychiatric history. Which of the following is the most appropriate treatment for this patient's condition?
Specific phobia | |
History & |
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Treatment |
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This patient's fear of heights is consistent with the diagnosis of specific phobia, in which he fears a specific object or situation (phobic stimulus). The first-line treatment for specific phobia is cognitive-behavioral therapy (CBT), which involves exposure to the phobic stimulus in a controlled setting.
Exposure is typically performed in a gradual manner (systematic desensitization), which results in decreased anxiety over time through habituation and extinction. Although in vivo exposure is optimal, imaginal and virtual reality exposure are also effective and may be more feasible. Exposure therapy has been shown to be superior to pharmacologic treatment in specific phobia.
(Choice A) Pharmacotherapy is not a first-line treatment for specific phobia. Medication (most commonly benzodiazepines [eg, alprazolam]) is appropriate when behavioral therapy is unavailable or the phobic stimulus is infrequently encountered. The risks for dependence, rebound anxiety, and cognitive impairment when using benzodiazepines generally outweigh the benefits.
(Choice B) Dialectical behavior therapy is useful for patients who struggle with emotion regulation and distress tolerance and is commonly used to treat borderline personality disorder.
(Choice D) Mirtazapine is an atypical antidepressant used in the treatment of major depressive disorder.
(Choice E) The selective serotonin reuptake inhibitor sertraline is a first-line treatment for panic disorder and generalized anxiety disorder (GAD), not specific phobia. This patient does not have the spontaneous, unprovoked panic attacks required for the diagnosis of panic disorder. His anxiety is specific to the repercussions of his phobia on his work performance and is not characteristic of the diffuse anxiety seen in GAD.
(Choice F) Trauma-focused psychotherapy is a form of CBT used to treat posttraumatic stress disorder (PTSD). This patient does not describe intrusive symptoms (eg, flashbacks, nightmares), pervasive hyperarousal, and negative thoughts related to his cousin's fall, which would be expected in PTSD. His recent onset of anxiety in response to the phobic stimulus of riding the elevator is characteristic of specific phobia.
Educational objective:
Specific phobia is characterized by a marked fear of a specific object or situation. Cognitive-behavioral therapy using exposure techniques is the preferred treatment.