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., Boston, MA 02114, USAPHARMACOTHERAPY OF PHOBIAS: COMMENTARIES _____________________________ 157combination [5].However, the magnitude of this added effect was notgreat, and it is not clear from a cost–benefit perspective that routineadministration of formal combined therapy is warranted.Thus, extra-polating from this work, a pressing issue in the clinical practice of theanxiety disorders, including social anxiety disorder and other phobicdisorders, is the identification of patients who might most benefit frominitial treatment with combined therapies and those who may best bestarted with monotherapy, with combined or augmentation interventionsreserved for partial or non-responders.Further, given limitations on theavailability of empirically based CBT in most settings, there is a pressing need to devise efficient and effective ways of embedding CBT into theroutine administration of pharmacotherapy of social phobia and otherphobic disorders.There is a growing consensus that exposure instructionsshould be included along with the prescription of medication for thetreatment of phobic disorders, with the recognition that even minimalencouragement and directions about exposure can have a salutary effect onpanic disorder and accompanying phobic disorders [6].The greaterdissemination of exposure-based treatments into pharmacologic practiceand the skilful blending of these therapeutic modalities are criticalchallenges for the field.Related to these concerns is the understudied area of treatment refractoryanxiety disorders.What to do with patients with social anxiety disorder or other phobic disorders who do not respond fully to initial treatment is anissue facing practising clinicians on a regular basis, and yet there is little empirically derived data to offer guidance.Fixed-dose studies do not, ingeneral, show evidence of a clear dose–response relationship for the anxiety disorders.However, identification of patients who may benefit from higherdoses earlier in treatment is an important clinical issue deserving ofsystematic inquiry.Further, there has been little done to date addressing the question of whether partial or non-responders to initial treatment benefitfrom increased doses of the initial medication, combination therapy orconsideration of alternative or augmentative strategies.Research on theseareas may provide important answers that will improve our ability torender optimal care to patients affected by these distressing and oftendisabling conditions.REFERENCES1.Gorman J.M., Kent J.M., Sullivan G.M., Coplan J.D.(2002) Neuroanatomicalhypothesis of panic disorder, revised.Am.J.Psychiatry, 157: 493–505.2.Pollack M.H., Marzol P.C.(2000) Course, complications and treatment of panic disorder.J.Psychopharmacol., 14: 25–30.158 __________________________________________________________________________________________ PHOBIAS3.Heimberg R.G., Liebowitz M.R., Hope D.A., Schneier F.R., Holt C.S., Welkowitz L.A., Juster H.R., Campeas R., Bruch M.A., Cloitre M.et al.(1998) Cognitive behavioral group therapy vs phenelzine therapy for social phobia: 12-weekoutcome.Arch.Gen.Psychiatry, 55: 1133–1141.4.Liebowitz M.R., Heimberg R.G., Schneier F.R., Hope D.A., Davies S., Holt C.S., Goetz D., Juster H.R., Lin S.H., Bruch M.A.et al.(1999) Cognitive-behavioral group therapy versus phenelzine in social phobia: long-term outcome.Depress.Anxiety, 10: 89–98.5.Barlow D.H., Gorman J.M., Shear M.K., Woods S.W.(2000) Cognitive-behavioral therapy, imipramine, or their combination for panic disorder: a randomizedcontrolled trial.JAMA, 283: 2529–2536.6.Swinson R.P., Soulios C., Cox B.J., Kuch K.(1992) Brief treatment of emergency room patients with panic attacks.Am.J.Psychiatry, 149: 944–946.3.7Progress in Pharmacotherapy for Social Anxiety Disorder andAgoraphobiaBruce Lydiard1Social phobia or social anxiety disorder (SAD) was accorded officialpsychiatric diagnostic status less than 20 years ago, but has been described in the medical literature for centuries.Hippocrates described such a patient over 2000 years ago: ‘‘He dare not come in company for fear he should bemisused, disgraced, overshoot himself in gestures or speeches or be sick; he thinks every man observes him’’ [1].The National Comorbidity Survey(NCS) estimated lifetime prevalence of SAD at 13.3% and 12-monthprevalence at 7.6%, making it the third most common psychiatric disorder,following only major depression and alcohol abuse/dependence [2].Despite this high prevalence, SAD remains woefully under-recognized,despite the availability of quick and easy-to-use screening tools [3] which could be easily applied in primary care settings [4].Two main subtypes of SAD exist.Roughly one-third of sufferers havediscrete social fears which focus almost entirely on public speaking, aregenerally less disabling, and have a better prognosis.The other two-thirds suffer from generalized SAD, a much more severe, potentially disabling,subtype in which all or nearly all interpersonal interactions outside of close friends and family are difficult to impossible [5].1 Department of Psychiatry, University of South Carolina, 1 Poston Road, Charleston, SC 29407, USAPHARMACOTHERAPY OF PHOBIAS: COMMENTARIES _____________________________ 159Generalized SAD often begins early in life: 35% of the time SAD occurs inindividuals before age 10.Thus, it is a disorder of children as well as adults [6].Further, as noted by the authors, it represents a risk factor for subsequent development of additional psychiatric disorders, especially depression.Pharmacological treatment for the discrete versus generalized subtypesshould be emphasized.Patients with generalized SAD require constanttreatment, preferably with a selective serotonin reuptake inhibitor (SSRI).Those individuals with speaking fears may be able to manage theirsymptoms acutely by using benzodiazepines or beta-blockers.Thoughempirical data are lacking for either of these classes, significant clinical experience indicates that they provide satisfactory relief of symptomsrelated to the feared situation.The average dosage of SSRIs used in the large clinical trials in whichflexible dosing was allowed suggests that patients with SAD may requiredosages higher than those with uncomplicated major depression.Forexample, Stein et al.reported that an average of 36.6 mg paroxetine per day was needed [7], while Liebowitz (personal communication, 2003) used168 mg daily of sertraline.Sertraline has also been shown to prevent relapse over a six-month study period [8].Very recently, venlafaxine, which is a serotonin-norepinephrine reuptakeinhibitor, has been approved for the treatment of generalized SAD aftersuccessful multicentre placebo-controlled studies (Wyeth Laboratories, data on file, 2003).The section on agoraphobia of Stein et al.’s review brings up the different theoretical constructs by which agoraphobia is viewed [ Pobierz całość w formacie PDF ]