Dr Robert London

Conquering Phobias

Clinical Psychiatry News - Volume 32, Issue 5, Page 43 (May 2004)

“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.
Session 1
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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. When this produced too much anxiety, he switched to the right side of the screen and imagined a pleasant scene (the reciprocal inhibition), which was intended to soften or even eliminate the anxiety produced by the phobia.

This in vitro exercise can be taught as a lifelong skill to be used when necessary. The patient's remaining nine sessions are done at elevator banks.
Session 2
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The instructor and the patient meet at a high-rise office building.

In this session, the patient does not go into the elevator. No subterfuge or “tricking the patient” is allowed. We assure the patient that “no elevator” means “no elevator,” so that the patient can begin the in vivo exposure with a minimum of anxiety and stress.

In the lobby, the patient and the instructor watch people enter and exit the elevator for 10-15 minutes; then the patient observes as the instructor goes in and out of the elevator 10 times. All discussions on the subject of elevators focus on elevator safety, possibly including safety statistics and the perspective that the elevator is an invention that has resulted in the betterment of mankind. The conversation remains positive; unpleasant hypotheticals are not discussed.
Session 3
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Together, the patient and the instructor enter and exit the elevator 15 times. Usually by the 10th time, the patient begins to feel relaxed. During free time, the in vitro desensitization technique can be practiced.
Session 4
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The tasks become more complicated. The patient enters and exits the elevator without the instructor 10-15 times—but never actually rides it. It is important to move through this part of the exercise quickly and to do so when the elevator is not busy.
Session 5
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The instructor takes a one-floor ride in the elevator, while the patient waits in the lobby until the instructor returns. This should be done 10-15 times.
Session 6
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Together, the instructor and patient take a one-floor elevator ride 10-15 times, with the clear understanding that the patient can stop at any time. By the 10th trip, the patient usually starts to feel comfortable.
Session 7
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This session is a repeat of session 6, because the crucial point needs reinforcement.
Session 8
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The challenge I designed in this program begins. The patient takes a one-floor elevator ride without the instructor. If this ride is successful, it is repeated 10 times, and by the 10th time, the patient will usually feel safe. Stress and anxiety will be reduced or eliminated. Gradual exposure will have worked.
Session 9
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Together, the instructor and patient go up and down 15 times, with each ride extending to as many floors as they wish.
Session 10
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The patient is encouraged to ride up and down the elevator 10 times—on his own.

In some cases, less work is needed; in others, more work is needed. Flexibility is a key part of success.

This combination of desensitization and gradual exposure becomes more effective and lasting if the patient continues to use the elevator regularly, as this patient did.

Infrequent elevator users need regular in vivo practice, as described above; they also need to use an elevator at least once a week on their own.

In my work, I was fortunate to have access to both an office assistant who understood mental health issues and residents who were part of the short-term psychotherapy program that I directed.

My patients have accepted the use of other professionals to help with their therapy.

From a broader perspective, team approaches like this are becoming the norm in contemporary medical care.

When this team approach was used at the Belleview Hospital outpatient psychiatric clinic, the program's structure was often modified to suit residents' and patients' needs.

In addition, the program was usually carried out in fewer than 10 sessions.

With ingenuity and creativity, we can develop these in vitro and in vivo techniques to treat many specific irrational fears, such as dog, cat, and insect phobias. Some modification is usually necessary for bridge, tunnel, and airplane phobias.

In the case of the elevator-phobic executive, this strategy proved extremely successful. He now routinely uses elevators with minimal anxiety.

Feel free to write me at cpnews@elsevier.com and let me know about strategies you have used to treat phobic disorders. I will try to pass them on to my readers.

PII: S0270-6644(04)70548-2

© 2004 International Medical News Group. Published by Elsevier Inc. All rights reserved.