A 32-year-old man comes to the office due to disabling anxiety. The patient was recently promoted to his company's headquarters, requiring him to work on the 48th floor of the building. As soon as he steps on the elevator, he feels panicky and faint, sweats profusely, and has heart palpitations. The patient is worried that he might have to resign if he is unable to control his anxiety. His fear of elevators dates back to childhood. He drinks 1 or 2 beers on weekends but does not use tobacco or illicit drugs. Which of the following is the most effective long-term treatment for this patient's condition?

Question

A 32-year-old man comes to the office due to disabling anxiety.  The patient was recently promoted to his company's headquarters, requiring him to work on the 48th floor of the building.  As soon as he steps on the elevator, he feels panicky and faint, sweats profusely, and has heart palpitations.  The patient is worried that he might have to resign if he is unable to control his anxiety.  His fear of elevators dates back to childhood.  He drinks 1 or 2 beers on weekends but does not use tobacco or illicit drugs.  Which of the following is the most effective long-term treatment for this patient's condition?

Quizplus · Accepted Answer

11ec160b_3647_81ff_9249_a5a7ca1883bc_MD0001_00 This patient's marked and immediate fear in a specific situation (ie, elevator as phobic stimulus) is consistent with a specific phobia. Although he feels panicky when confronted with the phobic stimulus, he does not have unexpected panic attacks as in panic disorder. Cognitive-behavioral therapy, involving systematic, repeated exposure to the phobic stimulus, is the treatment of choice for specific phobia. Exposure is typically performed in a gradual, step-wise manner, resulting in decreased anxiety over time as habituation and extinction occur. Confrontation with the phobic stimulus in a safe and controlled manner can be accomplished through in vivo (most effective), imaginal, and virtual reality exposure techniques. (Choice A) Benzodiazepines (eg, alprazolam) can be used in the acute treatment of specific phobia when there is lack of time, no available therapist, or infrequent encounters. It could be considered in the short-term treatment of this patient's anxiety while cognitive-behavioral therapy takes effect. Benzodiazepines, however, carry the risks of dependence, rebound anxiety, and cognitive impairment and would not be the appropriate long-term choice for this patient who must encounter the phobic stimulus at work on a daily basis. (Choices C and G) Escitalopram (a selective serotonin reuptake inhibitor), and venlafaxine (a serotonin-norepinephrine reuptake inhibitor) are used to treat depression in addition to panic disorder, generalized anxiety disorder, and social anxiety disorder. They are not first-line treatments for specific phobia. (Choice D) The beta blocker propranolol has been used to treat performance anxiety (a subtype of social anxiety disorder) but is not useful for specific phobia. (Choices E and F) These forms of psychotherapy would not address this patient's specific phobia directly. Psychodynamic psychotherapy focuses on developing insight into unresolved conflicts and the influence of past relationships on current life situations. Supportive psychotherapy is aimed at bolstering adaptive psychological defenses to help individuals cope with acute crises or chronic psychiatric illness. Educational objective: Exposure-based cognitive-behavioral therapy, in which patients are systematically confronted with their feared objects or situations, is the most effective long-term treatment for specific phobia. __________ References: Specific phobias. (http://www.ncbi.nlm.nih.gov/pubmed/19716991) Specific phobia. (http://www.ncbi.nlm.nih.gov/pubmed/29763098)

A 32-Year-Old Man Comes to the Office Due to Disabling