Treatment

Well until the fifties, the dominant theory of neuroses was that of psychoanalysis, developed by the Austrian physician Sigmund Freud. In simple words, it stated that a psychic symptom is just the tip of an iceberg. It's of no use to remove that tip, because ice floats up again, and the symptom reappears. Therefore, effective treatment should consist in destroying (or rather restructuring...) the whole iceberg, which is possible only after years of analysis.

For all purposes, however, this approach has fallen short of the expectations. After the fifties, new approaches started to be conceived. The first works of the South-African psychiatrist Joseph Wolpe (deceased a few months ago) introduced the concept of "reciprocal inhibition", which was later renamed to  "systematic desensitization", based on the work on reflex conditioning of James Watson, in the decade of 20s. Briefly, this great physician started to treat his phobic patients by associating pleasurable sensations and psychic and emotional relaxation to real or imagined situations of fear and avoidance. Since they are incompatible with fear, phobia tended to disappear within a short time.

Generally speaking, the treatment of phobias is based on the breakup of the links between unpleasant sensations and the situation or objects which cause the crises. Thus, if the patient reacts with fear upon entering a lift, the vicious circle which incorporates such learning must be broken.

This can be achieved in several ways. The best-known approach is called systematic desensitization. First the patient is trained by techniques of deep relaxation. Following this, the therapist instigates the patient to expose himself, gradually and systematically, to the object or situation which evokes fear. If all goes well, this results in a desensitization, i.e., the patient becomes insensitive to the former phobic stimuli.

After achieving a proper degree of training in relaxion, the patient is invited to write up a list of all his or her fears, since they may be many, and to rank them according to its severity, from the highest to the lowest. Desensitization starts them with the less severe of fears.

Let's use as an example the fear of using lifts. Once the patient is put into a deep state of relaxation, the therapist invites him to imagine that he is standing before a building. At any moment, the patient can beckon to the therapist, indicating that fear is increasing too much, thus interrupting the process. If not, the therapist goes on, deepening the process to a higher fear. Now he invites the patient to imagine that he is going inside the building and has stopped facing the lift doors. If this step is well tolerated by the patient, then he is invited to imagine that he is entering the lift, but that the doors are not going to close now. These steps go on, until the patient is able to tolerate with no fear that he is inside a lift crowded with people, in a tall building, moving and stopping momentarily with closed doors.

Once this phobia is succesfully treated, the therapist moves on to the next one, until all remaining in the list are desensitized. A successful resource is to monitor the physiological changes which accompany fear by using biofeedback equipment. Vital parameters such as heartbeat, frequency of breathing and the galvanic response of the skin (GSR) are recorded by computerized equipment and thus allowing for a more objectvie assessment of the changes (see the article on biofeedback in Brain & Mind)

Another modern variant is that of virtual desensitization. In this approach, the patient faces his fears not by imagining the situations, as in the conventional therapy, but by actually living them in a virtual environment generated by a computer. Generally the patient's pulse or GSR are monitored, and as soon as the therapist detects a significant increase, the computer-generated imagery is frozen and relaxation is induced by a suitable technique.

Other alternative and complementary forms of therapy have also been used. For example, the panic disorder has been treated by administering specific medication (generally a drug which acts on the brain neurotransmitter called serotonin, involved with affective disorders) and then encouraging the medicated patient to undergo exposure to the real, fear-elicitint situation, alone or in company of the therapist. Exposure is carried out in an orderly, graded and progressive fashion. Since the medication blocks out the development of anxiety or panic, eventually the brain link to phobia subsidizes and after a few exposures phobia is usually cured.

In phobias where no panic attacks are involved, an useful therapeutic method is called  "stress flooding". With the patient's consent, the brain is flooded with strong and repetitive images of the phobic stimuli, until the brain  "perceives" that there is no real danger associated with them. Interesting results have been described for this method, and it seems that it works well with phobias associated with the panic disorder.

Finally, another promising method is called EMDR (Eye Movement Desensitization and Reprocessing), which was originally devised to treat post-traumatic stress disorders. In this recent form of therapy (it is in use for little longer than 10 years), the two brain hemispheres are alternately stimulated with eye movements, tactile or auditory stimuli, at the same time that the therapist brings the patient to relive the thoughts, sensations and images related to the phobia. In this way, so the theory says, memories are reprocessed and the original phobic links are erased.

My own clinical experience is mainly in systematic desensitization therapy, which I have used for the last 15 years, and with biofeedback, in the last two years. My recent training with EMDR has me led to believe that it provides real promising effective treatment.