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Extinguishing phobia with integrated care

pexels-photo-1311887-2

Recent research published in PNAS, the journal of the American Academy of Sciences, shows that the combination of psychotherapy and cortisone in people suffering from specific phobia (in this case, the phobia of high places) is particularly effective in extinguishing fear. According to the latest statistics, about 30% of Americans and about 16-20% of Europeans experience an anxiety disorder at some point in their lives. The burden of individual and collective suffering and expense is truly considerable: tens of billions of dollars spent each year in the U.S. alone to cope with what is technically called “spectrum of anxiety” namely a wide variety of anxiety-based disorders, among which Panic Disorder and Post-Traumatic Stress Disorder excel. But so-called specific phobias are also widely spread and cover the fear of the square (agoraphobia), that of blood (hematophobia), water (hydrophobia), animals (zoophobia), contamination (misophobia), enclosed spaces (claustrophobia), high places (acrophobia) and so on.

Treatments

For years, attempts have been made to help these people by administering anti-anxiety drugs, but with very little results. Since the early 1980s, a cognitive behavioral psychotherapy has been successfully tested, which, in various ways, exposes the patient to the stimulus that creates the phobia by teaching him or her a path to extinguishing the phobic memory. A sequence of steps is usually established that gradually exposes the patient to phobic stimuli. The goal is to get the patient used to practicing, in a protected environment, those situations he usually avoids. The modes of exposure may be based on imagination–that is, the patient mentally reenacts phobic situations–or on direct, in vivo exposure, as they say.

For example, if a person suffers from acrophobia, first you have them go up an open elevator that takes them to the second floors, then to higher floors until they go up to the roof. Obviously, this procedure requires a big commitment, including time, from the therapist and the patient. Today it is possible to strap on a device equipped with glasses connected to a computer and take a virtual reality trip, taking, virtually, elevators, crossing bridges suspended over a ravine or looking out of a 44th floor window. And that’s what a research team, led by neuroscientists from Basel, did on 40 acrophobics. With a twist: one hour before the expository psychotherapy sessions, everyone received a pill, but one half of it contained 20 mg of hydrocortisone and the other half a placebo. The group, which unknowingly took cortisone, had significantly better results than the other group, although good.

Why cortisol

How can this be explained? We have known for more than eighty years, from Pavlov’s experiments on conditioning, that when the dog hears the sound of the bell without it being accompanied by the offer of food, at first it has a salivation reflex, and that is, it expects that, as happened in the conditioning phase, that sound will be accompanied by food, but if this does not happen, after a while it stops salivating, and that is, the conditioning has died out. But in reality, as Pavlov himself showed, there is not the erasure of conditional memory, but rather the flanking of it with a new memory.

Cortisol is the stress hormone that is essential to the process of memory formation. Without positive stress, without mental activation, memories are not formed. Stress is detrimental later, when it is necessary to recall the worked and filed memory. In the group of people with acrophobia, administration before psychotherapy of a cortisone, hydrocortisone, very close to natural cortisone, reinforced the formation of a new memory to replace the old phobic trace. It seems to be a good example where medicine and psychology come together to help people in need.

by Francesco Bottaccioli

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