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Case report

Fluvoxamine for phobia of storms Balon R. Fluvoxamine for phobia of storms. Acta Psychiatr Scand 1999: 100: 244-246. $2 Munksgaard 1999.

Specific phobias are not usually treated unless they are disabling. Behavioural therapy is the treatment of choice for disabling specific phobias. Pharmacotherapy is generally not considered to be effective in specific phobias, and is therefore not used for this indication. However, selective serotonin reuptake inhibitors have been reported to be effective in various anxiety disorders, and may be effective in specific phobias as well. This case report describes the successful treatment of phobia of storms with fluvoxamine in an 1 I-year-old boy. Fluvoxamine and other selective serotonin reuptake inhibitors may be a suitable option for treatment of disabling cases of specific phobia when behavioural therapy is not feasible for various reasons.

Introduction

Specific phobia is characterized by marked and persistent fear of clearly discernible, circumscribed objects or situations (1). Four subtypes (animal, natural environment, blood-injection-injury and situational) are specified in the Diagnostic and Statistical Manual of Mental Disorders (1). Treatment modalities, especially those of a phar- macological nature, have not been well studied. Barlow (2) pointed out that, because there is ‘near- unanimity of opinion among biological and psy- chological clinicians and investigators on the appropriateness of exposure-based procedures for simple phobia, near-unanimity of opinion also exists on the seeming lack of benefit of adding drugs to these procedures. For this reason, very little serious investigation on possible benefits of drugs in the treatment of simple phobia exists.’ He also quoted isolated pieces of evidence of possible contributions of benzodiazepines and beta-block- ers. A study by Zitrin et al. ( 3 ) did not find a significant contribution of adding imipramine to systematic desensitization in imagination in the treatment of simple phobia. Behavioural therapy, especially exposure, is considered to be the treat- ment of choice for simple phobia, while pharma- cotherapy is not generally considered to be effective.

Selective serotonin reuptake inhibitors (SSRIs) have been reported to be effective in various conditions, including anxiety disorders. Fluvox-

R. Balon Department of Psychiatry and Behavioral Neurosciences, Wayne State University School of Medicine, Detroit, Michigan, USA

Key words: specific phobia. fluvoxamine

Richard Balon. UPC-Jefferson, 2751 E Jefferson, 200, Detroit, MI 48207, USA

Accepted for publication March 15. 1999

amine, one of the SSRIs, has been used for the treatment of obsessive-compulsive disorder, depres- sion, social phobia (4) and other anxiety disorders. Nevertheless, a Medline search in the autumn of 1998 did not reveal any citations on the use of fluvoxamine in specific phobia. We here describe the successful treatment with fluvoxamine of phobia of storms in an 1 1-year-old boy.

Case report

A, an 1 l-year-old boy, presented with various ‘fears and anxieties and strange habits lately.’ His main complaint was an intense fear of storms, with a consequent fear of going outside. He was afraid to go to sleep when it was windy outside. He was aware of the fact that his fear was unreasonable, but said ‘1 can’t help it.’ He also admitted a fear of germs, with occasional handwashing, and showed a mildly depressed mood. He denied any panic attacks. He did not have any problems attending school, and only resisted going during stormy weather. He was diagnosed as suffering from a specific phobia, namely phobia of storms.

The patient’s past history revealed the use of various medications for major depression, school phobia and possible obsessive-compulsive disorder since the age of 9 years. However, he reported a prominent fear of clouds, rain, lightning and thunder at the age of 9 years too. He was treated with various

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medications, including clomipramine (‘helped a little bit, but made him irritable and he sweated mas- sively’), sertraline (‘made him nasty’), fluoxetine and imipramine. Both the boy and his mother agreed that none of these medications helped him significantly, nor were they problem-free.

After a discussion with the patient and his mother, during which she refused behavioural therapy, the patient was started on fluvoxamine. Due to his previous experience of bothersome side- effects of other drugs, we started him on a very low dose of fluvoxamine, 25 mglday.

After 3 weeks on fluvoxaniine, A reported a significant improvement. ‘Phobia was not totally gone’, and he was still occasionally looking out of the window watching for a storm. However, his mother reported that he was able to sleep in the tent during their family vacation. She considered this to be a significant improvement, because he had refused to sleep in tents because of his fear of storms during their previous vacations. He also denied any depression, was sleeping and eating well, and denied any side-effects. The fluvoxamine dose was increased to 50 mg/day. Three weeks later the patient felt even better. He was able to play outside during ‘gloomy weather’, and to walk in the rain.

Discussion

To my knowledge, this is the first reported successful case of treating a specific phobia, namely phobia of storms (keraunophobia, a natural environment subtype of specific phobia according to DSM-IV) (2), with fluvoxamine. Specific phobias are not frequently treated unless they are disabling. Behavioural therapy is usually the treatment of choice. However, pharmacotherapy might be initiated in occasional cases of disabling phobias, especially when gradual exposure might not be feasible for various reasons (e.g. infrequent, inci- dental occurrence of the phobic stimulus in the case of phobia of storms). Fluvoxamine, a fairly well- tolerated drug without substance abuse potential, seems to be a suitable option for these cases of specific phobia. Nevertheless, only double-blind placebo-controlled studies could confirm the valid- ity of this clinical observation.

References

1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 4th edn. Washington, DC: American Psychiatric Association, 1994.

2. BARLOW DH. Simple phobia. In: BARLOW DH, ed. Anxiety and its disorders. The nature and treatment of panic and anxiety. New York: Guilford Press, 1988;475498.

3. ZITRIN CM, KLEIN DF, WOERNER MG, Ross DC. Treatment

of phobias. 1. Comparison of imipramine hydrochloride and placebo. Arch Gen Psychiatry 1983;40:125-140.

4. JEFFERSON JW. Social phobia: a pharmacologic treatment overview. J Clin Psychiatry 1995;56 (Suppl. 5): 18-24.

Invited comment

This case report (1) raises two questions.

(i) Is this boy’s phobia to be regarded as specific, or as a feature of an underlying serotonergic spectrum disorder, including obsessions, school phobia and depression? Which are the next steps to take in order to demonstrate cost-efficiency of pharmacother- apy in specific phobias?

(ii)

Specific phobias are common. In a Swedish survey, 21.2% of women and 10.90/0 of men reported at least one phobia, and multiple phobias were reported by 5.4% and 1.5%,, respectively (2). The genetic contribution to specific phobias in a sample of Norwegian twins was 50%, that in a Swedish twin sample was 52%, while in Virginia twins it was 32% (3-5). The response to carbon dioxide challenge was moderately abnormal in two studies, and more so in situational phobias (e.g. claustrophobia) than in animal phobias (6). The degree of cerebral activa- tion also appears to depend on whether exposure is visuallin vivo or imagined (7). Distinct neuronal pathways are activated both by these fears and by other uncontrolled emotions in post-traumatic stress disorder, panic disorder and schizophrenia (8). The notion that these pathways are shared finds support in a survey from the USA, in which the number of fears in probands strongly predicted impairment, comorbidity and family psychopathol- ogy (9).

A Swedish government task force is currently reviewing the evidence for efficacy in treatments of anxiety disorders. Three placebo-controlled studies of benzodiazepines and two studies with beta- receptor-blocking agents in specific phobias were inadequately designed to show efficacy, while in one study imipraniine showed no additional benefit over behavioural therapy (Mats Fredriksson, Uppsala University, personal communication, February 1999).

There is a need for adequately powered studies of the use of medication in treatment of primary specific phobias. The only treatment shown to be effective to date is exposure therapy (10). Specific phobias tend to be dismissed as not being incapacitating, yet fear of syringes, dentists, or confinement during magnetic neuroimaging may impede and delay urgent medical procedures. Fear of birds may render one incapable of going outside in the summer. Fear of storms may progress to

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