{"id":956,"date":"2016-01-28T14:33:40","date_gmt":"2016-01-28T14:33:40","guid":{"rendered":"http:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/?p=956"},"modified":"2017-08-21T11:06:36","modified_gmt":"2017-08-21T11:06:36","slug":"primary-care-corner-with-geoffrey-modest-md-phobias-and-propranolol","status":"publish","type":"post","link":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2016\/01\/28\/primary-care-corner-with-geoffrey-modest-md-phobias-and-propranolol\/","title":{"rendered":"Primary Care Corner with Geoffrey Modest MD: Phobias and Propranolol"},"content":{"rendered":"<p><strong>By Dr. Geoffrey Modest <\/strong><\/p>\n<p>There was a recent op-ed in the NY Times by the psychiatrist Richard Friedman on phobias and medical therapy (see\u00a0<a href=\"http:\/\/www.nytimes.com\/2016\/01\/24\/opinion\/sunday\/a-drug-to-cure-fear.html?emc=edit_th_20160124&amp;nl=todaysheadlines&amp;nlid=67866768&amp;_r=0\">http:\/\/www.nytimes.com\/2016\/01\/24\/opinion\/sunday\/a-drug-to-cure-fear.html?emc=edit_th_20160124&amp;nl=todaysheadlines&amp;nlid=67866768&amp;_r=0<\/a> ).<\/p>\n<p>His points:<\/p>\n<ul>\n<li>29% of Americans have some anxiety at some point in their lives<\/li>\n<li>He\u00a0cites a pretty remarkable study on using propranolol to block this anxiety, perhaps\u00a0from blocking norepinephrine action\u00a0(see article and review below)<\/li>\n<li>He also raises the interesting contrary concern: stimulants (e.g. ritalin) can cause release of norepinephrine and could theoretically\u00a0enhance fear\/anxiety, or even PTSD in those exposed to trauma. He notes that soldiers exposed to stimulants did in fact have more<\/li>\n<\/ul>\n<p>A small study was done looking at the effects of the b-blocker propranolol in inhibiting memory\u00a0reconsolidation and decreasing the phobia\u00a0(see\u00a0Biological Psychiatry\u00a02015; 78:880). The stimulus for the study was that\u00a0fear memories are now considered not to be indelible memories, but ones which on reexposure to the object of fear, leads to neural protein synthesis and\u00a0reconsolidation of that memory.\u00a0Animal studies suggest that b-blockers can disrupt this process of reconsolidation and decrease anxiety.\u00a0Based on this model, a small\u00a0study was done of humans with arachnophobia.\u00a0<img loading=\"lazy\" decoding=\"async\" class=\"wp-image-958 alignright\" src=\"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/files\/2016\/01\/Wolf_spider_on_white.jpg\" alt=\"Wolf_spider_on_white\" width=\"254\" height=\"143\" \/><\/p>\n<p>Details:<\/p>\n<ul>\n<li>15 people with arachnophobia (fear of spiders) received a single dose of propranolol, 40mg, vs 15 who received placebo, after a 2-minute exposure to a tarantula. An additional group received propranolol without the arachnid exposure<\/li>\n<li>After the above treatment (propranolol or placebo), the patients stood in front of\u00a0an open-caged tarantula at a distance of 60cm, then were asked to approach and attempt to touch the spider with their bare fingertips. Patients were tested at 16 days post-exposure, 3 months, and again at 1 year<\/li>\n<\/ul>\n<p>Results:<\/p>\n<ul>\n<li>\u200bThe effect of the propranolol was striking and longstanding: patients were able to handle the tarantula after propranolol but not placebo, from the 16-day test to that at\u00a01 year, without any falloff over time. In fact, all of the participants in the propranolol group were able to touch the tarantula\u00a016 days later,\u00a03 months later and 1 year later.\u00a0In the other groups (both those on\u00a0placebo and those on\u00a0propranolol but\u00a0not previously exposed to the\u00a0tarantula), patients\u00a0&#8220;barely touched the container&#8221; and demonstrated\u00a0fears on\u00a0approaching the container throughout the follow-up period. So, it was not just giving propranolol alone:\u00a0taking\u00a0propranolol without the tarantula exposure had no protective\u00a0effect<\/li>\n<li>In the group exposed to the tarantula, there was no effect of the propranolol in the patients&#8217; self-declared fear of spiders\u00a0at the 16 day post-exposure test (though, as noted, they were able to\u00a0physically handle\u00a0the spider at that time). But at 3 months there was less reported fear of spiders, and this persisted for the 1-year test<\/li>\n<\/ul>\n<p>So, a few points:<\/p>\n<ul>\n<li>Pretty remarkable that a single dose of propranolol can block the phobia for at least one year (though there were\u00a0small numbers of patients in this study, propranolol\u00a0certainly seems worth trying, it being\u00a0a known and pretty innocuous med). Data from cognitive-behavioral therapy and extinction therapy (progressively increasing exposure to the feared object) show effectiveness, though that lasts only a brief time (personal testimony: I have some significant fear of heights. When I need to work on the roof of my house, it is really anxiety-provoking the first or second time up the ladder. But after a few times, I am fine going up and down, without concern &#8212; except that I am very careful. But then several months later, I am back to square one&#8230;.)<\/li>\n<li>And it is pretty interesting that the physiologic\u00a0effect of propranolol is initially\u00a0distinct from the cognitive effect, in that patients still stated they were\u00a0still\u00a0afraid of spiders at the day-16 test.<\/li>\n<li>There are also some preliminary evidence that b-blockers decrease\u00a0physiological responses to re-experiencing trauma in people with PTSD (it might be really interesting to try propranolol just after a person with PTSD has an experience which brings back memories of\u00a0their trauma&#8230;). But, as a conceptual aside,\u200b I have seen several articles on the use of prazosin for PTSD\u00a0(e.g., see AnnPharmacother 2007; 41: 1013)\u200b, especially for decreasing\u00a0the associated nightmares, and I\u00a0have treated several patients with great, rather unexpected success.\u00a0The concept is that sleep disorders are common with PTSD (70%), and that prazosin inhibits norepinephrine and perhaps thereby decreases the arousal in response to a stressor. In my experience, even very low dose prazosin has had dramatic results (e.g. 1-3\u00a0mg at night), though a recent article (Ther\u00a0Adv Psychopharmacol 2014; 4: 43) notes that often higher doses are needed for full responses. These researchers\u00a0also present 2 cases of patients of patients with psych comorbidities, one with PTSD and\u00a0underlying major depressive disorder, but with a lot of daytime symptoms as well (hyperarousal, flashbacks, and re-experiencing the trauma) who responded pretty dramatically to prazosin\u00a015mg in the am, 10mg at noon, and 20mg at night, and this high dose\u00a0was very well-tolerated. The second patient with long-standing\u00a0treatment-resistant major depressive disorder, PTSD and panic disorder and having failed a litany of meds, had lots of\u00a0flashbacks, hypervigilance, reliving the experience,\u00a0avoidance, nightmares, insomnia and concentration difficulties. She was titrated up to a dose of prazosin 15mg in am, 5mg at noon, and 10mg at night, and was also put on clomipramine for the depression, with a phenomenal response (PHQ-9 of 0 and asymptomatic PTSD).<\/li>\n<li>So, as more studies unfold,\u00a0the brain seems to be increasingly plastic\/reprogrammable (i.e., it is not set for life at age 2, or 20, or\u00a0&#8230;.)<\/li>\n<\/ul>\n","protected":false},"excerpt":{"rendered":"<p>Primary Care Corner with Geoffrey Modest MD: Phobias and Propranolol [&#8230;]<\/p>\n<p><a class=\"btn btn-secondary understrap-read-more-link\" href=\"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2016\/01\/28\/primary-care-corner-with-geoffrey-modest-md-phobias-and-propranolol\/\">Read More&#8230;<\/a><\/p>\n","protected":false},"author":148,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_jetpack_memberships_contains_paid_content":false,"footnotes":""},"categories":[14283],"tags":[],"class_list":["post-956","post","type-post","status-publish","format-standard","hentry","category-archive"],"jetpack_featured_media_url":"","jetpack_sharing_enabled":true,"_links":{"self":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/posts\/956","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/users\/148"}],"replies":[{"embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/comments?post=956"}],"version-history":[{"count":0,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/posts\/956\/revisions"}],"wp:attachment":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/media?parent=956"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/categories?post=956"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/tags?post=956"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}