A 28-year-old woman comes to the psychiatrist for help with her fear of flying. She states that for as long as she can remember, she has been afraid to fly. She has been able to do so, despite her fear, but she reports feeling trapped and extremely anxious each time she must do so. In addition, she has a great deal of anticipatory anxiety about any upcoming flight. She has recently taken a new job that requires flying for business at least twice per month and so would like to get rid herself of this fear. Which of the following treatment options is optimal for this young woman?
a. Identifying the patient's maladaptive assumptions about flying
b. Individual psychodynamic psychotherapy
c. Group therapy with patients also afraid of flying
d. Systematic desensitization
e. Alprazolam prn before flying
The answer is d. (Kaplan and Sadock, pp 877-878.) Systematic desensitization is the treatment of choice for cases of clearly identifiable anxiety-provoking stimuli, like this woman's fear of flying. While alprazolam might well manage this patient's anxiety while in the air, it will not rid her of the phobia, nor will it help with her anticipatory anxiety about the flight. Systemic desensitization is a form of behavioral therapy, and involves three steps: relaxation training; hierarchical construction of anxiety provoking situations (eg, this patient's list might start with a low-anxiety situation, such as just thinking about a flight that is scheduled for 6 months away, and end with a high-anxiety situation, such as actually imagining herself sitting in an airplane while it experiences turbulence); and then desensitization to the stimulus (proceeding through the list from least anxiety-provoking through most anxiety-provoking while maintaining oneself in a deeply relaxed state).
A 45-year-old man is diagnosed as having diabetes and will require insulin. His physician explains the use of the medication and tells the patient that he will need to be seen at frequent intervals until his glucose levels comes under good control. The patient has always been somewhat hostile with the physician, but upon hearing this news, he says angrily, “You doctors are always the same! You always want control—of my time, of my money, and now of my every action!” As far as the physician knows, this patient has never had an unpleasant encounter with a physician before. Which of the following is the most likely explanation for the patient's reaction to his doctor?
a. The patient is becoming delusional.
b. The patient is experiencing transference to this authority figure.