Phobia

What is phobia?

Social phobia:

Social phobia is a strong fear of being judged by others and of being embarrassed.This fear can be so strong that it gets in the way of going to work or school or doing other everyday things.

Everyone has felt anxious or embarrassed at one time or another. For example, meeting new people or giving a public speech can make anyone nervous. But people with social phobia worry about these and other things for weeks before they happen.

People with social phobia are afraid of doing common things in front of other people. For example, they might be afraid to sign a check in front of a cashier at the grocery store, or they might be afraid to eat or drink in front of other people, or use a public restroom. Most people who have social phobia know that they shouldn’t be as afraid as they are, but they can’t control their fear. Sometimes, they end up staying away from places or events where they think they might have to do something that will embarrass them. For some people, social phobia is a problem only in certain situations, while others have symptoms in almost any social situation.

 

Specific phobia:

A specific phobia is an intense, irrational fear of something that poses little or no actual danger. Some of the more common specific phobias are centered around closed-in places, heights, escalators, tunnels, highway driving, water, flying, dogs, and injuries involving blood. Such phobias aren’t just extreme fear; they are irrational fear of a particular thing. You may be able to ski the world’s tallest mountains with ease but be unable to go above the 5th floor of an office building. While adults with phobias realize that these fears are irrational, they often find that facing, or even thinking about facing, the feared object or situation brings on a panic attack or severe anxiety.

Specific phobias affect an estimated 19.2 million adult Americans1 and are twice as common in women as men. They usually appear in childhood or adolescence and tend to persist into adulthood. The causes of specific phobias are not well understood, but there is some evidence that the tendency to develop them may run in families.

If the feared situation or feared object is easy to avoid, people with specific phobias may not seek help; but if avoidance interferes with their careers or their personal lives, it can become disabling and treatment is usually pursued.

 

Types of Specific Phobia:

  • Animal Type: e.g. dogs, snakes, or spiders
  • Environment Type: e.g., heights, storms, water
  • physical Type: e.g. fear of seeing blood, receiving a blood test or shot, watching television shows that display medical procedures
  • Situational Type: e.g., airplanes, elevators, driving, enclosed places
  • Other Types: e.g., phobic avoidance of situations that may lead to choking, vomiting, or contracting an illness; in children, avoidance of loud sounds like balloons popping or costumed characters like clowns.

 

Posttraumatic stress disorder (PTSD)

  • Typical stresses inducing PTSD include physical assaults, violent accidents, rape, and combat trauma.
  • Individuals suffering from PTSD re-experience recurrent and intrusive images, thoughts or perceptions of the event, nightmares, and flashbacks
  • Symptoms of increased arousal include exaggerated startle response, irritability, anger, insomnia, and hypervigilance
  • Major depressive disorder, substance abuse and other anxiety disorders (such as panic disorder) are common comorbid conditions in PTSD

Acute stress disorder

  • Is similar to PTSD in that there is a precipitating traumatic event, but the duration of the disorder is limited to one month after the incident

Obsessive Compulsive Disorder (OCD)

  • Is an anxiety disorder with two key symptoms – obsessions, which are repetitive thoughts, and compulsions, which are repetitive behaiors.
  • OCD has an onset in adolescence and childhood, with the majority of cases beginning before age 30.
  • The lifetime prevalence of OCD is believed to be 2.5%
  • In adult OCD the male to female ratio is 1:1. But in childhood onset OCD the majority of individuals are male.

What are common causes of phobia?

Social Phobia:

  • Avoidant personality disorder
  • OCD (contamination anxiety)
  • Depression
  • Schizoid or paranoid spectrum
  • Schizophrenia spectrum related social deficits
  • Alcohol abuse
  • Stimulant drug abuse

Specific phobia:

  • OCD (fear of contamination)
  • Posttraumatic stress disorder (avoidance of upsetting stimuli)
  • Panic disorder with agoraphobia (avoidance of specific locales)

PTSD:

  • Somatoform disorders
  • Conversion symptoms
  • Dissociative symptoms
  • Anxiety disorders
  • Panic disorder
  • Depression with associated avoidance
  • Acute stress disorder
  • Malingering

OCD:

  • Eating disorders
  • Hypochondriasis with obsessions
  • Severe obsessive anxiety in panic disorder
  • Paranoid psychosis
  • Obsessive rumination in melancholic depression.

What are the symptoms of phobia?

  • fear of specific situations, animals or actions
  • sweatiness
  • palpitation
  • shortness of breath
  • chest tightness
  • shaking
  • hot flashes
  • chills
  • dry mouth
  • nausea or vomiting
  • choking sensation
  • fear of dying
  • fear of losing control
  • dizziness

What laboratory work ups are used for diagnosis of phobia?

There is no specific laboratory work up for diagnosis of phobia. However, special tests might be requested to rule out medical conditions that could mimic the symptoms of phobia.

The following are common investigations to rule out medical conditions that could present with symptoms of phobia:

  • CBC
  • Blood sugar
  • TSH, T4
  • Electrolytes
  • Urine drug screen

What treatments are available for phobia?

Social Phobia:

  • SSRIs are the treatment of choice
  • Paroxetine at an average dosage of 40 mg qd is one such option
  • SNRI antidepressant venlafaxine has been used successfully
  • Mirtazapine is also effective
  • Beta-blockers and benzodiazepines can be used as needed to reduce anxiety in specific situations to reduce performance anxiety and tremor
  • Monoamine oxidase inhibitors (MAOIs) have been found to be effective particularly in treatment refractory patients.
  • Exposure treatment.
  • Individual cognitive therapy followed by social skills training is superior to non-specific supportive psychotherapy as psychotherapeutic treatment for social phobia

Specific phobias:

  • Benzodiazepines may be used as-needed in situations such as fear of airplane, …
  • The treatment of choice for this disorder is exposure therapy

PTSD:

  • SSRIs are the mainstay of treatment
  • Sertraline (Zoloft) is efficacious for short term treatment and longer term prevention
  • SNRIs medications are efficacious too
  • MAOIs are effective in particularly in the treatment of intrusive symptoms
  • Lithium, anticonvulsants, and clonidine may improve symptoms including irritability
  • Atypical antipsychotics in lower doses have been demonstrated to be of some benefit.
  • Trazodone and benzodiazepines may be of benefit in reducing sleep disturbance.
  • Prazosin has been demonstrated to reduce nightmares
  • CBT such as graded exposure (imaginal and/ or in vivo), prolonged exposure, cognitive reprocessing and virtual reality exposure are effective
  • Behavioral therapies
  • Virtual reality exposure

OCD:

  • The first line treatment: high dose SSRIs
  • Clomipramine (TCA) is another effective option but its anticholinergic side effects limits its utility
  • In treatment refractory OCD: clomipramine in combination with in low dosage with SSRI medications, with careful monitoring of clomipramine blood levels.
  • Behavioral treatment of OCD is based on exposure and response prevention techniques
  • Cognitive therapy based on cognitive reformulation of the perception of danger and expectations about anxiety and its consequences
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