Snapshot A 40-year-old male presents to his psychiatrist with complaint of feeling excessively anxious in social situations. He feels extreme distress in crowds and avoids socializing and going to events due to fear that he will be ridiculed by others. When forced into conversations, he begins hyperventilating, is diaphoretic, and develops palpitations. He has been invited to deliver a lecture at his alma mater during a class reunion next week and asks for medications to "calm him down." After questioning that reveals an unremarkable history of medical conditions or substance use, the psychiatrist prescribes the patient a short course of propranolol. The patient agrees to follow up with the psychiatrist after the class reunion for cognitive behavioral therapy. Introduction Overview severe, marked, persistent (> 6 months) fear or anxiety as a result of the presence or anticipation of an object or situation person recognizes fear is excessive person avoids phobic trigger phobic disorders encompass 3 DSM-V diagnoses social anxiety disorder fear of an interpersonal situation specific phobia overwhelming, persisting fear of an object or situation agoraphobia fear of being alone in public places Epidemiology Prevalence in the US social anxiety disorder - 7% specific phobia - 7-9% agoraphobia - 1.7% Demographics incidence in women vs. men is ~ 1.5-2 to 1 social anxiety disorder majority of patients experience onset between ages 8-15 years specific phobias most develop during childhood then eventually disappear agoraphobia onset peaks in late adolescence and early adulthood ETIOLOGY Pathophysiology ↑ activation in the prefrontal and orbitofrontal cortex, anterior cingulate cortex, insula, and amygdala with phobia-related triggers sympathetic nervous system activation results in ↑ pulse and blood pressure Associated conditions anxiety depression substance abuse Presentation Symptoms anxiety/severe emotional distress avoidance of feared object/situations Physical exam manifestations of anxiety sweating palpitations ↑ blood preassure and pulse dyspnea dizziness tremor DIAGNOSIS Exposure to stimulus almost invariably provokes immediate anxiety response may present as panic attack Person recognizes fear as excessive or unreasonable Situations are avoided or endured with anxiety/distress Significant interference with daily routine, occupational/social functioning, and/or marked distress Treatment Lifestyle cognitive behavioral therapy (CBT) indications first-line therapy for specific phobia Medical selective serotonin reuptake inhibitors (SSRIs) (e.g., paroxetine, sertraline) indication treatment of social anxiety disorder and agoraphobia selective serotonin/norepinephrine reuptake inhibitors (SNRI) (e.g., venlafaxine) indication treatment of social anxiety disorder and agoraphobia β-blockers (e.g.,propanolol) indication treatment of specific performance phobia (e.g., giving a speech) Prognosis Most patients respond to treatment with adequate resolution of symptoms Specific phobias often eventually disappear after childhood Prognosis influenced by several factors diagnosis severity level of functioning prior to symptom onset motivation for treatment presence of a social support system compliance with medications and/or psychotherapy