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Snapshot
  • A 40-year-old male visits a psychiatrist because he feels "extremely shy." He feels anxious socializing and going to events for fear that he would be ridiculed by others. When he is forced into conversation he hyperventilates, 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 reunion for cognitive behavioral therapy.
Introduction
  • Lifetime prevalence of specific phobias is 12-16%
  • Social phobia (social anxiety disorder) prevalence within 1 year is roughly 7%
    • equally affects men and women
Presentation
  • Specific phobia
    • marked and persistent (> 6 months) fear that is excessive or unreasonable
    • cued by presence or anticipation of specific object or situation
    • types: animal/insect, environment, blood/infections, situational (closed spaces), other
  • Social phobia (social anxiety disorder)
    • marked and persistent (>  6 months) fear of social or performance situations in which one is exposed to unfamiliar people or to possible scrutiny by others
    • fear of acting in humiliating or embarrassing way
      • public speaking, initiating conversation, dating, eating in public
    • may coexist with avoidant personality disorder
Evaluation
  • 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
  • First line: psychotherapy (more efficacious than medication)
    • cognitive behavior therapy
  • Pharmcological options
    • SSRIs/SNRIs
    • acute situations
      • short acting benzodiazepines (alprazolam) 
      • β-blocker 
        • indicated for specific performance phobia (such as speaking)  
 

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