Updated: 8/16/2020

Phobic Disorders

Review Topic
  • 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.
  • 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
  • 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
  • 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
  • Symptoms
    • anxiety/severe emotional distress
    • avoidance of feared object/situations
  • Physical exam
    • manifestations of anxiety
      • sweating
      • palpitations
      • ↑ blood preassure and pulse
      • dyspnea
      • dizziness
      • tremor
  • 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
  • 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)

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