Phobias

Three types: agoraphobia, social phobia, specific phobia

Aetiology

  • Typically early onset
    • Agoraphobia - 50% presented by 20; 75% by early 30’s
    • Social and specific phobias - 80% by early adolescence; 75% by early 20’s

Pathophysiology

  • Fear recognised by patient as irrational
  • Typified by avoidance and anticipatory anxiety

Agoraphobia

  • A fairly well-defined cluster of phobias embracing fears of leaving home, entering shops, crowds and public places, or travelling alone in trains, buses or planes
  • Avoidance of the phobic situation is often prominent, and some people with agoraphobia experience little anxiety because they are able to avoid their phobic situations
  • May be a primary disorder or, more often, secondary to other pathology (e.g. panic disorder or depression)

Clinical presentation

  • Often involves other people, alcohol or technology to avoid anxiety
    • Others do shopping (for or with the patient)
    • Drink alcohol to overcome fear
    • Go shopping to 24 hour store at night
      (when quiet)
    • Internet shopping

Management

  1. Self-help
  1. CBT or SSRI if long standing or no benefit from CBT
  1. Consider tricyclics e.g. clomipramine, desipramine if there is no improvement after 12 weeks and further medication is indicated

Specific phobia

  • A marked and persistent fear that is excessive or unreasonable, cued by the presence or anticipation of a specific object or situation e.g. flying, heights, animals or insects, receiving an injection or seeing blood

Clinical presentation

  • Exposure to the phobic stimulus almost invariably provokes an immediate anxiety response, akin to a panic attack
  • The person recognises that the fear is excessive or unreasonable
  • The phobic situation(s) is avoided or else endured with intense anxiety or distress
  • Normal functioning impaired by the avoidance, anxious anticipation, or distress in the feared situation(s)

Management

  • Behavioural therapy - exposure
    • Graded therapy/systemic desensitisation
    • Add CBT if necessary
  • SSRIs/SNRIs if required

Social phobia/ social anxiety disorder

  • A persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others
  • Increased bilateral activation of the amygdala and increased rCBF to the amygdala (and related limbic areas) that normalizes on successful treatment (pharmacological or psychological)

Clinical presentation

  • The individual fears that he or she will act in a way (or show anxiety symptoms) that will be embarrassing and humiliating
    • Typically this occurs in relatively small social settings
    • Exposure to the feared situation almost invariably provokes anxiety, which may take the form of a situationally bound panic attack
    • Linked to behavioural inhibition - tendency to react to novel situations by avoidance and withdrawal to safety
  • Common anxiety symptoms are:
    • Blushing or shaking
    • Fear of vomiting
    • Urgency or fear of micturition or defaecation
  • Can result in poor school performance, school refusal, poor employment history

Management

  1. Individual CBT
  1. SSRI (escitalopram or sertraline) - review at 12 weeks
  1. SSRI plus CBT
  1. Alternative SSRI (fluvoxamine or paroxetine) or SNRI (venlafaxine)
  1. MAOI (moclobemide)