Phobic Disorders

Snapshot

• A 32-year-old man is brought to his primary care physician by his sister. The patient describes an intense fear of going outside by himself. While in college, he was uncomfortable in large crowds and whenever he was forced to use public transportation, and these feelings have worsened with time. He now rarely leaves his house and has food and groceries delivered to him. His sister convinced him to leave the house to accompany him to his doctor’s appointment, noting that he is always anxious and nervous to go out in public. (Agoraphobia)

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
      • primary fear is of being negatively evaluated 
      • commonly manifests as fear of being in social situations, of being observed, or public speaking and performance
      • leads to avoidance behavior as the patient avoids situations where they can be evaluated by others
    • specific phobia
      • overwhelming, persisting fear of an object or situation
    • agoraphobia 
      • fear of being alone in public places
      • primary fear is of being trapped and unable to escape
• 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 ↑ HR and BP
• 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

Presentation

• Symptoms
  • anxiety/severe emotional distress
  • avoidance of feared object/situations
• Physical exam
  • manifestations of anxiety
    • sweating
    • palpitations
    • ↑ BP and heart rate
    • dyspnea
    • dizziness
• tremor

Treatment

• Lifestyle 
  • cognitive behavioral therapy (CBT)
    • indications
      • first-line therapy for specific phobia
• Medical
  • selective serotonin reuptake inhibitors (SSRIs) (e.g., paroxetine and 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)

Complications

• Suicide attempts and suicidal ideation
• Substance abuse