Day # 67: Phobia

Today we will discuss specific phobias. We will cover the clinical features, epidemiology, clinical pearls, and treatment options for phobias.


Today's Content Level: Beginner, Intermediate



CLINICAL FEATURES


•A phobia is an intense, excessive, and unreasonable fear of a specific object or situation. The feared trigger is sometimes called the phobic stimulus.


•The object or situation almost always provokes immediate fear or anxiety. This intense fear leads to avoidance of the stimulus or endurance of the anxiety.


•The fear may be anticipation of harm (fear of being bitten by a dog) or they may fear their response to the stimulus (fainting if they get on an elevator).


The diagnostic criteria for specific phobias are as follows 1:

  • Persistent, excessive fear caused by a phobic stimulus. The fear/anxiety is out of proportion to any actual danger/threat.

  • Exposure triggers an immediate fear response.

  • Situation or object is avoided when possible or tolerated with intense anxiety.

  • Duration ≥ 6 months.


•Also remember that to make any diagnosis you need to determine that it causes significant distress or impairment, symptoms are not attributable to a substance or medical illness, and symptoms are not better explained by another mental disorder.



EPIDEMIOLOGY AND PATHOGENESIS


Epidemiology

  • Phobias, as a group, are the most common psychiatric disorder in women and the second most common in men (after substance-related).

  • Lifetime prevalence >10%.

  • Can present at any age, but mean age of onset is 10 years old. (13 years old for social anxiety disorder).

  • Higher rates in women compared to men (2:1). This varies, however, depending on the type of phobic stimulus.


Risk Factors / Pathogenesis

  • Patients will sometimes, but not always, have a past experience that either triggered their phobia (ex: bit by a dog) or conditioned their fear response (ex: patient with fear of flying experiences turbulence).

  • There may also be genetic risks. Certain phobias have a particularly high familial tendency (blood-injection-injury being one of the highest).



CLINICAL PEARLS


Common specific phobias include:

  • "Animals": commonly dogs (cynophobia), snakes (phidiophobia), mice, spiders (arachnophobia), and other insects (entomophobia).

  • Situational: examples include enclosed spaces (claustrophobia), open places (agoraphobia), airplanes (pteromerhanophobia), elevators, buses.

  • Environmental: heights (acrophobia), bodies of water, storms (astraphobia).

  • Medical: common examples are needles (trypanophobia), blood (hemophobia), injuries, receiving injections or medical procedures. Patients with blood-injury-injection specific phobia may experience bradycardia and hypotension and lead to vasovagal fainting.

  • Social: fear of scrutiny or acting in a humiliating way with significant anxiety and avoidance. This is now known as a distinct disorder we will discuss later (social anxiety disorder).


•Many patients with specific phobias can live relatively normal lives and may not seek treatment and thus not receive a diagnosis. For example, consider that someone with phidiophobia (fear of snakes) may avoid hiking in highly wooded areas, but otherwise their function in life is not significantly impaired. However another individual with phidiophobia may not leave the house due to their fears.


•The most commonly diagnosed causes of specific phobia involves phobia that cause functional or lifestyle impairments and are intrusive to every day life (eg, fear of driving, fear of vomiting, fear of open spaces).


•Patients with a specific phobia demonstrate insight by recognizing their phobia is excessive fear. Unfortunately, the exposure still provokes an anxiety response and often leads to the avoidance of the stimulus.


•As with most other anxiety disorders, patients with specific phobias have higher rates of comorbid anxiety disorders, mood disorders, and substance abuse.



TREATMENT


•First-line treatment for a specific phobia is psychotherapy with an emphasis on exposure to the stimulus. Medications may be considered as second-line or as adjuncts in certain cases.


Psychotherapy

  • Cognitive Behavioral Therapy (CBT): Considered first-line with strong evidence for effectiveness. CBT for phobias include exposure therapy.

  • Exposure Therapy: Common examples of exposure therapy are systematic desensitization or flooding. While exposed to the stimulus the patients are coached in various grounding techniques such as breathing exercises and relaxation techniques to reduce their anxiety to a normal level.

  • Systemic desensitization involves repeated exposures that gradually increase the level of exposure to a feared stimulus. It is generally a slower method but more effective. Example -> treating cynophobia (fear of dogs) might start with imagining a dog in your mind -> looking at pictures/videos of dogs -> going to the park and watching them play -> being in the same room -> and finally petting a dog.

  • Flooding involves a sudden confrontation with the patient's full fear along with teaching various grounding techniques while exposed. Generally a faster method but less effective.

  • Other options with evidence of effectiveness: Psychodynamic Psychotherapy (PDP); Virtual Therapy (exposure through computer-generated simulations); Hypnotherapy; Family therapy.


Pharmacotherapy

  • In general pharmacotherapy is second-line for treatment of specific phobias.

  • SSRIs/SNRIs: May be used for patient's that frequently encounter the phobic stimulus so as to bring down the overall levels of anxiety. Also commonly used if comorbid anxiety disorders or depressive disorders are present.

  • Some prescribers may utilize PRN medications for patients that infrequently encounter the stimulus (example: flying for a vacation). Commonly used are benzodiazepines (such as lorazepam), hydroxyzine, or beta-blockers (propranolol).

  • Many providers would argue that PRN use can limit psychotherapeutic focus on not avoiding the anxious stimulus. Thus therapy should be prioritized!



CONCLUSION


I hope you learned something today. Next up will be a review quiz and then we will jump back in with social anxiety disorder.


Resources for today's post include: Kaplan and Sadock's Synopsis of Psychiatry, DSMV, Pocket Psychiatry, and First Aid for the Psychiatry Clerkship.











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