Phobias ا.د.الهام الجماس

Simple or specific phobias Essence Social phobia Simple or specific phobias Agoraphobia Symptoms of incapacitating anxiety (psychological and/or autonomic) are not secondary delusional or obsessive thoughts and are restricted to particular social situations, leading to a desire for escape or avoidance (which may reinforce the strongly held belief of social inadequacy). Recurring excessive and unreasonable psychological or autonomic symptoms of anxiety, in the (anticipated) presence of a specific feared object or situation leading, whenever possible, to avoidance. DSM-IV distinguishes 5 subtypes: animals, aspects of the natural environment, blood/injection/injury, situational, and Other. Anxiety and panic symptoms associated with places or situations where escape may be difficult or embarrassing e.g. of crowds, public places, traveling alone or away from home), leading to avoidance.

Simple or specific phobias Epidemiology Social phobia Simple or specific phobias Agoraphobia Lifetime rates vary from 2.4% (ECA) to 12.1% (NCS), 12mth prevalence 6.8% (NCS); male = female for those seeking treatment (however community surveys suggest male > female); bimodal distribution with peaks at 5 yrs and between 11-15 yrs often patients do not present until they are in their 30s. Prevalence: lifetime 12.5%, 12-mth (NCS) 8.7%, 6-mth (ECA) 4.5-11.9%; Male/female = 1:3; animal/situational phobias may be more common in female; main age of occurrence mainly in childhood /adolescence (mean 15yrs): animal phobias -7yrs, blood injection/injury-8 claustrophobia -20yrs. Prevalence (6 month) 2.8-5.8% ; Male/female = 1:3; as for panic disorder, there is a bimodal distribution with the first being somewhat broader (15-35 yrs). In later life agoraphobic symptoms may develop secondary to physical frailty, with the associated fear of exacerbating medical problems or having an accident.

Simple or specific phobias Management Social phobia Simple or specific phobias Agoraphobia Psychological CBT, in either an individual or group setting, should be considered as a first-line therapy (along with SSRIs/MAOIs) and may be better at preventing relapse. Components of this approach include relaxation training/anxiety management (for autonomic arousal), social skills training, and integrated exposure methods (modelling and graded exposure). Pharmacological B-blockers (e.g. atenolol) may reduce autonomic arousal, particularly for specific social phobia (e.g. performance anxiety). For more generalised social anxiety, both SSRIs (e.g. fluoxetine, paroxetine, sertraline) and MAOIs (e.g. phenelzine) are significantly more effective. Other treatment possibilities include RIMAs (e.g. moclobemide) or the addition of a BDZ (e.g. clonazepam, alprazolam) or buspirone Behavioural therapy ”treatment of choice: methods aim to reduce the fear response e.g. Wolpe's systematic desensitisation with relaxation and graded exposure (either imaginary or in vivo). Other techniques: reciprocal inhibition, flooding (not better than graded exposure), and modelling. Cognitive methods: education/anxiety management, coping skills/strategies”may enhance long-term outcomes. Generally not used, except in severe cases to reduce fear avoidance (with BDZs e.g. diazepam) and allow the patient to engage in exposure techniques (2°-blockers may be helpful, but benefit is not sustained). Clear 2° depression may require an antidepressant. Antidepressants As for panic disorder. BDZs short-term use only (may reinforce avoidance) most evidence for alprazolam/clonazepam. Behavioural methods Exposure techniques (focused on particular situations or places), relaxation training, and anxiety management. Cognitive methods Teaching about bodily responses associated with anxiety/education about panic attacks, modification of thinking errors