Phobic disorders

The basis of phobic disorders is a persistent, intense, unreasonable fear (phobia) of situations, circumstances, or objects. This fear provokes anxiety and avoidance. Phobic disorders are divided into general (agoraphobia, social phobia) and specific. The causes of phobias are unknown. Diagnosis of phobic disorders is based on anamnesis. In the treatment of agoraphobia and social phobia, drug therapy, psychotherapy (for example, exposure therapy, cognitive-behavioral therapy), or both methods are used. Some phobias are treated mainly only with exposure therapy.

[ 1 ], [ 2 ], [ 3 ], [ 4 ], [ 5 ], [ 6 ], [ 7 ]

Categories of phobic disorders

Agoraphobia

Agoraphobia involves “forward anxiety,” the fear of being in situations or places that cannot be quickly escaped or where help will not be provided when intense anxiety develops. The patient tries to avoid such situations or, if they do, experiences severe anxiety. Agoraphobia can occur on its own or as part of panic disorder.

Agoraphobia without panic disorder affects approximately 4% of women and 2% of men over a 12-month period. Typically, the disorder begins in the early 20s; onset after age 40 is rare. The most common situations that cause fear include, for example, standing in line at a store or bank, sitting in the middle of a row at a theater or classroom, or using public transportation, such as a bus or airplane. Some patients develop agoraphobia after a panic attack in typical agoraphobic situations. Other patients simply feel discomfort in such situations and do not develop panic attacks or develop them much later. Agoraphobia often disrupts the patient's functioning and, if severe, can lead to the patient not leaving the house.

[ 8 ], [ 9 ], [ 10 ]

Social phobia (social anxiety disorder)

Social phobia is the fear and anxiety of being in certain social situations, of being the center of attention. The patient avoids these situations or endures them with pronounced anxiety. Patients with social phobia understand the excessiveness and unreasonableness of their fear.

Social phobia affects approximately 9% of women and 7% of men in a 12-month period, but the lifetime incidence is at least 13%. Men are more likely than women to develop severe forms of social anxiety and avoidant personality disorder.

Fear and anxiety in people with social phobia often focus on embarrassment and humiliation that will occur if they do not live up to the expectations of others. Frequently, concerns are related to the fact that anxiety may become noticeable through blushing, sweating, vomiting, or trembling (sometimes a trembling voice), or that it will not be possible to correctly express one's thoughts and find the right words. As a rule, the same actions alone do not cause anxiety. Situations in which social phobia is often observed include public speaking, participating in theatrical performances, playing musical instruments. Other possible situations include eating with other people, situations where it is necessary to sign in the presence of witnesses, and using public baths. In the generalized type of social phobia, anxiety is observed in a wide variety of social situations.

Specific phobias

A specific phobia is a fear and anxiety about a specific situation or object. This situation or object is avoided if possible, but if this is not possible, anxiety quickly increases. The level of anxiety can reach a panic attack. Patients with specific phobias usually understand that their fear is unfounded and excessive.

Specific phobias are the most common anxiety disorders. Among the most common phobias are fear of animals (zoophobia), heights (acrophobia), and thunderstorms (astraphobia, brontophobia). Specific phobias affect approximately 13% of women and 4% of men over a 12-month period. Some phobias cause minor inconveniences: for example, fear of snakes (ophidophobia) in a city dweller if he or she is not offered a walk in an area where snakes live. On the other hand, some phobias can significantly impair a person's functioning, for example, fear of closed spaces (claustrophobia) in patients who are forced to use an elevator while working on the upper floors of skyscrapers. Fear of blood (hemophobia), injections, and pain (trypanophobia, belonephobia) or injury (traumatophobia) is observed to some degree in at least 5% of the population. Patients with fear of blood, needles, or injury, unlike other phobias and anxiety disorders, may develop syncope due to a pronounced vasovagal reflex causing bradycardia and orthostatic hypotension.

Diagnosis of phobic disorders

Clinical diagnosis is based on the criteria of the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV).

[ 11 ], [ 12 ], [ 13 ], [ 14 ], [ 15 ], [ 16 ]

Prognosis and treatment of phobic disorders

Without treatment, agoraphobia tends to become chronic. Sometimes agoraphobia can resolve without formal treatment, perhaps in those patients whose behavior is somewhat similar to exposure therapy. However, if agoraphobia interferes with functioning, then treatment is necessary. The prognosis for specific phobias without treatment can vary, as it may be easy to avoid situations or objects that cause fear and anxiety.

Many phobic disorders are characterized by avoidance behavior, so exposure therapy is the preferred form of psychotherapy. With the help of a therapist, the patient identifies the object of his or her fear, confronts it, and interacts with it until the anxiety gradually decreases through habituation. Exposure therapy helps in more than 90% of cases if strictly followed, and is, in fact, the only necessary treatment for specific phobias. Cognitive behavioral therapy is effective for agoraphobia and social phobia. Cognitive behavioral therapy involves both teaching the patient to monitor and control distorted thoughts and false beliefs and teaching exposure therapy techniques. For example, patients who describe an increase in heart rate or a feeling of suffocation in certain situations or places are explained that their worries about a heart attack are unfounded, and in such situations, patients are taught the response of slowing their breathing or other relaxation techniques.

Short-term therapy with benzodiazepines (eg, lorazepam 0.5-1 mg orally) or beta-blockers (usually propranolol 10-40 mg orally is preferred, ideally given 1-2 hours before exposure) is particularly useful when the feared object or situation cannot be avoided (eg, when a person with a phobia of flying is forced to fly due to time constraints) or when cognitive behavioral therapy is either undesirable or ineffective.

Many patients with agoraphobia also have panic disorder, and many benefit from SSRI therapy. SSRIs and benzodiazepines are effective for social phobia, but SSRIs are probably preferable in most cases because, unlike benzodiazepines, they do not interfere with cognitive behavioral therapy. Beta blockers are useful for immediate phobia symptoms.