Phobia (social, specific, agoraphobia)

Question 1

Define phobia.

Answer 1

Definition of a phobia (Marks)

• Fear out of proportion to the demands of the situation
• It cannot be reasoned away
• It is beyond voluntary control
• Fear leads to avoidance of the feared situation, and can lead to disability

Question 2

How common are phobias? When do they usually begin? Who is most affected by specific phobias vs social phobias vs agoraphobia?

Answer 2

• Lifetime prevalence: 5-10%
• Often starts in childhood (5-9)
• Environmental and injury phobias: mid 20’s
• Animals, storms, heights, illness, injury, death

Specific phobias: F>M

Social phobia: F= M

Agoraphobia F>M

Question 3

What are the general signs of phobia?

Answer 3

• Avoidance
• Fear
• Disability

Question 4

What is the aetiology of phobias?

Answer 4

Genetics: Up to ¾ of affected probands have a 1st degree relative with the same phobia

Phobias may also develop through modelling (i.e. watching a parent) or by information transfer (i.e. being taught to be frightened of something)

Operant / classical conditioning

Question 5

What is the prognosis with phobias starting in childhood vs adulthood?

Answer 5

Simple phobias that originate in childhood continue for many years.

Phobias starting in adult life after stressful events have a better prognosis (70-80% with CBT)

Question 6

Define agoraphobia. Does this only occur in confined spaces?

Answer 6

A fear of being in situations where escape to a safe place (usually home) might be difficult or that help wouldn’t be available if things go wrong.

Occurs in open & confined spaces where it may be difficult to leave without attracting attention.

NB: Agoraphobia literally means ‘fear of the market place’

Question 7

How do you diagnose agoraphobia?

Answer 7

Anxiety in at least 2 of the following:

• crowds,
• public places,
• travelling away from home,
• travelling alone

Avoidance of phobic situation must be prominent

Question 8

Describe the onset of agoraphobia.

Answer 8

May be gradual or precipitated by a sudden panick attack.

Usually starts in 20s-30s

Question 9

What makes agoraphobia better vs worse?

Answer 9

Worse: with increasing distance from home or difficulty returning

Better: travelling with a dependable companion (or sometimes car) increases range and makes some situations more bearable

Question 10

What may be comorbid in agoraphobia?

Answer 10

Depression in 40%

Question 11

What must you exclude in agoraphobia?

Answer 11

Check that psychological and autonomic sx’s not due to psychotic / delusional thoughts.

Question 12

What are 3 signs of agoraphobia?

Answer 12

• House bound
• Panic attacks
• Dependent on another person

Question 13

What is the prognosis of agoraphobia?

Answer 13

Disabling and crippling, even without panic.

Fluctuating course

Depression 40%

Question 14

What are some differentials for agoraphobia?

Answer 14

Depression can cause social withdrawal and is commonly comorbid with agoraphobia.

Social phobia: the fear here is of scrutiny or humiliation.

Obsessive–compulsive disorder: time-consuming rituals can confine people to their home.

Schizophrenia: patients may stay at home because of social withdrawal or as a way of avoiding perceived persecutors.

Question 15

Define social phobia.

Answer 15

• Marked fear of being the focus of attention, or fear of behaving in a way that will be embarrassing or humiliating

Question 16

Give 4 signs and symptoms of social phobia.

Answer 16

• Fear of criticism by others.
• Feeling self-conscious
• Avoidance of phobic situations
• Substance abuse
• Tremor
• Panic attacks
• Social withdrawal
• Complain about embarassing symptoms e.g.
  
  • blushing
  • trembling
  • sweating
  • urinary frequency

May have specific worries e.g. eating in public. Affects everyday interactions such as pubic speaking, meetings, dates.

Question 17

True or false: patients with social phobia do not tolerate large crowds.

Answer 17

False - They tolerate an anonymous crowd, unlike agoraphobic patients, but small groups (e.g. dinner parties, board meetings) feel very intimidating

Question 18

Who is most affected by social phobia? When is the onset?

Answer 18

• F= M
• Onset in late teens (17 – 30)
• Continuous course
• The first episode occurs in a public place, usually without any reason

Question 19

What is the prognosis with social phobia?

Answer 19

• Generally present for life
• Complications: alcohol and drug dependence (usually prescribed)
• Secondary depression

Question 20

What are the differential diagnoses for social phobia?

Answer 20

Shyness: some people are naturally shy and feel uncomfortable in social situations. In social phobia, there is overt fear.

Agoraphobia: the need to get somewhere safe is more important than the fear of scrutiny.

Anxious (avoidant) personality disorder: there is a lifelong history of disabling shyness and anxiety.

• *Poor social skills/autistic spectrum disorders
  (e. g. Asperger’s syndrome)**: people who are socially awkward will not show good social skills when relaxed—they remain awkward.

Benign essential tremor: this tremor is familial, worse in social situations, and responds to benzodiazepines and alcohol. There are no other features of anxiety

Schizophrenia/psychosis: patients may avoid social situations because of paranoia or because they have delusions that they are being watched. Patients with social phobia recognize that their fears are exaggerated.

Question 21

Define specific phobias.

Answer 21

These phobias are restricted to a single, specific situation
(e.g. spiders = arachnophobia).

Question 22

When do specific phobias usually develop?

Answer 22

They often develop in childhood, although sometimes begin later, usually after a frightening experience.

Question 23

What is the management of phobias?

Answer 23

CBT with exposure therapy (typically 12 weeks):

• Done through desensitization
• Hierarchy
• Exposure to stimulus without avoidance behavior
• Allows for habituation
• Weekly sessions + homework

Medication:

• SSRI / Venlafaxine
• Beta-blockers

Benzodiazepines (Should be avoided)

Question 24

Describe how exposure therapy helps in phobias.

Answer 24

1. When there is no actual harm the body can only remain anxious for a short period of time (usually <45min)
2. Then habituation sets in and aniety levels drop
3. Eventually the fear dies out (extinction)
4. This is usually donse through a graded approach (hierarachy) called desensitisation, starting with the least frigtening situations first

Question 25

What does exposure therapy target in social phobia?

Answer 25

1. In social phobia the patient engages in safety behaviours and excessive self-monitoring to reduce the risk of embarrassment.
2. These make things worse—focusing attention on one’s own performance means not listening and responding properly to others.
3. Therapy involves dropping these ‘safety behaviours’ whilst exposing the patient to social situations in order to challenge their assumptions.
4. Video feedback and role-play may be helpful.

Question 26

What does exposure therapy in agoraphobia involve?

Answer 26

1. Tasks might include going shopping in a small, local shop, before progressing to a big supermarket.
2. Involves staying in the situation until the anxiety has abated.
3. The first attempt at a task might be with a companion (e.g. spouse) and once successful, is repeated alone.