Psychiatry - Neurosis/Simple or Specific Phobias Flashcards
Simple or Specific Phobias?
- 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-5 distinguishes the subtypes: animals, natural environment, blood, injection, injury, situational, and ‘other’
Aetiology:
- Genetic and environmental factors play a role
Simple or Specific Phobias?
Comorbidity and Differentials?
Comorbidity:
- Lifetime risk for patients with specific phobias experiencing at least one other lifetime psychiatric disorder is over 80%, particularly other anxiety disorders (panic, social phobia) and mood disorders (mania, depression, dysthymia)
- However, rates of substance misuse are considerably less than in other anxiety disorders
Differential diagnosis:
- Panic disorder, agoraphobia, social phobia, hypochondriasis, OCD, psychosis
Simple or Specific Phobias?
Management?
Psychological:
- Behavioural therapy: Exposure
- Other techniques: Flooding (not better than graded exposure)
- Cognitive methods: Education/anxiety management, coping skills/strategies, and cognitive restructuring—may enhance long-term outcomes
Pharmacological:
- Only in severe cases to reduce fear/avoidance e.g. BDZs diazepam to allow the patient to engage in exposure.
- β-blockers may be helpful - reduce sympathetic arousal not subjective fear
- Clear secondary depression may require an antidepressant
Course:
- Without treatment = runs a chronic, recurrent course. Individuals may not present unless life changes force them to confront the feared object or situation
Simple or Specific Phobias?
Social Phobias?
Symptoms of incapacitating anxiety (psychological and/or autonomic) are not 2° 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)
Symptoms / Signs:
- Somatic symptom: Blushing, trembling, dry mouth, perspiration when exposed to the feared situation
- Excessive fear of humiliation, embarrassment, or others noticing how anxious they are
- Self-critical and perfectionists
- Avoidance = Difficulty in maintaining social/sexual relationships, educational problems (difficulties in interactions with other students/oral presentations) or vocational problems (work in less demanding jobs, well below their abilities) Thoughts of suicide are relatively common.
Simple or Specific Phobias?
Social Phobias?
Comorbidity and Differentials?
Comorbidity:
- High level of psychiatric comorbidity with the most common disorders including simple phobia, agoraphobia, panic disorder, generalized anxiety disorder, PTSD, depression/dysthymia, and substance misuse
Differential diagnosis:
- Other anxiety and related disorders (esp. generalized anxiety disorder, agoraphobia, OCD), poor social skills, anxious/avoidant personality traits, depressive disorders, secondary avoidance due to delusional ideas in psychotic disorders, and substance misuse
Simple or Specific Phobias?
Social Phobias?
Management?
Psychological
- CBT: Individual or group setting = 1st line with SSRIs/MAOIs
- Includes relaxation training/anxiety management (for autonomic arousal), social skills training, integrated exposure methods (modelling and graded exposure), and cognitive restructuring
Pharmacological
- β-blockers (e.g. atenolol) may reduce autonomic arousal (e.g. performance anxiety = specific social phobia)
- For more generalized social anxiety – ADx
- Other treatment possibilities: RIMAs (e.g. moclobemide) or adding BDZ
Course
• Without Tx = chronic lifelong condition
• Not related to gender, age, duration, premorbid functioning etc
• Extreme childhood shyness - early signs of social phobia
• If Tx = 90% response rates with combined approaches
• Long-term – medication is best - relapse rates are high on discontinuation
