[19] Phobic Anxiety Disorder

Question 1

What is a phobia?

Answer 1

A phobia is an intense, irrational fear of an object, situation, place, or person that is recognised as excessive (out of proportion to the threat) or unreasonable

Question 2

What is agoraphobia?

Answer 2

Agoraphobia is a fear of public spaces, or fear of entering a public space from which immediate escape would be difficult in the event of a panic attack

Question 3

How is agoraphobia maintained?

Answer 3

By avoidance, which prevents deconditioning and sets up a viscous cycle of anxiety

Question 4

What is social phobia, or social anxiety disorder?

Answer 4

A fear of social situations which may lead to humiliation, criticism, or embarrassment

Question 5

When does social phobia usually begin?

Answer 5

Late adolescence

Question 6

What is specific (isolated) phobia?

Answer 6

A fear restricted to a specific object or situation

Question 7

What causes specific phobia?

Answer 7

There is usually a conditioning event early in life, i.e. a frightening experience. There is possibly a role for learned behaviour, e.g. from parents

Question 8

What are the risk factors for phobic anxiety disorder?

Answer 8

• Aversive experiences
• Stress and negative life events
• Other anxiety disorders
• Mood disorders
• Substance misuse disorders
• Family history

Question 9

What are the biological symptoms of phobic anxiety disorder?

Answer 9

Tachycardia is the usual autonomic response, however in some phobias there is a vasovagal response which might lead to syncope.

Other biological symptoms are the same as for generalised anxiety disorder

Question 10

What are the psychological symptoms of phobic anxiety disorder?

Answer 10

• Anticipatory anxiety
• Inability to relax
• Urge to avoid the feared situation
• Fear of dying

Question 11

What are the ICD-10 diagnostic criteria for agoraphobia?

Answer 11

Marked and consistent fear or avoidance of at least two of;

• Crowds
• Public spaces
• Travelling alone
• Travelling away from home

There should be symptoms of anxiety in the feared situation with at least two symptoms present together (and at least one symptom of autonomic arousal).

There should be significant emotional distress due to the avoidance or anxiety symptoms, which is recognised as excessive or unreasonable.

Symptoms should be limited to, or predominate in, feared situation

Question 12

What are the ICD-10 diagnostic criteria for social phobia?

Answer 12

Marked fear, or marked avoidance of being the focus of attention, or fear of acting in a way that will be embarrassing or humiliating, with at least two of the symptoms of anxiety in the feared situation, plus one of the following;

• Blushing
• Fear of vomiting
• Urgency or fear of micturition/defecation

There should be significant emotional distress due to the avoidance or anxiety symptoms, which is recognised as excessive or unreasonable.

Symptoms should be limited to, or predominate in, feared situation

Question 13

What are the ICD-10 criteria for specific phobia?

Answer 13

Marked fear or avoidance of a specific object or situation (that is not agoraphobia or social phobia), and symptoms of anxiety in the feared situation.

There should be significant emotional distress due to the avoidance or anxiety symptoms, which is recognised as excessive or unreasonable.

Symptoms should be limited to, or predominate in, feared situation

Question 14

How is phobic anxiety disorder investigated?

Answer 14

• History
• MSE
• Questionnaires – Social Phobia Inventory

Question 15

What are the differential diagnoses of phobic anxiety disorder?

Answer 15

• Panic disorder
• PTSD
• Anxious personality disorder
• Somatoform disorder
• Adjustment disorder
• Depression
• Schizophrenia
• Organic (as with generalised anxiety disorder)

Question 16

How are phobic anxiety disorders managed in general?

Answer 16

• Advise avoidance of anxiety-inducing substances, e.g. caffeine
• Screen for significant co-morbidities, such as substance misuse and personality disorders
• Refer to specialist if there is a risk of self-harm, suicide, self-neglect, or significant co-morbidity

Question 17

How is agoraphobia managed?

Answer 17

• CBT is psychological intervention of choice. The behavioural component includes graduated exposure and desensitization.
• SSRIs are the first-line pharmacological agent

Question 18

How is social phobia managed?

Answer 18

• CBT (individual or group) specifically designed for social phobia and graduated exposure can be used
• Pharmacological interventions include SSRIs, SNRIs, and if no response to these, MAOIs
• Psychodynamic psychotherapy for those who decline CBT or medication

Question 19

How is specific phobia managed?

Answer 19

• Exposure, either using self-help methods, or more formally though CBT
• Benzodiazepines can be used as anxiolytic in the short term, for example if they need an urgent CT and are claustrophobic