Phobic Disorders Clinical Presentation

  • Author: Adrian Preda, MD; Chief Editor: Iqbal Ahmed, MBBS, FRCPsych (UK)   more...
 
Updated: Mar 29, 2011
 

History

Phobias can be disabling and cause severe emotional distress, leading to other anxiety disorders, depression, suicidal ideation, and substance-related disorders, especially alcohol abuse or dependence. The physician must inquire about these areas as well.

Inquire about the amount of caffeine intake (including coffee, caffeinated teas, or sodas). Considering the overall noradrenergic hyperdrive of this group of patients, even moderate amounts of coffee might exacerbate the anxiety response and symptoms.

Social anxiety disorder

Ask the patient about any difficulties in social situations, such as speaking in public, eating in a restaurant, or using public washrooms. Fear of scrutiny by others or of being embarrassed or humiliated is described commonly by people with social anxiety disorder (social phobia).

Specific phobias

If specific (simple) phobias are suspected, specific questions need to be asked about irrational and out-of-proportion fear to specific situations (eg, animals, insects, blood, needles, flying, heights).

Agoraphobia

Inquire about any intense anxiety reactions that occur when the patient is exposed to specific situations such as heights, animals, small spaces, or storms. Other areas of inquiry should include fear of being trapped without escape (eg, being outside the home and alone; in a crowd of unfamiliar people; on a bridge, in a tunnel, in a moving vehicle).

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Physical Examination

Anxiety is the most common feature in phobic disorders. Manifestations include the following (which should be asked about and examined):

  • Elevated heart rate
  • Elevated blood pressure
  • Tremor
  • Palpitations
  • Diarrhea
  • Sweating
  • Dyspnea
  • Paresthesias
  • Dizziness

Because anxiety manifests with a number of physical symptoms, any patient who presents with a de novo complaint of physical symptoms that suggests an anxiety disorder should have a physical examination and basic laboratory workup to rule out medical conditions that might present with anxietylike symptoms (see Differentials).

For a patient who presents for a repeat visit with similar complaints, after medical contributors have been ruled out, a careful mental status examination might be better suited than repeat physical examination and laboratory investigations.

When considering anxiety as the primary suspect, the physician should always remember that over time, patients with anxiety do develop medical conditions at the same rate as other patients. In other words, a diagnosis of anxiety, although changing the threshold for investigation of physical symptoms, should not deprive the patient of regular follow-up examinations as otherwise indicated.

More than 75% of the patients with a diagnosis of blood-injection-injury type phobia report a history of fainting in situations in which they are presented with a trigger. An initial increase in the heart rate and blood pressure is followed by decreased heart rate and blood pressure, resulting in fainting. Of note, this physiologic response is different from the typical response seen in other phobias, in which exposure is followed by increased heart rate and blood pressure.[1]

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Mental Status Examination

The physician should assess the patient’s appearance, behavior, ability to cooperate with the examination, level of activity, speech, mood and affect, thought processes and content, insight, and judgment.

In a situation in which the patient is acutely confronted with the object of his or her phobia, the patient's mental status examination is significant for an anxious affect, with a restricted range. Neurovegetative signs (such as tremor or diaphoresis) might be present. The patient also reports feeling anxious (mood) and can clearly identify the reason for his/her anxiety (thought content). The thought content is significant for phobic ideation (unrealistic and out-of-proportion fears). Insight might be impaired, especially during exposure, but most times, the patient has preserved insight, and although they report that they cannot control their feelings, they also acknowledge that the severity of their fears is not justified.

At any other time, a patient with phobic disorder has a mental status within normal limits, with the exception of thought content positive for phobic ideation. Of note, phobic ideas might remain undisclosed unless questions about phobias are specifically asked. Phobias do not present with suicidal or homicidal ideation, but comorbid conditions commonly associated with phobias, including depression and other anxiety disorders, do present with suicidal or homicidal ideation. If comorbid conditions exist, a specific assessment of the suicidal and homicidal risk should also be completed.

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Contributor Information and Disclosures
Author

Adrian Preda, MD  Health Sciences Associate Professor of Psychiatry and Human Behavior, University of California Irvine School of Medicine

Adrian Preda, MD is a member of the following medical societies: International Congress of Schizophrenia Research, Schizophrenia International Research Society, and Society of Biological Psychiatry

Disclosure: Nothing to disclose.

Specialty Editor Board

Mohammed A Memon, MD  Chairman and Attending Geriatric Psychiatrist, Department of Psychiatry, Spartanburg Regional Medical Center

Mohammed A Memon, MD is a member of the following medical societies: American Association for Geriatric Psychiatry, American Medical Association, and American Psychiatric Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Chief Editor

Iqbal Ahmed, MBBS, FRCPsych (UK)  Faculty, Department of Psychiatry, Tripler Army Medical Center; Clinical Professor of Psychiatry, Clinical Professor of Geriatric Medicine, University of Hawaii, John A Burns School of Medicine

Iqbal Ahmed, MBBS, FRCPsych (UK) is a member of the following medical societies: Academy of Psychosomatic Medicine, American Association for Geriatric Psychiatry, American Neuropsychiatric Association, American Psychiatric Association, American Society of Clinical Psychopharmacology, and Royal College of Psychiatrists

Disclosure: Nothing to disclose.

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