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Phobic Disorders Clinical Presentation

  • Author: Adrian Preda, MD; Chief Editor: Iqbal Ahmed, MBBS, FRCPsych(UK)  more...
 
Updated: Jul 30, 2014
 

History

Phobic disorders 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.

If social anxiety disorder (social phobia) is suspected, 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 commonly described by people with this disorder.

If a specific phobia is suspected, ask about irrational and out-of-proportion fear or avoidance of particular objects or situations (eg, animals, insects, blood, needles, flying, or heights). Assess intensity and course of fear.

If agoraphobia is suspected, inquire about any intense anxiety and avoidance of the feared object/situation following exposure 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, or in a moving vehicle).

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Physical Examination

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

  • 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 suggestive of an anxiety disorder should undergo a physical examination to help rule out medical conditions that might present with anxietylike symptoms (see Differentials). If a patient presents for a repeat visit with similar complaints, after medical contributors have been ruled out, a careful mental status examination might be preferable to repeat physical examination and laboratory investigations.

When considering anxiety as the primary suspect, the physician should always remember that over time, patients with anxiety are just as likely to develop medical conditions as other patients are. Accordingly, a diagnosis of anxiety, though changing the threshold for investigation of physical symptoms, should not keep the patient from receiving regular follow-up examinations as otherwise indicated.

More than 75% of patients with blood-injection-injury type phobia report a history of fainting in situations where they are presented with a trigger. Initial increases in heart rate and blood pressure are followed by decreases in both parameters, resulting in fainting. This physiologic response differs from the typical response seen in other phobias, in which exposure is followed by increased heart rate and blood pressure.[1]

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 where the patient is abruptly confronted with the object of his or her phobia, his or her mental status examination will be significant for an anxious affect, with a restricted range. Neurovegetative signs (eg, tremor or diaphoresis) may 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 may be impaired, especially during exposure, but in most cases, insight is preserved. Although patients still report that they cannot control their feelings, they also acknowledge that the severity of their fears is not justified.

At any other time, the mental status of a patient with phobic disorder is within normal limits, except for thought content positive for phobic ideation. These phobic ideas may remain undisclosed unless specific questions about phobias are asked. Phobic disorders themselves do not present with suicidal or homicidal ideation, but comorbid conditions commonly associated with them (eg, depression and other anxiety disorders) often do. If comorbid conditions exist, the suicidal and homicidal risk should also be specifically assessed.

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Complications

If left untreated, social anxiety disorder or agoraphobia can result in tremendous morbidity. The patient becomes restricted to the most familiar surroundings (eg, a house) or the most trusted people (eg, a family member or spouse), and his or her ability to work and relate to other people is substantially impaired. In addition, there is a considerable risk of substance abuse with this degree of isolation,[33] and social anxiety disorder has been associated with an increased risk of subsequent depression.[34]

Specific phobia has been associated with increased risk for suicide attempts and possibly suicidal ideation.[32] Individuals with this disorder may also be limited by having to avoid buildings (in the case of acrophobia), elevators (in the case of claustrophobia), or even their own lawn (eg, for fear of snakes). As a general rule, less impairment is observed in specific phobia than in social anxiety disorder or agoraphobia.

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Contributor Information and Disclosures
Author

Adrian Preda, MD Professor of Clinical Psychiatry and Human Behavior, Director of Residency Program in Psychiatry, Vice-Chair, Department of Psychiatry and Human Behavior, University of California, Irvine, School of Medicine

Adrian Preda, MD is a member of the following medical societies: American Association for the Advancement of Science, American Psychiatric Association, International College of Neuropsychopharmacology, International Congress of Schizophrenia Research, Schizophrenia International Research Society, Society of Biological Psychiatry

Disclosure: Nothing to disclose.

Chief Editor

Iqbal Ahmed, MBBS, FRCPsych(UK) Faculty, Department of Psychiatry, Tripler Army Medical Center; Clinical Professor of Psychiatry, Uniformed Services University of the Health Sciences; 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 Neuropsychiatric Association, American Society of Clinical Psychopharmacology, Royal College of Psychiatrists, American Association for Geriatric Psychiatry, American Psychiatric Association

Disclosure: Nothing to disclose.

Acknowledgements

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

References
  1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). Washington, DC: American Psychiatric Association Press; 2000.

  2. Mathew SJ, Coplan JD, Gorman JM. Neurobiological mechanisms of social anxiety disorder. Am J Psychiatry. 2001 Oct. 158(10):1558-67. [Medline].

  3. Kendler KS, Karkowski LM, Prescott CA. Fears and phobias: reliability and heritability. Psychol Med. 1999 May. 29(3):539-53. [Medline].

  4. Fyer AJ, Mannuzza S, Chapman TF, Liebowitz MR, Klein DF. A direct interview family study of social phobia. Arch Gen Psychiatry. 1993 Apr. 50(4):286-93. [Medline].

  5. Van Houtem CM, Laine ML, Boomsma DI, Ligthart L, van Wijk AJ, De Jongh A. A review and meta-analysis of the heritability of specific phobia subtypes and corresponding fears. J Anxiety Disord. 2013 May. 27(4):379-88. [Medline].

  6. LeBeau RT, Glenn D, Liao B, et al. Specific phobia: a review of DSM-IV specific phobia and preliminary recommendations for DSM-V. Depress Anxiety. 2010 Feb. 27(2):148-67. [Medline].

  7. Linares IM, Trzesniak C, Chagas MH, Hallak JE, Nardi AE, Crippa JA. Neuroimaging in specific phobia disorder: a systematic review of the literature. Rev Bras Psiquiatr. 2012 Mar. 34(1):101-11. [Medline].

  8. Tillfors M, Furmark T, Marteinsdottir I, Fredrikson M. Cerebral blood flow during anticipation of public speaking in social phobia: a PET study. Biol Psychiatry. 2002 Dec 1. 52(11):1113-9. [Medline].

  9. Tillfors M, Furmark T, Marteinsdottir I, Fischer H, Pissiota A, Långström B, et al. Cerebral blood flow in subjects with social phobia during stressful speaking tasks: a PET study. Am J Psychiatry. 2001 Aug. 158(8):1220-6. [Medline].

  10. Lanzenberger RR, Mitterhauser M, Spindelegger C, Wadsak W, Klein N, Mien LK, et al. Reduced serotonin-1A receptor binding in social anxiety disorder. Biol Psychiatry. 2007 May 1. 61(9):1081-9. [Medline].

  11. Lanzenberger R, Wadsak W, Spindelegger C, Mitterhauser M, Akimova E, Mien LK, et al. Cortisol plasma levels in social anxiety disorder patients correlate with serotonin-1A receptor binding in limbic brain regions. Int J Neuropsychopharmacol. 2010 Oct. 13(9):1129-43. [Medline].

  12. Freitas-Ferrari MC, Hallak JE, Trzesniak C, Filho AS, Machado-de-Sousa JP, Chagas MH, et al. Neuroimaging in social anxiety disorder: a systematic review of the literature. Prog Neuropsychopharmacol Biol Psychiatry. 2010 May 30. 34(4):565-80. [Medline].

  13. Ahs F, Pissiota A, Michelgård A, Frans O, Furmark T, Appel L, et al. Disentangling the web of fear: amygdala reactivity and functional connectivity in spider and snake phobia. Psychiatry Res. 2009 May 15. 172(2):103-8. [Medline].

  14. Caseras X, Giampietro V, Lamas A, Brammer M, Vilarroya O, Carmona S, et al. The functional neuroanatomy of blood-injection-injury phobia: a comparison with spider phobics and healthy controls. Psychol Med. 2010 Jan. 40(1):125-34. [Medline].

  15. Straube T, Mentzel HJ, Miltner WH. Waiting for spiders: brain activation during anticipatory anxiety in spider phobics. Neuroimage. 2007 Oct 1. 37(4):1427-36. [Medline].

  16. Kessler RC, Petukhova M, Sampson NA, Zaslavsky AM, Wittchen HU. Twelve-month and lifetime prevalence and lifetime morbid risk of anxiety and mood disorders in the United States. Int J Methods Psychiatr Res. 2012 Sep. 21(3):169-84. [Medline]. [Full Text].

  17. Lewis-Fernández R, Hinton DE, Laria AJ, et al. Culture and the anxiety disorders: recommendations for DSM-V. Depress Anxiety. 2010 Feb. 27(2):212-29. [Medline].

  18. Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005 Jun. 62(6):593-602. [Medline].

  19. Wolitzky-Taylor KB, Castriotta N, Lenze EJ, Stanley MA, Craske MG. Anxiety disorders in older adults: a comprehensive review. Depress Anxiety. 2010 Feb. 27(2):190-211. [Medline].

  20. Ruscio AM, Brown TA, Chiu WT, Sareen J, Stein MB, Kessler RC. Social fears and social phobia in the USA: results from the National Comorbidity Survey Replication. Psychol Med. 2008 Jan. 38(1):15-28. [Medline]. [Full Text].

  21. Ollendick TH, King NJ, Muris P. Fears and phobias in children: phenomenology, epidemiology and aetiology. Child Adolesc Ment Health. 2002. 7:98–106.

  22. Wittchen HU, Jacobi F, Rehm J, et al. The size and burden of mental disorders and other disorders of the brain in Europe 2010. Eur Neuropsychopharmacol. 2011 Sep. 21(9):655-79. [Medline].

  23. Beesdo K, Knappe S, Pine DS. Anxiety and anxiety disorders in children and adolescents: developmental issues and implications for DSM-V. Psychiatr Clin North Am. 2009 Sep. 32(3):483-524. [Medline]. [Full Text].

  24. Kessler RC, Chiu WT, Jin R, Ruscio AM, Shear K, Walters EE. The epidemiology of panic attacks, panic disorder, and agoraphobia in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2006 Apr. 63(4):415-24. [Medline]. [Full Text].

  25. Fehm L, Pelissolo A, Furmark T, Wittchen HU. Size and burden of social phobia in Europe. Eur Neuropsychopharmacol. 2005 Aug. 15(4):453-62. [Medline].

  26. Wittchen HU, Stein MB, Kessler RC. Social fears and social phobia in a community sample of adolescents and young adults: prevalence, risk factors and co-morbidity. Psychol Med. 1999 Mar. 29(2):309-23. [Medline].

  27. Wittchen HU, Gloster AT, Beesdo-Baum K, Fava GA, Craske MG. Agoraphobia: a review of the diagnostic classificatory position and criteria. Depress Anxiety. 2010 Feb. 27(2):113-33. [Medline].

  28. Bruce SE, Yonkers KA, Otto MW, Eisen JL, Weisberg RB, Pagano M, et al. Influence of psychiatric comorbidity on recovery and recurrence in generalized anxiety disorder, social phobia, and panic disorder: a 12-year prospective study. Am J Psychiatry. 2005 Jun. 162(6):1179-87. [Medline].

  29. Schneier FR, Heckelman LR, Garfinkel R, Campeas R, Fallon BA, Gitow A, et al. Functional impairment in social phobia. J Clin Psychiatry. 1994 Aug. 55(8):322-31. [Medline].

  30. Lochner C, Mogotsi M, du Toit PL, Kaminer D, Niehaus DJ, Stein DJ. Quality of life in anxiety disorders: a comparison of obsessive-compulsive disorder, social anxiety disorder, and panic disorder. Psychopathology. 2003 Sep-Oct. 36(5):255-62. [Medline].

  31. Matza LS, Revicki DA, Davidson JR, Stewart JW. Depression with atypical features in the National Comorbidity Survey: classification, description, and consequences. Arch Gen Psychiatry. 2003 Aug. 60(8):817-26. [Medline].

  32. Sareen J, Cox BJ, Afifi TO, de Graaf R, Asmundson GJ, ten Have M, et al. Anxiety disorders and risk for suicidal ideation and suicide attempts: a population-based longitudinal study of adults. Arch Gen Psychiatry. 2005 Nov. 62(11):1249-57. [Medline].

  33. Stein MB, Stein DJ. Social anxiety disorder. Lancet. 2008 Mar 29. 371(9618):1115-25. [Medline].

  34. Beesdo K, Bittner A, Pine DS, Stein MB, Höfler M, Lieb R, et al. Incidence of social anxiety disorder and the consistent risk for secondary depression in the first three decades of life. Arch Gen Psychiatry. 2007 Aug. 64(8):903-12. [Medline].

  35. Magee WJ, Eaton WW, Wittchen HU, McGonagle KA, Kessler RC. Agoraphobia, simple phobia, and social phobia in the National Comorbidity Survey. Arch Gen Psychiatry. 1996 Feb. 53(2):159-68. [Medline].

  36. Liotti G. Phobias of Attachment-Related Inner States in the Psychotherapy of Adult Survivors of Childhood Complex Trauma. J Clin Psychol. 2013 Aug 28. [Medline].

  37. Baldwin DS, Anderson IM, Nutt DJ, Bandelow B, Bond A, Davidson JR, et al. Evidence-based guidelines for the pharmacological treatment of anxiety disorders: recommendations from the British Association for Psychopharmacology. J Psychopharmacol. 2005 Nov. 19(6):567-96. [Medline].

  38. de Beurs E, van Balkom AJ, Van Dyck R, Lange A. Long-term outcome of pharmacological and psychological treatment for panic disorder with agoraphobia: a 2-year naturalistic follow-up. Acta Psychiatr Scand. 1999 Jan. 99(1):59-67. [Medline].

  39. Pelissolo A. [Efficacy and tolerability of escitalopram in anxiety disorders: a review]. Encephale. 2008 Sep. 34(4):400-8. [Medline].

  40. National Prescribing Service Limited. Escitalopram (Lexapro, Esipram) for generalised anxiety disorder and social anxiety disorder (social phobia). NPS RADAR. Available at http://bit.ly/dOARMJ.

  41. Stein DJ, Ipser JC, van Balkom AJ. Pharmacotherapy for social anxiety disorder. Cochrane Review. Chichester, UK: John Wiley and Sons, Ltd; 2009.

  42. Westenberg HG. Recent advances in understanding and treating social anxiety disorder. CNS Spectr. 2009 Feb. 14(2 Suppl 3):24-33. [Medline].

  43. Ravindran LN, Stein MB. The pharmacologic treatment of anxiety disorders: a review of progress. J Clin Psychiatry. 2010 Jul. 71(7):839-54. [Medline].

  44. Davidson JR. Pharmacotherapy of social anxiety disorder: what does the evidence tell us?. J Clin Psychiatry. 2006. 67 Suppl 12:20-6. [Medline].

  45. Offidani E, Guidi J, Tomba E, Fava GA. Efficacy and Tolerability of Benzodiazepines versus Antidepressants in Anxiety Disorders: A Systematic Review and Meta-Analysis. Psychother Psychosom. 2013 Sep 20. 82(6):355-362. [Medline].

  46. Van Ameringen M, Allgulander C, Bandelow B, Greist JH, Hollander E, Montgomery SA, et al. WCA recommendations for the long-term treatment of social phobia. CNS Spectr. 2003 Aug. 8(8 Suppl 1):40-52. [Medline].

  47. Practice guideline for the treatment of patients with panic disorder. Work Group on Panic Disorder. American Psychiatric Association. Am J Psychiatry. 1998 May. 155(5 Suppl):1-34. [Medline].

  48. Pohl RB, Wolkow RM, Clary CM. Sertraline in the treatment of panic disorder: a double-blind multicenter trial. Am J Psychiatry. 1998 Sep. 155(9):1189-95. [Medline].

  49. Michelson D, Lydiard RB, Pollack MH, Tamura RN, Hoog SL, Tepner R, et al. Outcome assessment and clinical improvement in panic disorder: evidence from a randomized controlled trial of fluoxetine and placebo. The Fluoxetine Panic Disorder Study Group. Am J Psychiatry. 1998 Nov. 155(11):1570-7. [Medline].

  50. Uhlenhuth EH, Balter MB, Ban TA, Yang K. International study of expert judgment on therapeutic use of benzodiazepines and other psychotherapeutic medications: VI. Trends in recommendations for the pharmacotherapy of anxiety disorders, 1992-1997. Depress Anxiety. 1999. 9(3):107-16. [Medline].

  51. Shear MK, Beidel DC. Psychotherapy in the overall management strategy for social anxiety disorder. J Clin Psychiatry. 1998. 59 Suppl 17:39-46. [Medline].

  52. [Guideline] Mayor S. NICE advocates computerised CBT. BMJ. 2006 Mar 4. 332(7540):504. [Medline]. [Full Text].

  53. Barlow JH, Ellard DR, Hainsworth JM, Jones FR, Fisher A. A review of self-management interventions for panic disorders, phobias and obsessive-compulsive disorders. Acta Psychiatr Scand. 2005 Apr. 111(4):272-85. [Medline].

  54. Masia Warner C, Fisher PH, Shrout PE, Rathor S, Klein RG. Treating adolescents with social anxiety disorder in school: an attention control trial. J Child Psychol Psychiatry. 2007 Jul. 48(7):676-86. [Medline].

  55. Bunnell BE, Beidel DC, Mesa F. A Randomized Trial of Attention Training for Generalized Social Phobia: Does Attention Training Change Social Behavior?. Behav Ther. 2013 Dec. 44(4):662-673. [Medline].

  56. Ayala ES, Meuret AE, Ritz T. Treatments for blood-injury-injection phobia: a critical review of current evidence. J Psychiatr Res. 2009 Oct. 43(15):1235-42. [Medline].

  57. Rothbaum BO, Anderson P, Zimand E, Hodges L, Lang D, Wilson J. Virtual reality exposure therapy and standard (in vivo) exposure therapy in the treatment of fear of flying. Behav Ther. 2006 Mar. 37(1):80-90. [Medline].

  58. Paquette V, Lévesque J, Mensour B, Leroux JM, Beaudoin G, Bourgouin P, et al. "Change the mind and you change the brain": effects of cognitive-behavioral therapy on the neural correlates of spider phobia. Neuroimage. 2003 Feb. 18(2):401-9. [Medline].

  59. Schienle A, Schäfer A, Hermann A, Rohrmann S, Vaitl D. Symptom provocation and reduction in patients suffering from spider phobia: an fMRI study on exposure therapy. Eur Arch Psychiatry Clin Neurosci. 2007 Dec. 257(8):486-93. [Medline].

  60. Sánchez-Meca J, Rosa-Alcázar AI, Marín-Martínez F, Gómez-Conesa A. Psychological treatment of panic disorder with or without agoraphobia: a meta-analysis. Clin Psychol Rev. 2010 Feb. 30(1):37-50. [Medline].

  61. Hudson C, Hudson S, MacKenzie J. Protein-source tryptophan as an efficacious treatment for social anxiety disorder: a pilot study. Can J Physiol Pharmacol. 2007 Sep. 85(9):928-32. [Medline].

 
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