Phobias

Specialties > General practice

Background knowledge 🧠

Definition

A phobia is an intense, irrational fear of a specific object, situation, or activity that leads to avoidance behaviour.
Classified as an anxiety disorder.
Unlike general anxiety disorders, phobias are usually linked to a specific trigger.
Can be debilitating if the phobic stimulus is commonly encountered.

Epidemiology

Affects approximately 10% of the UK population.
More common in females (2:1 ratio compared to males).
Onset usually occurs in childhood or adolescence, but can develop at any age.
Specific phobias are the most common type.
High comorbidity with other anxiety disorders and depression.

Aetiology and Pathophysiology

Genetic predisposition: Family history increases risk.
Environmental factors: Traumatic experiences linked to the phobic stimulus.
Neurobiological factors: Dysregulation in the amygdala and other brain regions involved in fear processing.
Cognitive-behavioural theories: Learned responses from negative experiences.
Evolutionary theories: Some phobias (e.g., fear of snakes) may have evolutionary survival advantages.

Types

Specific phobias: Fear of specific objects or situations (e.g., heights, spiders).
Social phobia (Social anxiety disorder): Fear of social situations where one may be judged.
Agoraphobia: Fear of situations where escape might be difficult (e.g., open or crowded places).
Complex phobias: Involve a deeper psychological impact and include social phobia and agoraphobia.
Common phobic stimuli: Animals, natural environments, blood/injections, situational (e.g., flying).

Clinical Features 🌡️

Symptoms

Intense fear or anxiety when exposed to the phobic stimulus.
Anticipatory anxiety: Fear of encountering the phobic stimulus even when it is not present.
Physical symptoms: Palpitations, sweating, trembling, dizziness.
Avoidance behaviour: Actively avoiding situations or objects that trigger the phobia.
Impaired daily functioning: Severe cases may lead to significant limitations in daily activities.

Signs

Visible distress or agitation when discussing or encountering the phobic stimulus.
Autonomic arousal: Tachycardia, hyperventilation, sweating.
Avoidance of certain places or activities that may expose them to the phobia.
May present with somatic symptoms: Headaches, gastrointestinal discomfort.

Investigations 🧪

Tests

Diagnosis is primarily clinical based on patient history and symptomatology.
Use of standardised anxiety scales: e.g., the Fear Questionnaire, Hamilton Anxiety Scale.
Consider differential diagnoses: Rule out other anxiety disorders, PTSD, OCD.
Assessment for comorbid conditions: Depression, substance misuse.
Physical examination if somatic symptoms are severe to exclude other medical conditions.

Management 🥼

Management

Cognitive Behavioural Therapy (CBT): First-line treatment, particularly exposure therapy.
Pharmacotherapy: SSRIs or benzodiazepines for short-term use in severe cases.
Supportive therapy: Psychoeducation, relaxation techniques.
Lifestyle modifications: Regular exercise, stress management strategies.
Consider referral to specialist services for complex phobias or treatment-resistant cases.

Complications

Social isolation: Due to avoidance behaviour.
Impaired occupational functioning: Inability to attend work or perform job duties.
Increased risk of depression and other mental health disorders.
Substance misuse: As a coping mechanism.
Reduced quality of life: Chronic anxiety and avoidance behaviours.

Prognosis

Good prognosis with appropriate treatment, particularly CBT.
Early intervention improves outcomes.
Chronic course if untreated, with potential worsening of symptoms.
Some phobias may resolve spontaneously, especially in children.
Ongoing management may be required for complex phobias.

Key Points

Phobias are a common and treatable anxiety disorder.
Key management is through CBT, particularly exposure therapy.
Pharmacotherapy is an adjunct, not first-line, except in severe cases.
Early diagnosis and intervention are crucial to prevent complications.
Consider underlying causes and comorbidities when assessing patients with phobias.

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