Transcript Phobias

‫‪Phobias‬‬
‫ا‪.‬د‪.‬الهام الجماس‬
Essence
Agoraphobia
Anxiety
and panic
symptoms associated
with places or situations
where escape may be
difficult or embarrassing
e.g. of crowds, public
places, traveling alone or
away from home),
leading to avoidance.
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-IV distinguishes 5
subtypes:
animals,
aspects
of the natural
environment,
blood/injection/injury,
situational, and
Other.
Social phobia
Symptoms of
incapacitating
anxiety
(psychological
and/or autonomic)
are
not secondary
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).
Epidemiology
Agoraphobia
Prevalence
(6 month)
2.8-5.8% ;
Male/female = 1:3; as for
panic disorder,
there is a bimodal
distribution with the first
being somewhat broader
(15-35 yrs).
 In later life agoraphobic
symptoms may develop
secondary to physical
frailty, with the associated
fear of exacerbating
medical problems or
having an accident.
Simple or specific
phobias
Prevalence:
lifetime
12.5%,
12-mth (NCS) 8.7%,
 6-mth (ECA)
4.5-11.9%;
Male/female = 1:3;
animal/situational
phobias may be more
common in female; main
age of occurrence mainly
in childhood /adolescence
(mean 15yrs):
animal phobias -7yrs,
blood injection/injury-8
 claustrophobia -20yrs.
Social phobia
Lifetime
rates vary from
2.4% (ECA) to 12.1%
(NCS),
12mth prevalence 6.8%
(NCS);
male = female for those
seeking treatment
(however community
surveys suggest male >
female);
 bimodal distribution with
peaks at 5 yrs and
between 11-15 yrs
often patients do not
present until they are in
their 30s.
Management
Agoraphobia
Pharmacological

Antidepressants As for panic
disorder.
BDZs short-term use only (may
reinforce avoidance)
most
evidence for
alprazolam/clonazepam.
Psychological

Behavioural methods Exposure
techniques (focused on particular
situations or places), relaxation
training, and anxiety management.
 Cognitive methods Teaching
about bodily responses associated
with anxiety/education about panic
attacks, modification of thinking
errors
Simple or specific
phobias
Behavioural
therapy
”treatment of choice: methods aim to
reduce the fear response e.g. Wolpe's
systematic desensitisation with relaxation
and graded exposure (either imaginary or
in vivo).
 Other techniques: reciprocal inhibition,
flooding (not better than graded
exposure), and modelling. Cognitive
methods: education/anxiety management,
coping skills/strategies”may enhance longterm outcomes.
Pharmacological
Generally not used, except in severe
cases to reduce fear avoidance (with
BDZs e.g. diazepam) and allow the patient
to engage in exposure techniques (2°blockers may be helpful, but benefit is not
sustained). Clear 2° depression may
require an antidepressant.
Social phobia
Psychological
CBT,
in either an individual or group
setting, should be considered as a firstline therapy (along with SSRIs/MAOIs)
and may be better at preventing relapse.
Components of this approach include
relaxation training/anxiety management
(for autonomic arousal), social skills
training, and integrated exposure methods
(modelling and graded exposure).
Pharmacological
 B-blockers (e.g. atenolol) may reduce
autonomic arousal, particularly for specific
social phobia (e.g. performance anxiety).
For more generalised social anxiety, both
SSRIs (e.g. fluoxetine, paroxetine,
sertraline) and MAOIs (e.g. phenelzine)
are significantly more effective. Other
treatment possibilities include RIMAs (e.g.
moclobemide) or the addition of a BDZ
(e.g. clonazepam, alprazolam) or
buspirone