Specific Phobias

Overview

Definition

A phobia Phobia A phobia can be defined as an irrational fear that results in avoidance of the feared subject, activity, or situation. Social Anxiety Disorder is defined as an irrational fear that results in avoidance of the feared subject, activity, or situation. 

• The fear can occur in anticipation Anticipation The apparent tendency of certain diseases to appear at earlier age of onset and with increasing severity in successive generations. Huntington Disease of the situation/activity, during exposure, or even upon hearing the name of the stimulus.
• Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with specific phobia Phobia A phobia can be defined as an irrational fear that results in avoidance of the feared subject, activity, or situation. Social Anxiety Disorder might have a good insight Insight Psychiatric Assessment, knowing that their fear is excessive, or might have poor insight Insight Psychiatric Assessment. 
• Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship commonly have multiple specific phobias Phobias Neurological Examination, and each would need to be specified in a diagnosis.

Epidemiology

• The estimated lifetime prevalence Prevalence The total number of cases of a given disease in a specified population at a designated time. It is differentiated from incidence, which refers to the number of new cases in the population at a given time. Measures of Disease Frequency of social phobia Social phobia Anxiety disorder characterized by the persistent and irrational fear, anxiety, or avoidance of social or performance situations. Social Anxiety Disorder in the United States is 7%–12.5%.
• More common in females than in males
• Bimodal age at onset:
  • Blood-injection injury and natural environment phobias Phobias Neurological Examination occur in childhood.
  • Situational phobias Phobias Neurological Examination more often occur in adulthood.

Pathophysiology

• Genetics Genetics Genetics is the study of genes and their functions and behaviors. Basic Terms of Genetics:
  • 1st-degree relatives of individuals with specific phobias Phobias Neurological Examination have an increased risk (up to 31%) of having the disorder, but with a different stimulus. 
  • Twin studies point to a stronger influence of environmental factors than genetic factors.
• Neurobiologic: Hyperactivation of the amygdala Amygdala Almond-shaped group of basal nuclei anterior to the inferior horn of the lateral ventricle of the temporal lobe. The amygdala is part of the limbic system. Limbic System: Anatomy and insula (structures involved in negative emotional responses) has been associated with phobic disorders.
• Personality traits:
  • Disgust sensitivity: predisposition to experience disgust in response to certain stimuli (certain animals Animals Unicellular or multicellular, heterotrophic organisms, that have sensation and the power of voluntary movement. Under the older five kingdom paradigm, animalia was one of the kingdoms. Under the modern three domain model, animalia represents one of the many groups in the domain eukaryota. Cell Types: Eukaryotic versus Prokaryotic or blood injections)
  • Anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder sensitivity: fear of the sensations or behaviors of anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder due to the belief that the anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder symptoms are harmful
• Environmental factors:
  • Traumatic events, the associated stress, prior and subsequent exposure to a stimulus, and the support obtained affect specific phobias Phobias Neurological Examination.
  • Processes that lead to fear development:
    • Direct conditioning: being hurt or frightened or having the feeling of helplessness leads to anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder toward the situation/subject.
    • Vicarious acquisition: observing someone with the fearful or anxious behavior
    • Informational transmission: obtaining information from others or through media (e.g., shark attacks, plane crashes)

Clinical Presentation and Diagnosis

Specifiers

Main types of specific phobias Phobias Neurological Examination based on the nature of the stimulus:

• Animal:
  • Spiders: arachnophobia
  • Dogs: cynophobia
  • Insects: entomophobia
• Natural environment:
  • Heights: acrophobia
  • Water: aquaphobia 
  • Thunderstorms: astraphobia
• Blood-injection injury:
  • Injections/needles: trypanophobia or belenophobia
  • Dental procedure: odontophobia 
• Situational:
  • Flying: aviophobia
  • Enclosed places: claustrophobia Claustrophobia Magnetic Resonance Imaging (MRI)
• Other (cannot be categorized as above):
  • Costumed characters: masklophobia
  • Loud sounds: phonophobia or ligyrophobia
  • Vomiting Vomiting The forcible expulsion of the contents of the stomach through the mouth. Hypokalemia: emetophobia

Clinical features and diagnosis

• Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship present with:
  • Excessive anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder about, or fear of, a specific object or situation
  • This behavior is almost always provoked when exposed to the stimulus:
    • Intense fear, with physiologic arousal (↑ HR or BP)
    • Crying, clinging, freezing in children
  • Avoidance behavior
  • The fear and anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder lead to functional impairment (e.g., avoids travel because of fear of flying, cannot find a job because of fear of driving).
• Symptoms persist ≥ 6 months
• The fear and anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder is not due to any underlying medical condition mental disorder or to substance use disorder.
• Diagnosis is based on the presenting symptoms.
• Without treatment, the phobia Phobia A phobia can be defined as an irrational fear that results in avoidance of the feared subject, activity, or situation. Social Anxiety Disorder persists throughout the lifetime.

Management

• Specific phobia Phobia A phobia can be defined as an irrational fear that results in avoidance of the feared subject, activity, or situation. Social Anxiety Disorder is treatable, but very few patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship seek treatment. 
• Psychotherapy Psychotherapy Psychotherapy is interpersonal treatment based on the understanding of psychological principles and mechanisms of mental disease. The treatment approach is often individualized, depending on the psychiatric condition(s) or circumstance. Psychotherapy:
  • Exposure-based CBT: 1st-line treatment 
  • Goal: desensitize patient to source of phobia Phobia A phobia can be defined as an irrational fear that results in avoidance of the feared subject, activity, or situation. Social Anxiety Disorder 
  • In vivo exposure: most effective long-term treatment for specific phobias Phobias Neurological Examination 
• Pharmacotherapy:
  • Generally, medications alone are not useful in this disorder except in certain situations, as anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder may return upon discontinuation of medications. 
  • Short-acting benzodiazepines Benzodiazepines Benzodiazepines work on the gamma-aminobutyric acid type A (GABAA) receptor to produce inhibitory effects on the CNS. Benzodiazepines do not mimic GABA, the main inhibitory neurotransmitter in humans, but instead potentiate GABA activity. Benzodiazepines might be used in patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with claustrophobia Claustrophobia Magnetic Resonance Imaging (MRI) (fear of enclosed places, such as an MRI machine). 
  • D-cycloserine (DCS):
    • Partial N-methyl-d-aspartate (NMDA) receptor Receptor Receptors are proteins located either on the surface of or within a cell that can bind to signaling molecules known as ligands (e.g., hormones) and cause some type of response within the cell. Receptors agonist 
    • Investigational, but shows some evidence of augmenting CBT during exposure therapy

Other Anxiety Disorders

The following table summarizes the most important information about anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder disorders.

Differential Diagnosis

• Panic disorder Panic disorder Panic disorder is a condition marked by recurrent and episodic panic attacks that occur abruptly and without a trigger. These episodes are time-limited and present with cardiorespiratory (palpitations, shortness of breath, choking), GI (nausea, abdominal distress), and neurologic (paresthesias, lightheadedness) symptoms. Panic Disorder: chronic mental disorder marked by recurrent and episodic panic attacks that occur abruptly without a trigger Trigger The type of signal that initiates the inspiratory phase by the ventilator Invasive Mechanical Ventilation. Panic disorder Panic disorder Panic disorder is a condition marked by recurrent and episodic panic attacks that occur abruptly and without a trigger. These episodes are time-limited and present with cardiorespiratory (palpitations, shortness of breath, choking), GI (nausea, abdominal distress), and neurologic (paresthesias, lightheadedness) symptoms. Panic Disorder is associated with anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder or fear of having another attack or its complications and some behavioral changes. If the panic attack Panic attack A panic attack is not a mental disorder. Rather, this disorder is a sudden, spontaneous, time-limited period (minutes to an hour) of heightened anxiety or intense fear, often with physical symptoms. Panic Disorder is triggered by a known, identified trigger Trigger The type of signal that initiates the inspiratory phase by the ventilator Invasive Mechanical Ventilation, then the correct diagnosis would be specific phobia Phobia A phobia can be defined as an irrational fear that results in avoidance of the feared subject, activity, or situation. Social Anxiety Disorder. 
• Social phobia Social phobia Anxiety disorder characterized by the persistent and irrational fear, anxiety, or avoidance of social or performance situations. Social Anxiety Disorder: also called social anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder disorder (SAD). Social phobia Social phobia Anxiety disorder characterized by the persistent and irrational fear, anxiety, or avoidance of social or performance situations. Social Anxiety Disorder is the fear or avoidance of social interactions because of concerns about being embarrassed, occurring in > 1 social situation for > 6 months. Treatment includes CBT, antidepressants ( SSRIs SSRIs Serotonin Reuptake Inhibitors and Similar Antidepressants, serotonin Serotonin A biochemical messenger and regulator, synthesized from the essential amino acid l-tryptophan. In humans it is found primarily in the central nervous system, gastrointestinal tract, and blood platelets. Serotonin mediates several important physiological functions including neurotransmission, gastrointestinal motility, hemostasis, and cardiovascular integrity. Receptors and Neurotransmitters of the CNS– norepinephrine Norepinephrine Precursor of epinephrine that is secreted by the adrenal medulla and is a widespread central and autonomic neurotransmitter. Norepinephrine is the principal transmitter of most postganglionic sympathetic fibers, and of the diffuse projection system in the brain that arises from the locus ceruleus. Receptors and Neurotransmitters of the CNS reuptake inhibitor ( SNRIs SNRIs Serotonin Reuptake Inhibitors and Similar Antidepressants)), and β-blockers for performance-only subtypes. People with social phobia Social phobia Anxiety disorder characterized by the persistent and irrational fear, anxiety, or avoidance of social or performance situations. Social Anxiety Disorder are afraid of being negatively judged by others.  
• Intoxication (on cocaine Cocaine An alkaloid ester extracted from the leaves of plants including coca. It is a local anesthetic and vasoconstrictor and is clinically used for that purpose, particularly in the eye, ear, nose, and throat. It also has powerful central nervous system effects similar to the amphetamines and is a drug of abuse. Cocaine, like amphetamines, acts by multiple mechanisms on brain catecholaminergic neurons; the mechanism of its reinforcing effects is thought to involve inhibition of dopamine uptake. Local Anesthetics or hallucinogens): Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with cocaine Cocaine An alkaloid ester extracted from the leaves of plants including coca. It is a local anesthetic and vasoconstrictor and is clinically used for that purpose, particularly in the eye, ear, nose, and throat. It also has powerful central nervous system effects similar to the amphetamines and is a drug of abuse. Cocaine, like amphetamines, acts by multiple mechanisms on brain catecholaminergic neurons; the mechanism of its reinforcing effects is thought to involve inhibition of dopamine uptake. Local Anesthetics use disorder or hallucinogen Hallucinogen Drugs capable of inducing illusions, hallucinations, delusions, paranoid ideations, and other alterations of mood and thinking. Despite the name, the feature that distinguishes these agents from other classes of drugs is their capacity to induce states of altered perception, thought, and feeling that are not experienced otherwise. Hallucinogen Use Disorder use disorder can develop a specific phobia Phobia A phobia can be defined as an irrational fear that results in avoidance of the feared subject, activity, or situation. Social Anxiety Disorder when they are intoxicated with either substance. Symptoms of intoxication include agitation Agitation A feeling of restlessness associated with increased motor activity. This may occur as a manifestation of nervous system drug toxicity or other conditions. St. Louis Encephalitis Virus, psychosis, hemodynamic instability ( hypertension Hypertension Hypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension, tachycardia Tachycardia Abnormally rapid heartbeat, usually with a heart rate above 100 beats per minute for adults. Tachycardia accompanied by disturbance in the cardiac depolarization (cardiac arrhythmia) is called tachyarrhythmia. Sepsis in Children), diaphoresis, and mydriasis Mydriasis Dilation of pupils to greater than 6 mm combined with failure of the pupils to constrict when stimulated with light. This condition may occur due to injury of the pupillary fibers in the oculomotor nerve, in acute angle-closure glaucoma, and in adie syndrome. Glaucoma. Acute intoxication is distinguished from specific phobia Phobia A phobia can be defined as an irrational fear that results in avoidance of the feared subject, activity, or situation. Social Anxiety Disorder by history taking, physical exam, and urine toxicology screen. 
• Agoraphobia Agoraphobia Agoraphobia is fear or anxiety in a situation that would be difficult to leave or to obtain help in the event that one develops panic-like symptoms. Situations include being in public or open spaces, lines, crowds, or public transport. Agoraphobia: fear or anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder occurring while facing different situations in which it would be difficult to leave or to obtain help in the event of having panic-like symptoms. Situations include being in public or open spaces, crowds, or public transport. In specific phobia Phobia A phobia can be defined as an irrational fear that results in avoidance of the feared subject, activity, or situation. Social Anxiety Disorder, multiple fears are present (e.g., getting hurt by a spider Spider Arthropods of the class arachnida, order araneae. Except for mites and ticks, spiders constitute the largest order of arachnids, with approximately 37, 000 species having been described. The majority of spiders are harmless, although some species can be regarded as moderately harmful since their bites can lead to quite severe local symptoms. Spider Bites, being stuck in an elevator). In agoraphobia Agoraphobia Agoraphobia is fear or anxiety in a situation that would be difficult to leave or to obtain help in the event that one develops panic-like symptoms. Situations include being in public or open spaces, lines, crowds, or public transport. Agoraphobia, there is fear of panic symptoms and being unable to get help or escape Escape With constant immune mechanisms holding unstable tumor cells in equilibrium, tumor-cell variants may emerge. These cancer cells may express fewer antigens on their surfaces or lose their MHC class I expression.Variants may also protect themselves from T-cell attack via expression of IC molecules on their surfaces, like normal cells.Creation of an immunosuppressive state in the microenvironment is another way to grow without immunologic interference. Cancer Immunotherapy.