Phobic Disorders

Phobic disorders consist of persistent, unreasonable, intense fears (phobias) of situations, circumstances, or objects. The fears provoke anxiety and avoidance. Phobic disorders are classified as general (agoraphobia and social phobia) or specific. The causes of phobias are unknown. Phobic disorders are diagnosed based on history. Treatment for agoraphobia and social phobia is drug therapy, psychotherapy (eg, exposure therapy, cognitive-behavioral therapy), or both. Some phobias are treated mainly with exposure therapy.

Geriatric Essentials

• Social phobia may be especially disabling in the elderly, particularly when an elderly person has developed the phobia secondary to an embarrassing experience in public (such as falling in the common dining room of a retirement community).

Phobic disorders affect some elderly people but are most common among young and middle-age adults, particularly women.

Symptoms

Agoraphobia: Agoraphobia is fear of and anticipatory anxiety about being trapped in situations or places without a way to escape easily and without help if intense anxiety develops. The situations are avoided or they may be endured but with substantial anxiety. Agoraphobia can occur alone or as part of panic disorder. Common examples of situations or places that create fear and anxiety include standing in line at a bank or using public transportation. Agoraphobia often interferes with function and, if severe enough, can cause a person to become housebound.

Social phobia: Social phobia is fear of and anxiety about exposure to certain social or performance situations. These situations are avoided or endured but with substantial anxiety. People with social phobia recognize that their fear is unreasonable and excessive. Fear and anxiety in people with social phobia often centers on being embarrassed or humiliated if they fail to meet expectations. Situations in which social phobia is common include public speaking and playing a musical instrument for an audience. A more generalized type of social phobia produces anxiety in a broad array of social situations.

Specific phobia: A specific phobia is fear of and anxiety about a particular situation or object. The situation or object is usually avoided when possible, but if exposure occurs, anxiety quickly develops. The anxiety may intensify to the level of a panic attack. People with specific phobias typically recognize that their fear is unreasonable and excessive.

Specific phobias are the most common anxiety disorders. Among the most frequent are fear of animals (zoophobia), heights (acrophobia), and thunderstorms (astraphobia, brontophobia). Some cause little inconvenience--eg, fear of snakes (ophidiophobia) in a city dweller, unless the person is asked to hike in an area where snakes are found. However, others interfere severely with functioning--eg, fear of closed places (claustrophobia), such as a car.

Diagnosis

Diagnosis is clinical based on criteria in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Text Revision (DSM-IV-TR).

Treatment

Agoraphobia may disappear without formal treatment, possibly because some affected people conduct their own form of exposure therapy. However, if agoraphobia interferes with functioning, treatment is needed. Social phobia is almost always chronic, and treatment is needed. The need for treatment of specific phobias is more variable when untreated, because it may be easy to avoid the situation or object that causes fear and anxiety.

When a phobia causes a person to avoid situations, circumstances, or objects, exposure therapy (a form of psychotherapy) is the treatment of choice. With structure and support from a clinician, patients seek out, confront, and remain in contact with what they fear and avoid until their anxiety is gradually relieved through a process called habituation. Exposure therapy helps > 90% of those who follow it faithfully and is almost always the only treatment needed for specific phobias.

Cognitive-behavioral therapy is effective for agoraphobia and social phobia. Cognitive-behavioral therapy involves teaching patients to recognize and control their distorted thinking and false beliefs and instructs them on modifying behavior so that it is more adaptive.

Very short-term therapy with a benzodiazepine (eg, lorazepam 0.25 mg po) or a -blocker (propranolol 10 mg po is usually preferred), ideally about 1 to 2 h before the exposure, is occasionally useful when exposure to an object or situation cannot be avoided (eg, when a person who has a phobia of flying must fly on short notice) and cognitive-behavioral therapy is either unwanted or has not been successful.

This topic was last updated September 2005.