Phobic Disorders

Phobia: irrational fear of specific objects, places or situations, or activities
the fear is irrational, excessive & disproportionate to actual danger

3 types of phobias:

Social phobia

A marked or persistent > 6 months
fear of 1/more social or performance situations
- When exposed to unfamiliar people
- Fear of possible scrutiny by others
- having a conversation
- meeting unfamiliar people
- being observed (e.g. – eating or drinking)
- performing in front of others (e.g. – giving a speech).
will act in a way or show anxiety symptoms that will be negatively evaluated (i.e. – will be humiliating or embarrassing: will lead to rejection or offend others).
Avoidance
- Feared social or performance situations are avoide
- interferes significantly with person’s
  - normal routine
  - occupation fx
  - social activities or relationships
Person recognises that the fear is excessive or unreasonable
not due to
- direct effects of a substance
- general medical condition
- better accounted for by another mental disorder
If individual is < 18yrs, the duration is at least 6 mths

Epidemiology:
- Tends to run in families
DDx:
- Up to 72% of individuals have another psychiatric disorder diagnosis
- Other anxiety disorders
- Mood disorders
- Schizoid & avoidant personality disorders

In performance-type social anxiety disorder
1. beta-blockers have been used for performance anxiety
Cognitive behavioural therapy with exposure
1. first-line
2. gold-standard treatment for social anxiety disorder.

1st line	Monotherapy: escitalopram, fluvoxamine, fluvoxamine CR, paroxetine, paroxetine CR, pregabalin, sertraline, venlafaxine XR
2nd line	Monotherapy: alprazolam, bromazepam, citalopram, clonazepam, gabapentin, phenelzine
3rd line	Monotherapy: atomoxetine, bupropion SR, clomipramine, divalproex, duloxetine, fluoxetine, mirtazapine, moclobemide, olanzapine, selegiline, tiagabine, topiramate.
Adjunctive therapy	Aripiprazole, buspirone, paroxetine, risperidone
Not recommended	Monotherapy: atenolol, buspirone, imipramine, levetiracetam, propranolol, quetiapine Adjunctive therapy: clonazepam, pindolol

Beta-blockers
- have been successfully used in clinical practice for performance situations such as public speaking.
Benzodiazepines
- be used at any time if there is an acute and severe exacerbation of agitation or anxiety in individuals with SAD who do not have co-morbid alcohol or substance abuse.
- should be used as a short term solution only as 1⁄4 of patients with generalized SAD have co-morbid substance use

fear of being unable to escape a place or situation to such an extent that he/she learns to avoid it
fear of being unable to get help in the event of a panic attack
Marked fear or anxiety about at least 2 of the following 5 situations:
- Public transportation (e.g. – automobiles, buses, trains, ships, planes)
- Open spaces (e.g. – parking lots, malls, marketplaces, bridges)
- Enclosed places (e.g. – rooms, shops, theatres, cinemas)
- Crowds or standing in line
- Being outside of home alone
avoids these situations because of thoughts that:
- Escape might be difficult, or
- Help might not be available in the event of developing panic-like symptoms or other incapacitating or embarrassing symptoms (e.g. – fear of falling or fear of incontinence in the elderly).
the fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more
Beyond the panic attack symptoms (see above), other incapacitating or embarrassing symptoms include symptoms such as:
- Vomiting and inflammatory bowel symptoms
- In older adults, a fear of falling
- In children, a sense of disorientation and getting los
Epidemiology
- F > M
- chronic lifelong condition
- attacks fluctuate in frequency, intensity & severity