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Phobic Disorders

Practice Essentials

Collectively, phobic disorders (including social anxiety disorder [social phobia], specific phobia, and agoraphobia) are the most common forms of psychiatric illness, surpassing the rates of mood disorders and substance abuse. Severity can range from mild and unobtrusive to severe and can result in incapacity to work, travel, or interact with others.

Signs and symptoms

In obtaining a history from a patient with symptoms of a phobic disorder, the physician should inquire about the following:

Other anxiety disorders

Depression

Suicidal ideation

Substance-related disorders

Caffeine intake

Alcohol intake

Difficulties in social situations (in suspected social anxiety disorder)

Irrational and out-of-proportion fear or avoidance of particular objects or situations (in suspected specific phobia)

Intense anxiety reactions with exposure to specific situations (in suspected agoraphobia)

Anxiety is the most common feature in phobic disorders. Manifestations include the following:

Sweating

Palpitations

Elevated blood pressure

Elevated heart rate

Dyspnea

Dizziness

Tremor

Diarrhea

Paresthesias

Because anxiety manifests with a number of physical symptoms, any patient who presents with a de novo complaint of physical symptoms suggestive of an anxiety disorder should undergo a physical examination to help rule out medical conditions that might present with anxietylike symptoms.

For a patient with a suspected phobic disorder, the mental status examination should assess the following:

Appearance

Behavior

Ability to cooperate with the examination

Level of activity

Speech

Mood and affect

Thought processes and content

Insight

Judgment

Findings in a patient with a phobic disorder may include the following:

Psychomotor agitation, restlessness

Diaphoresis

Anxious mood and affect upon abrupt confrontation with the object of the phobia

Ability to identify the reason for the anxiety

Thought content significant for phobic ideation (unrealistic and out-of-proportion fears)

Preserved insight (usually; may be impaired, especially during exposure)

If comorbid conditions are present, possible suicidal or homicidal ideation

See Presentation for more detail.

Diagnosis

To rule out anxiety secondary to medical conditions, the following tests may be helpful:

Thyroid function tests

Fasting glucose

Calcium

24-hour urine for 5-hydroxyindoleacetic acid (5-HIAA)

Drug screen

Electrocardiography (ECG) and cardiac enzyme tests

Electroencephalography (EEG) – Seizure disorders (these conditions may mimic anxiety)

Where another medical illness, such as a seizure disorder, is suspected, the following Imaging studies may be considered:

Head computed tomography (CT) 

Head magnetic resonance imaging (MRI)

Head positron emission tomography (PET)

Cardiac echocardiography

See Workup for more detail.

Management

Treatment of phobic disorders usually consists of pharmacotherapy, psychotherapy, or some combination thereof.

Pharmacotherapy for social anxiety disorder may include the following:

Paroxetine and sertraline (FDA-approved)

Venlafaxine (FDA-approved)

Escitalopram, citalopram, fluoxetine, and fluvoxamine

Phenelzine

Moclobemide (not approved in the United States)

Tricyclic antidepressants (TCAs)

Beta-blockers (eg, propranolol)

Selected anticonvulsants (eg, gabapentin, pregabalin, valproic acid, topiramate, and tiagabine)

No controlled studies have demonstrated the efficacy of psychopharmacologic intervention for specific phobias. As-needed administration of a short-acting benzodiazepine may be useful for temporary anxiety relief in specific situations.

Agents that may be considered for agoraphobia include the following:

SSRIs (eg, escitalopram, citalopram, fluoxetine, fluvoxamine, paroxetine, and sertraline),

Venlafaxine and reboxetine

Some TCAs (eg, clomipramine and imipramine)

Some benzodiazepines (eg, alprazolam, lorazepam, diazepam, and clonazepam)

Mirtazapine

Moclobemide

Psychotherapeutic interventions that may be helpful for treating phobic disorders include the following:

Social anxiety disorder (social phobia) – Self-exposure monotherapy, computer-based exposure training, clinician-led exposure, or combination therapies (eg, self-exposure and cognitive-behavioral therapy (CBT)/self-help manual)

Specific phobia – CBT-based approach, including gradual desensitization; relaxation and breathing control techniques; exposure therapy

Agoraphobia – Combination of exposure therapy, relaxation, and breathing retraining

See Treatment and Medication for more detail.

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