Phobias

para>Anxiety may be expressed by crying, tantrums, or clinging. Fear of animals and other environmental objects are usually transitory in childhood.

Preadolescent children are often not aware that their fears are excessive or unreasonable.

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EPIDEMIOLOGY

Incidence

Predominant age: mean age of onset is 20 years for agoraphobia; 15 years for specific phobias; 15 years for social phobia
Predominant sex: female > male

Prevalence
In the general U.S. population, the 12-month and lifetime prevalence, respectively, are as follows: ‚

Agoraphobia without panic: 0.8% and 1.4%
Specific phobia: 8.7% and 12.5%
Social phobia: 6.8% and 12.1%

ETIOLOGY AND PATHOPHYSIOLOGY

Not well understood, but exaggerated amygdala, anterior cingulate, and insular activity increase fear and create mental stress " “induced heart rate, and BP increases
A complex interplay of genetic vulnerability, developmental neurobiology, and environmental vulnerability may lead to persistence/exaggeration of a learned response, perhaps learned initially as a protective mechanism (e.g., avoidance of large dogs by a child).

Genetics

Social phobia and agoraphobia are correlated with genetically influenced introversion and neuroticism.
Specific phobias tend to run in the family, especially blood-injection-injury type, which has very high familial tendency.

RISK FACTORS

Female sex (Phobias are the most common psychiatric disorders among women.)
First-degree relatives with the disorder
Traumatic experience
In children, observation of others with phobic reactions
Social phobia is strongly associated with a perceived lack of control over one 's own life. Other risk factors include low self-esteem, low education level, emotional neglect, major depression, and significant recent life stressors.

COMMONLY ASSOCIATED CONDITIONS

Other anxiety and mood disorders, as well as abuse of alcohol and other substances
Most patients with agoraphobia experience panic disorder as well.

DIAGNOSIS

HISTORY

A major finding is the presence of irrational or ego-dystonic fear of a specific situation, activity, or object with associated avoidant behavior. ‚

PHYSICAL EXAM

Symptoms associated with exposure to phobic stimuli may include signs of sympathetic activation, pallor, dizziness, or paresthesias.
Perform a mental status exam.

DIFFERENTIAL DIAGNOSIS

Psychiatric differential diagnosis includes the following:
- Other anxiety disorders (panic disorder, obsessive-compulsive disorder, generalized anxiety disorder, posttraumatic stress disorder [PTSD])
- Mood disorders (bipolar disorder): Treat mood state first.
- Avoidant personality disorder: history since childhood of fear of scrutiny by others
- Alzheimer disease and autism: Fears are of new places and new things because of difficulty learning.
Agoraphobia is almost always preceded by panic or a panic-like state. The key feature of social phobia is fear of scrutiny by others. A specific phobia is a narrowly focused fear (e.g., a fear of needles, etc.).
Consider underlying medical causes such as thyroid dysfunction, alcohol/benzodiazepine withdrawal, alcoholism and substance use (particularly hallucinogens, sympathomimetics, dextromethorphan), hypoglycemia, steroids, interferon, myocardial infarction (MI), hypoxia, preictal and postictal states, pheochromocytoma, hyperparathyroidism, cerebrovascular disease, and CNS tumors.

DIAGNOSTIC TESTS & INTERPRETATION

Initial Tests (lab, imaging)

To rule out medical causes, if suspected (see "Differential Diagnosis " ť)
CBC, CMP, TSH, EKG

TREATMENT

Treat major psychiatric disorders first, (bipolar, schizophrenia, alcoholism), as phobic symptoms may resolve.
Benzodiazepines are used in clinical setting because of rapid clinical response, but there is high risk of abuse and dependence.
More effective behavioral techniques include cognitive-behavioral therapy (CBT) and exposure therapy.

GENERAL MEASURES

CBT, including exposure, cognitive restructuring, and relaxation techniques, has been shown to be effective for social phobia and agoraphobia (1)[B].
Exposure-based treatment is superior to pharmacology and alternative psychotherapeutic approaches and placebo in the treatment of specific phobias (2)[A].
While treating phobias, family therapy directed toward education and support is often beneficial.

MEDICATION

First Line

Studies show effectiveness of SSRIs for agoraphobia (3)[B] and social phobia (4)[A]. If the patient has bipolar disorder, treat this first because antidepressants (e.g., SSRIs) can make bipolar disorder worse.
- Citalopram 10 to 40 mg/day, escitalopram 5 to 20 mg/day, fluoxetine 10 to 80 mg/day, fluvoxamine 50 to 300 mg/day, paroxetine 10 to 60 mg/day, sertraline (25 to 200 mg/day). In patients with panic disorder, start lower than the FDA recommendations to enable patients to tolerate medications.
Venlafaxine XR, 75 to 225 mg/day, a serotonin norepinephrine reuptake inhibitor (SNRI), has been shown to be as effective and well tolerated for social phobia (5,6)[B].
Buspirone 15 to 60 mg/day, a serotonin-receptor agonist, also may be used in the treatment of social phobia; can be used to augment SSRIs.
Taper treatment after 6 to 12 months, if possible; can be restarted if symptoms recur.
A short-acting benzodiazepine (alprazolam, 0.5 to 2 mg) may be helpful in treating acute fears (e.g., of flying).

ALERT

New FDA guidelines for citalopram: Do not use in excess of 40 mg in adults and 20 mg in patients >60 years of age due to risk of QT prolongation.

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Second Line

Benzodiazepines quickly reduce fears associated with panic, but they are second-line due to long-term tolerance and abuse potential. Use with extreme caution in patients with alcoholism.
- Also useful in treatment of social phobia
- Alprazolam 0.5 to 4 mg/day, lorazepam 2 to 6 mg/day, clonazepam 0.5 to 6 mg/day
- Discontinue gradually because of the risk for withdrawal seizures and rebound panic/anxiety.
Ž ˛-Blockers decrease sympathetic stimulation and can be used for performance anxiety.
- Choices include propranolol 10 to 60 mg and atenolol 25 to 100 mg 30 to 60 minutes before activity (fewer CNS side effects).
- Monitor for hypotension and bradycardia.
Tricyclic antidepressants (TCAs) are as effective as SSRIs for panic symptoms associated with agoraphobia (although not as well tolerated).
- Start with ≤25 mg of a tricyclic. May increase 25 mg every 3 days to target dose
  - Imipramine 50 to 300 mg/day, desipramine 50 to 300 mg/day, nortriptyline 25 to 150 mg/day, clomipramine 25 to 150 mg/day
  - Anticholinergic, antihistaminic, orthostatic side effects are common. Increased risk of death after MI if on TCAs

ALERT

Although the SSRIs and SNRIs are first-line treatment, benzodiazepines prescription continue to rise. Short-term benzodiazepine use may be useful, but long-term use is associated with abuse, dependence (7)[B], and functional loss (8)[B].
Clonazepam is a long-acting benzodiazepine and may be more useful than other benzodiazepines.

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ISSUES FOR REFERRAL

Consider neurology consult if seizures are suspected.
Referral for outpatient psychotherapy (CBT)

COMPLEMENTARY & ALTERNATIVE MEDICINE

Inositol 12 to 18 g/day may benefit those with panic disorder and, possibly, agoraphobia.
No good evidence supports the use of St. John 's wort, valerian, Sympathyl, passion flower, or cannabis in the treatment of anxiety disorders (9).

INPATIENT CONSIDERATIONS

Admission Criteria/Initial Stabilization
Monitoring/treatment may be indicated in the setting of acute suicidality/comorbid alcohol and substance abuse. ‚

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

Patient Monitoring

Outpatient, as needed for medical management
Referral for outpatient psychotherapy (CBT)

DIET

Consider the restriction of stimulants, such as caffeine, that may exacerbate anxiety. ‚

PATIENT EDUCATION

Understanding the diagnosis and treatment is important for both the patient and friends and family, who can provide a support system.
Anxiety and Depression Association of America: http://www.adaa.org/
Social Phobia/Social Anxiety Association: http://socialphobia.org
Understanding social phobia: http://www.aafp.org/afp/1999/1115/p2322.html

PROGNOSIS

Most patients will experience resolution of symptoms with appropriate treatment.
Even after successful treatment of agoraphobia and social phobia, residual symptoms/relapses may occur.

COMPLICATIONS

Avoidance behavior may lead to significant impairment in social and vocational life.
Morbidity is often more severe in agoraphobia and social phobia than in specific phobia.
Commonly overlooked comorbidity is bulimia nervosa.
Alcohol and substance abuse is common.

REFERENCES

11 Rodebaugh ‚ TL, Holaway ‚ RM, Heimberg ‚ RG. The treatment of social anxiety disorder. Clin Psychol Rev. 2004;24(7):883 " “908.22 Wolitzky-Taylor ‚ KB, Horowitz ‚ JD, Powers ‚ MB, et al. Psychological approaches in the treatment of specific phobias: a meta-analysis. Clin Psychol Rev. 2008;28(6):1021 " “1037.33 Ham ‚ P, Waters ‚ DB, Oliver ‚ MN. Treatment of panic disorder. Am Fam Physician. 2005;71(4):733 " “739.44 Schneier ‚ FR. Pharmacotherapy of social anxiety disorder. Expert Opin Pharmacother. 2011;12(4):615 " “625.55 Liebowitz ‚ MR, Mangano ‚ RM, Bradwejn ‚ J, et al. A randomized controlled trial of venlafaxine extended release in generalized social anxiety disorder. J Clin Psychiatry. 2005;66(2):238 " “247.66 Liebowitz ‚ MR, Gelenberg ‚ AJ, Munjack ‚ D. Venlafaxine extended release vs placebo and paroxetine in social anxiety disorder. Arch Gen Psychiatry. 2005;62(2):190 " “198.77 Fujii ‚ K, Uchida ‚ H, Suzuki ‚ T, et al. Dependence on benzodiazepines in patients with panic disorder: a cross-sectional study. Psychiatry Clin Neurosci. 2015;69(2):93 " “99. doi:10.1111/pcn.1220388 Petrov ‚ ME, Sawyer ‚ P, Kennedy ‚ R, et al. Benzodiazepine (BZD) use in community-dwelling older adults: longitudinal associations with mobility, functioning, and pain. Arch Gerontol Geriatr. 2014;59(2):331 " “337.99 Saeed ‚ SA, Bloch ‚ RM, Antonacci ‚ DJ. Herbal and dietary supplements for treatment of anxiety disorders. Am Fam Physician. 2007;76(4):549 " “556.

CODES

ICD10

F40.9 Phobic anxiety disorder, unspecified
F40.00 Agoraphobia, unspecified
F40.218 Other animal type phobia
F40.11 Social phobia, generalized
F40.220 Fear of thunderstorms
F40.01 Agoraphobia with panic disorder
F40.02 Agoraphobia without panic disorder
F40.10 Social phobia, unspecified
F40.210 Arachnophobia
F40.242 Fear of bridges
F40.8 Other phobic anxiety disorders
F40.291 Gynephobia
F40.298 Other specified phobia
F40.243 Fear of flying
F40.228 Other natural environment type phobia
F40.241 Acrophobia
F40.240 Claustrophobia
F40.233 Fear of injury
F40.232 Fear of other medical care
F40.231 Fear of injections and transfusions
F40.230 Fear of blood
F40.290 Androphobia

ICD9

300.20 Phobia, unspecified
300.22 Agoraphobia without mention of panic attacks
300.29 Other isolated or specific phobias
300.23 Social phobia
300.21 Agoraphobia with panic disorder

SNOMED

Phobic disorder (disorder)
Agoraphobia (disorder)
Zoophobia (finding)
Social phobia (disorder)
Agoraphobia with panic attacks
Agoraphobia without mention of panic attacks
Simple phobia

CLINICAL PEARLS

CBT is a first-line, long-term effective treatment of panic with agoraphobia and social phobia. Behavioral exposure therapies are first-line, long-term effective treatments for specific phobias.
Rule out more serious psychiatric diagnoses (especially PTSD) and underlying medical conditions.
Use of cannabis for anxiety must be identified, addressed, and treated appropriately.
Benzodiazepines quickly reduce fears associated with panic but are second-line treatment due to long-term tolerance and abuse potential. Use with caution in patients with alcoholism.

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