Phobias – Causes, Symptoms, Diagnosis, Treatment and Ongoing care
- A persistent, excessive, and unreasonable fear of an object, activity, place, or situation. Stimulus is actively avoided or endured with extreme anxiety and dread. Adolescents and adults are usually aware that their reaction is abnormal.
- To qualify as a true disorder, symptoms must cause significant distress, interfere with normal social and vocational functioning, and result in a perceived loss of freedom.
- The American Psychiatric Association (DSM-IV-TR) classifies phobias as anxiety disorders and divides them into 3 categories (1):
- Agoraphobia: Fear and avoidance of situations that may be difficult or embarrassing to escape in the event of panic-like symptoms. May involve fear of crowds, enclosed spaces (e.g., elevators, automobiles, or airplanes), or simply being alone (at home or away from home). Usually secondary to a coexisting panic disorder but may be a primary condition. See topic Panic Disorder.
- Specific phobia (formerly simple phobia):
- Fear and avoidance of clearly discernible, circumscribed objects or situations. Often divided into animal-type (e.g., snakes, spiders), environmental-type (e.g., storms, height), blood-injection/injury type, or situational-type (e.g., enclosed spaces, planes, crowds).
- Common specific phobias: Zoophobia (animals), brontophobia (thunderstorms), acrophobia (heights), nosophobia (disease), thanatophobia (death)
- Blood-injection/injury phobia associated with a strong vasovagal reaction
- Social phobia (social anxiety disorder): Fear and avoidance of certain social or performance situations where embarrassment or humiliation may occur under scrutiny of others. Individuals may experience marked anticipatory anxiety in advance of upcoming feared events.
- Anxiety may be expressed by crying, tantrums, freezing, or clinging. Fears of animals and other objects in the natural environment are common and usually transitory in childhood.
- Children are often not aware that their fear is excessive or unreasonable.
- Predominant age: Median age of onset 20 years for agoraphobia, 7 years for specific phobias, and 13 years for social phobia
- Predominant sex: Female > Male
In the general US population, the 12-month and lifetime prevalence (respectively):
- Agoraphobia without panic: 0.8% and 1.4%
- Specific phobia: 8.7% and 12.5%
- Social phobia: 6.8% and 12.1%
- Female sex
- 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.
There is some evidence of a genetic predisposition to phobias, but specific genes have not been identified.
- Still not fully understood
- When presented with social-threat stimuli, patients with social phobia exhibit a hyperactive neural and behavioral emotional response.
- Research on agoraphobia, when related to panic disorder, has focused on brain areas, including the amygdala, locus ceruleus, and hippocampus, as well as on the neurotransmitters norepinephrine, serotonin, and GABA.
- Evidence suggests a complex interplay among genetic vulnerability, development neurobiology, and environment.
- Vulnerability may lead to persistence or exaggeration of a learned response, perhaps learned initially as a protective mechanism (such as avoidance of large dogs by small children).
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.
Major finding is presence of irrational or ego-dystonic fear of a specific situation, activity, or object with associated avoidant behavior.
- Symptoms associated with exposure to phobic stimulus may include signs of sympathetic activation, pallor, dizziness, or paresthesias.
- Mental status exam should be performed.
Diagnostic Tests & Interpretation
Initial lab tests
No diagnostic laboratory tests for phobia
- Psychiatric differential diagnosis includes
- Other anxiety disorders (panic disorder, OCD, GAD, PTSD)
- Mood disorders (depression)
- Schizoid personality disorder
- Avoidant personality disorder
- Must consider underlying medical causes such as thyroid dysfunction, seizure disorder, pheochromocytoma, hypoglycemia, hyperparathyroidism, cerebrovascular disease, CNS tumors, and substance use (particularly hallucinogens and sympathomimetics).
- Differentiate phobias from appropriate fear and normal shyness. Individuals with social phobia have more symptoms and functional impairment and a lower quality of life.
Best treatment is an appropriate combination of pharmacotherapy and psychotherapy.
- Studies show effectiveness of selective serotonin reuptake inhibitors (SSRIs) for agoraphobia (2)[A] and social phobia (3)[A]:
- Citalopram (10–60 mg/d), escitalopram (10–20 mg/d), fluoxetine (20–80 mg/d), fluvoxamine (50–300 mg/d), paroxetine (10–60 mg/d), and sertraline (50–200 mg/d)
- Venlafaxine ER (75–225 mg/d divided b.i.d./t.i.d.), a serotonin-norepinephrine reuptake inhibitor (SNRI), has been shown to be as effective and well tolerated as SSRIs for social phobia (4,5)[A].
- Benzodiazepines reduce panic severity; best used in combination with other therapies (2,6)[A]:
- Also useful in treatment of social phobia (7)[A]
- Alprazolam (0.5–4 mg/d), lorazepam (2–6 mg/d), clonazepam (0.5–6 mg/d)
- Use with caution in patients with history of substance abuse. Discontinue gradually because of the risk for withdrawal seizures.
- Buspirone (15–60 mg/d), a serotonin-receptor agonist, also may be used in the treatment of social phobia; can be used to augment SSRIs.
- Treatment with these drugs should continue for 6–12 months before slowly tapering. Can be restarted if symptoms recur (2,8).
- There is no good evidence for the use of medications for specific phobias. A short-acting benzodiazepine may be helpful in treating fear of flying.
- β-Blockers decrease sympathetic stimulation. Can be used for performance anxiety.
- Choices include propranolol 10–80 mg and atenolol 30–100 mg (fewer CNS side effects).
- Monitor for hypotension and bradycardia.
- TCAs as effective as SSRIs for agoraphobia (though not as well tolerated) (9)[A]:
- Imipramine (50–300 mg/d), desipramine (75–300 mg/d), nortriptyline (60–150 mg/d), and clomipramine (25–100 mg/d)
- Anticholinergic and cardiac side effects common. Use with caution.
- Monoamine oxidase inhibitor (MAOI) phenelzine (45–90 mg/d) is effective in the treatment of social phobia but less well tolerated (7)[A]. Do not use with other antidepressants, decongestants, diet pills, meperidine (Demerol), dextromethorphan, levodopa, and sympathomimetics. Avoid tyramine in diet.
- Cognitive behavioral therapy (CBT) including exposure, cognitive restructuring, and relaxation techniques have been shown to be effective for social phobia and agoraphobia (10)[A].
- Exposure-based treatment is superior to alternative psychotherapeutic approaches and placebo in the treatment of specific phobias (11)[A].
Issues for Referral
Consider neurology consult if seizures are suspected; medicine consult if an underlying medical cause is suspected.
Complementary and Alternative Medicine
- Inositol 12–18 g/d is superior to placebo and similar to SSRIs in reducing intensity and frequency of panic attacks.
- There is no good evidence to support the use of St. John’s wort, valerian, Sympathyl, passionflower, or cannabis in the treatment of anxiety disorders (12).
- Not necessary in most cases
- Monitoring or treatment may be indicated in the setting of acute suicidality or comorbid alcohol and substance abuse.
Outpatient as needed
- Consider restriction of stimulants, such as caffeine, that can exacerbate anxiety.
- One study showed that a tryptophan-rich diet resulted in significant improvement in symptoms of social phobia (13)[B].
- If taking phenelzine or other MAOIs, a tyramine-free diet must be followed to decrease the risk of hypertensive crisis.
- Many resources are available. Understanding the diagnosis and treatment is important not only for the patient but also for friends and family, who can provide a caring support system.
- Anxiety Disorders Association of America: http://adaa.org
- The Social Phobia/Social Anxiety Association: http://socialphobia.org
- Patient education on understanding social phobia: http://www.aafp.org/afp/991115ap/991115b.html
- Most patients will experience resolution of symptoms with appropriate treatment.
- Even after successful treatment of agoraphobia and social phobia, residual symptoms or relapse may occur.
- 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.
- Alcohol and substance abuse is common.
1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders (DSM-IV-TR), 4th ed. Washington, DC: American Psychiatric Association, 2000.
2. Ham P, Waters DB, Oliver MN. Treatment of panic disorder. Am Fam Physician. 2005;71:733–9.
3. Stein DJ, Ipser JC, van Balkom AJ. Pharmacotherapy for social anxiety disorder. Cochrane Database of Systematic Reviews. 2000, Issue 4. Art. No.: CD001206. DOI:10.1002/14651858.CD001206.pub2.
4. Liebowitz MR, et al. A randomized controlled trial of venlafaxine extended release in generalized social anxiety disorder. J Clin Psychiatr. 2005;66(2):238–47.
5. Liebowitz MR, Gelenberg AJ, Munjack D. Venlafaxine extended release vs placebo and paroxetine in social anxiety disorder. Arch Gen Psychiatry.2005;62:190–8.
6. Pollack MH, Allgulander C, Bandelow B, et al. WCA recommendations for the long-term treatment of panic disorder. CNS Spectr. 2003;8:17–30.
7. Blanco C, et al. Pharmacological treatment of social anxiety disorder: A meta-analysis. Depression Anxiety. 2003;18(1):29–40.
8. Van Ameringen M, Allgulander C, Bandelow B, et al. WCA recommendations for the long-term treatment of social phobia. CNS Spectr. 2003;8:40–52.
9. Bakker A, van Balkom AJ, Spinhoven P. SSRIs vs. TCAs in the treatment of panic disorder: a meta-analysis. Acta Psychiatr Scand. 2002;106:163–7.
10. Rodebaugh TL, Holaway RM, Heimberg RG. The treatment of social anxiety disorder. Clin Psychol Rev. 2004;24:883–908.
11. Wolitzky-Taylor KB, Horowitz JD, Powers MB, et al. Psychological approaches in the treatment of specific phobias: A meta-analysis. Clin Psychol Rev. 2008.
12. Saeed SA, Bloch RM, Antonacci DJ. Herbal and dietary supplements for treatment of anxiety disorders. Am Fam Physician. 2007;76:549–56.
13. Hudson C, Hudson S, MacKenzie J. Protein-source tryptophan as an efficacious treatment for social anxiety disorder: a pilot study. Can J Physiol Pharmacol.2007;85:928–32.
See Also (Topic, Algorithm, Electronic Media Element)
Anxiety; Depression; Dissociative Disorders; Obsessive-compulsive Disorder; Post-Traumatic Stress Disorder (PTSD); Schizophrenia
- 300.20 Phobia, unspecified
- 300.21 Agoraphobia with panic disorder
- 300.22 Agoraphobia without mention of panic attacks
- 300.23 Social phobia
- 300.29 Other isolated or specific phobias
- 54587008 simple phobia (disorder)
- 191722009 agoraphobia with panic attacks (disorder)
- 191723004 agoraphobia without mention of panic attacks (disorder)
- 25501002 social phobia (disorder)
- 386808001 phobia (finding)
- Phobias are common, potentially debilitating, but treatable conditions.
- Must rule out more serious psychiatric diagnoses and underlying medical conditions.
- Treatment consists of an appropriate combination of psychotherapy and medication and is usually effective. Relapse and/or symptom persistence is common in social phobia and agraphobia.