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Phobias

by Helen Farrell, MD
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    00:01 Now, let’s talk about phobias, starting with this case example of Sam.

    00:08 Sam is a 28-year-old sales representative who’s been terrified of animals since she was a child.

    00:16 That didn’t cause many problems before because her family opted not to have pets, and Sam preferred to play indoors.

    00:24 But now that she’s an adult, Sam is working in sales, and her job requires extensive travel.

    00:30 She was on a plane once which needed to make an emergency landing after going through significant turbulence.

    00:37 And now, she’s terrified of flying Not only that but she’s struggling in her job because she doesn’t like to eat in front of other people.

    00:45 This is a problem because many of her business deals are done over lunches or dinners.

    00:50 And although Sam is very engaging on an individual basis, she often finds ways to avoid giving any speeches or presentations to large audiences because she’s afraid of embarrassing herself.

    01:03 Keeping that case example in mind, let’s think about what is a phobia.

    01:07 Sam has a lot going on, and let’s start by defining phobia.

    01:11 So it’s an irrational fear that leads to an avoidance of the fear to object or situation.

    01:19 There are different types of phobias, specific phobias and social phobias.

    01:25 Here is an important point.

    01:27 Specific phobias involve a fear of objects or things, while social phobias involve the fear of embarrassing oneself in public.

    01:37 So, how would you define a specific phobia? Well, it’s an anxiety disorder characterized by clinically significant fear of a particular object or situation that leads to avoidant behavior.

    01:51 Now, how would you define social phobia? It’s the feared situation as related to social settings in which the patient might be embarrassed or humiliated in front of other people.

    02:03 And again, some common examples of social phobia include public speaking, eating in public, and using a public restroom.

    02:13 Phobias are the most common mental disorders.

    02:16 At least 5% to 10% of the U.S. population is affected.

    02:21 And specific phobias occur far more frequently than social phobias.

    02:26 The age of onset -- the range is huge, it’s 5 to 35, but the average age of onset is in the mid teens.

    02:33 Females are affected more often than males.

    02:37 Now, an important note about the epidemiology of phobias, the age of onset depends on the type of phobia.

    02:44 For example, animal and blood injection injury phobias are much more likely to occur in childhood, whereas situational or natural environmental phobias tend to occur in late adolescents or even adulthood.

    02:59 Phobias can also be induced by traumatic events that can occur throughout one’s life.

    03:06 The development of a specific phobia is influenced by a complex interaction of biological, psychological, and social and environmental factors.

    03:17 Let’s go through them one by one.

    03:19 When it comes to genetics, how do specific phobias run in families? Well, we tend to think that they aggregate in families.

    03:28 First-degree relatives of individuals with specific phobias have an increased risk all the way up to close to 31%.

    03:36 This may be associated with an inherited exaggerated vasovagal response.

    03:42 And first-degree relatives of patients with social phobias are also more likely to develop that disorder.

    03:48 So behaviorally, what triggers phobias? Well, often, traumatic events.

    03:54 And neurobiologically speaking, what parts of the brain are connected with phobias? It’s specific neuroanatomical pathways, things including the hyper activation of the amygdala and insula, structures involved in negative emotional responses.

    04:13 When it comes to personality, what are the traits that affect development of phobias? There’s something called disgust sensitivity.

    04:22 This is the tendency to experience disgust in response to certain stimuli, a developmental factor for certain animal and blood injection injury phobias.

    04:33 There’s also anxiety sensitivity that some people experience.

    04:37 This is a dispositional variable reflecting beliefs that the physical sensations of anxiety are somehow harmful.

    04:45 And it has also been found to be elevated in specific phobia, particularly in situational types.

    04:52 When it comes to cognition, how does the cognitive factor affects phobias? There’s an attentional bias to threat-related information, and perceptual and cognitive distortions are consistent within one’s phobia.

    05:08 What social or environmental factors affect phobias? The answer is the context of a traumatic event, stress at the time of the event, previous and subsequent exposure to a phobic stimulus, and one’s level of support.

    05:27 And when it comes to the evolutionary pathway, what types of fears are there? Well, fears may be innate, such as a fear of scorpions, snakes, or heights, or they can be biologically predetermined.

    05:42 When it comes to the assessment, you want to consider what are some specifiers for phobias.

    05:48 There are animal types: spiders, insects, dogs.

    05:52 There’s natural environmental: things like heights, storms, water.

    05:57 Blood-injection injury is another type, such as needles or invasive medical procedures.

    06:04 Situational subtypes, things like being on an airplane or elevator or being inside the enclosed space.

    06:12 Other types are situations that could lead to choking, vomiting, loud noises, and even seeing costumed characters.

    06:22 So, going back to our case study, consider Sam, and she’s had a lot of issues and fears going on since she was a young child, all the way through her adulthood into her career.

    06:33 So, what types of phobias do you think Sam has been exhibiting? There are a few, right? So Sam has both specific and social phobias.

    06:43 She’s afraid of animals and flying.

    06:46 In addition, she has fears of public speaking and also eating in front of others for fear that she will embarrass herself.

    06:55 What co-morbidities is Sam at risk for developing? So, what other disorders could she develop here along with her phobias? Well, she’s at risk for a few things; agoraphobia, OCD, PTSD, and separation anxiety disorder.

    07:13 You want to be sure to also screen her for an eating disorder as many people with fears of eating in public will later go on to develop some maladaptive eating behaviors that can lead to its own disorder.

    07:26 Let’s define these one by one now.

    07:29 So agoraphobia, that’s anxiety in situations where the person perceives the environment to be unsafe, where there’s no easy way to get out.

    07:39 So this often comes up in open public market spaces, public transportation, during times when somebody is at shopping malls, and it can be very debilitating.

    07:52 How about OCD? This is a psychiatric disorder in which patients have recurrent intrusive thoughts or obsessions that increase anxiety and are relieved by performing standardized behaviors or compulsive acts.

    08:09 Well, what’s separation anxiety disorder? This is a condition in which an individual becomes fearful and nervous when away from home or separated from a loved one.

    08:21 And how about PTSD? That’s an anxiety disorder that is the response to a life-threatening event in which an individual re-experiences the trauma, avoids places, and experiences numbing or hyperarousal.

    08:41 When it comes to diagnosing and assessing phobia, patient must meet all of the following criteria.

    08:47 So they have a marked fear of anxiety about a specific object or situation.

    08:53 The phobic object or situation almost always provokes an immediate fear or anxiety.

    09:00 And the phobic object or situation is actively avoided or endured but with intense fear and anxiety.

    09:08 The fear or anxiety is out of proportion to the actual danger posed by the specific object or situation.

    09:16 The fear, anxiety, or avoidance is persistent and it can last for typically, six months or even longer.

    09:24 The fear, anxiety, or avoidance causes clinical distress and impairment in day to day functioning.

    09:32 And other medical and psychiatric conditions have been ruled out before diagnosing a phobia.

    09:40 It’s important to consider the socio-cultural context of an individual when assessing for a phobic disorder.

    09:49 Now, how would you treat phobias? Let’s start with specific phobia.

    09:54 The prognosis is actually excellent with exposure-based treatment.

    09:59 Medication is actually not useful here.

    10:02 Instead, systematic desensitization along with supportive therapy is useful.

    10:08 This gradually exposes the patient to a fear to object or situation while teaching them relaxation and breathing techniques so they can manage their anxieties as they arise.

    10:20 Social phobias, actually, are treated with medication.

    10:24 SSRIs, such as paroxetine are FDA approved for the treatment of social anxiety disorder.

    10:32 Beta-blockers can also be very helpful in controlling symptoms of performance anxiety.

    10:38 And also, therapy is useful.

    10:40 Cognitive and behavioral therapies are very useful in addition to medication.

    10:46 So, what would your treatment approach for Sam be? Well, probably multi-fold.

    10:51 You might address her specific phobia by targeting that specific phobia with a non-pharmacological approach offering her gradual exposure.

    11:00 For example, showing her pictures, of flying, of animals, maybe going to the movies where she’ll watch some of these things.

    11:08 And then when it comes to her fear of flying, maybe take her to an airport; send her off on a short flight.

    11:14 And when it comes to her fear of dogs, you might actually introduce her to a small puppy, and then later, invite her to go to a dog park.

    11:23 When it comes to her social phobias, this might require a more invasive approach including treatment with an SSRI or beta-blocker, so you can reduce some of the somatic symptoms such as heart racing and so forth, and then in addition, offer some therapy to her.

    11:40 This concludes our overview of phobias both specific and social phobia.

    11:44 You now should have an awareness of how to assess, diagnose, and manage these disorders as they arise.


    About the Lecture

    The lecture Phobias by Helen Farrell, MD is from the course Major Psychiatric Disorders. It contains the following chapters:

    • Types of Phobias
    • Different Factors thate Lead to Phobias
    • Co-morbidities
    • Diagnosis of Phobia

    Included Quiz Questions

    1. An irrational fear that leads to avoidance of the feared object or situation.
    2. An irresistible urge to move the legs typically in the evenings.
    3. A state of heightened overall activation with enhanced affective expression.
    4. Repetitive intrusive thoughts or images causing distress.
    5. Sudden short-lasting movements or sounds during an otherwise normal behavior.
    1. Social phobias are far more frequently seen than specific phobias.
    2. At least 5-10% of the US population is affected.
    3. Phobias are the most common mental disorders.
    4. Average age of onset is in the mid-teens.
    5. Females are more commonly affected than males.
    1. The occipital lobe is involved in the development of phobias.
    2. Specific phobias aggregate in families.
    3. First degree relatives of the patients with social phobias are more likely to develop the disorder.
    4. Traumatic events can trigger phobias in some patients.
    5. Fears can be innate and biologically determined.
    1. Anxiety sensitivity
    2. Disgust sensitivity
    3. Mistrust sensitivity
    4. Social sensitivity
    5. Positional sensitivity
    1. Fear of getting separated from a loved one or home.
    2. Fear of open spaces, public places, or simply being outside home.
    3. Fear of life threatening events.
    4. Fear of heights.
    5. Fear of stage performance.
    1. SSRIs
    2. Exposure based treatment
    3. Systemic desensitization
    4. Relaxation techniques
    5. Breathing techniques

    Author of lecture Phobias

     Helen Farrell, MD

    Helen Farrell, MD


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