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Background: A phobia is defined as an irrational fear that produces a conscious avoidance of the
feared subject, activity, or situation. The affected person usually recognizes that the reaction is
excessive. Phobic disorders can be divided into 3 types: specific phobias, social phobia, and
agoraphobia.

The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition (DSM-IV) defines specific phobia as a strong, persisting fear of an object or situation,
whereas social phobia is a strong, persisting fear of an interpersonal situation in which embarrassment
can occur. Agoraphobia is defined as the fear of being alone in public places (eg, a supermarket),
particularly places from which a rapid exit would be difficult in the course of a panic attack. At least
75% of patients with agoraphobia experience panic disorder as well. Specific phobia is more common
than social phobia. Examples of specific phobia include animal type, natural environment type (eg,
height, water, storm), blood injection/injury type, situational type (eg, planes, elevators, enclosed
spaces), and other types.

• In the US: Occurrence of phobias as a whole is as follows: Prevalence of 1 month is 6.2%.

Prevalence of 6 months is 7.7%. Lifetime rate is 12.5%. Occurrence of phobia by type is as follows:
Specific phobia has a 6-month prevalence of 4.5-11.8%. Social phobia has a lifetime prevalence of 1.9-
3.2%. Agoraphobia has a lifetime prevalence of 2.5-6.5%.

• Internationally: European data generally are similar to those of the United States.

Sex:

• Specific phobia has a female-to-male ratio of 2:1.

• Social phobia is more common in women, but more men seek treatment due to career issues.

• Agoraphobia has a female-to-male ratio of 2-3:1.

Age: Most anxiety disorders appear earlier in life. Animal phobias are most common at the elementary
school level. Other phobias appear later on. Agoraphobia and social phobia tend to reach a peak
prevalence in later adolescence or early adulthood. Age of onset depends on the phobia.

The physician will want to question the patient about any difficulties in social situations, such as
speaking in public, eating in a restaurant, or using public washrooms. Fear of scrutiny by others or of
being embarrassed or humiliated is described most commonly by people with social phobia.
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Furthermore, inquire about any intense anxiety reactions that occur when the patient is exposed to
specific situations such as heights, animals, small spaces, or storms. Other areas of inquiry include fear
of being trapped without escape (eg, being outside the home and alone; in a crowd of unfamiliar people;
on a bridge, in a tunnel, in a moving vehicle [agoraphobia]).

Phobias can cause emotional distress, leading to other anxiety disorders, major depressive
disorders, and substance-related disorders, especially alcohol use disorder. The physician must inquire
about these areas as well.
Specific phobia

(слайд 2) In general, specific phobia appears earlier than social phobia or agoraphobia. Examples include
the following: Animal phobia appears at a mean age of 7 years. Blood phobia appears at a mean age of 9
years. Dental phobia appears at a mean age of 12 years. Claustrophobia appears at a mean age of 20 years.

Specific phobia can be acquired by conditioning, modeling, traumatic experience, or even may have a
genetic component (eg, blood-injury phobia).

Specific phobia usually responds to behavioral therapy treatment. No controlled studies to date
demonstrate the efficacy of psychopharmacological intervention. Gradual desensitization is the most
commonly used treatment for specific phobia. Other treatments include cognitive approaches, relaxation,
and breathing control techniques.

Agoraphobia

Agoraphobia usually begins in late adolescence to early adulthood.

Agoraphobia may be the result of repeated, unexpected panic attacks, which, in turn, may be linked
to cognitive distortions, conditioned responses, and/or abnormalities in noradrenergic, serotonergic, or
gamma-aminobutyric acid (GABA)–related neurotransmission.

Agoraphobia, specifically the panic attacks that usually occur, most often responds to treatment with
a selective serotonin reuptake inhibitor (SSRI). Tricyclic antidepressants (TCAs) and monamine oxidase
inhibitors (MAOIs) also have demonstrated efficacy in controlled trials. Benzodiazepines can be used either
as an adjunct or as primary treatment. However, benzodiazepines usually are not chosen as a first-line
treatment because of the potential for abuse, particularly if a previous history of substance dependence
exists. Another effective form of treatment for panic disorder and agoraphobia is cognitive behavioral
therapy. Family and group therapy also help.
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Social phobia

Most social phobias begin before age 20 years.

Social phobia can be initiated by traumatic social experience (eg, embarrassment) or by social skills deficits
that produce recurring negative experiences. A hypersensitivity to rejection, perhaps related to serotonergic
or dopaminergic dysfunction, is present. Current thought is that social phobia appears to be an interaction
between biological and genetic factors and environmental events.

Both pharmacotherapy and psychotherapy are useful in treating social phobia. Social phobia
typically responds to either an SSRI or an MAOI. Failing this, patients sometimes respond to high-potency
benzodiazepines. Beta-blockers, clonidine, and buspirone usually are not helpful for long-term treatment,
although beta-blockers (eg, propranolol) may be useful for the circumscribed treatment of performance
anxiety on a prn basis.

Further Outpatient Care:

• Outpatient follow-up usually is needed through resolution of symptoms. After symptoms are
resolved, physician can (1) attempt a taper of medication and therapy and (2) monitor for relapse.

In/Out Patient Meds:

• Continue medication regimen for at least 6-12 months.

• If symptoms have resolved and the patient is not experiencing excessive stress, the physician can
taper the patient off medication gradually.

• Psychotherapy usually helps make the transition off medication more successful.

(слайд 3) Prognosis:

• Most patients respond to treatment, with good resolution of symptoms.

• Patients with specific phobia often recover to the highest level of functioning, while agoraphobics or
social phobics either may have residual symptoms or run a greater risk of relapse even after successful
treatment.

• Social phobics with extensive deficits in social skills may not respond well to treatment.