Phobias are intense fears to specific objects/situations that are triggered upon exposure or anticipated exposure to the phobic stimulus. People tend to avoid situations where phobias are present, or they are endured with intense anxiety. The excessive fear can cause functional impairments and difficulties in lifestyle.
They are some of the most common and fortunately some of the most treatable psychiatric disorders.
Pathophysiology
Hyperactivity of the amygdala, anterior cingulate cortex and insula are behind the development of phobias. The amygdala secretes hormones that control fear and aggression and does not stop secreting them until the stimulus is removed. When presented with a benign stimulus afterwards, there may be a hyperactive response transiently before realising that this is not the phobic stimulus. For example, patients with arachnophobia presented with a picture of a spider develop a fear a response, but when presented with a picture of a snake they also feel this response transiently before returning to their normal state. Some phobic stimuli include:
- Animals - e.g. arachnophobia
- Situational - lifts, flying, open spaces (agoraphobia), enclosed spaces (claustrophobia)
- Natural environment - heights, storms, water.
- Blood, injections, injury - aichmophobia is the fear of sharp objects
- Other - choking, vomiting and clowns.
Let’s discuss some of these further…
Agoraphobia is the fear of open spaces and the related components (such as the presence of crowds). It may also be considered as the fear of leaving one’s home (a place of comfort) as it may be difficult to return to this comfortable, safe environment easily (i.e. no escape route).
It occurs in 20’s - 30’s most frequently. It may be gradual or may manifest as a sudden panic attack.
Commonly there is co-morbid depression and sexual problems.
ICD-11 criteria states that these are phobias to highly specific situations (spiders, heights, thunder, flying, blood etc.). They most commonly present in youth and resolve in early adulthood.
Patients tend to have avoidance behaviours towards these stimuli. Exposure to the stimuli may lead to bradycardia, hypotension and syncope upon exposure.
Severity depends on the affect on their quality of life. For example, a pilot who has a fear of flying, or a surgeon with haemophobia may impact their life significantly.
It is important to exclude co-morbid depression in these individuals.
This is the most common anxiety disorder. It is also known as social anxiety disorder.
ICD-11 states that it is the fear of scrutiny by other people in comparatively small groups (5-6 people) → avoidance of social situations. They are generally comfortable with 1-2 people, but struggle when there are more people.
This may present as a generalised social anxiety (any social setting) or it may manifest as difficulty in certain situations, for example with public speaking.
It may be precipitated by stressful, humiliating experiences; death of a parent; separation; chronic stress. There also may be a component of genetic susceptibility.
😷 Presentation
- Blushing
- Palpitations
- Trembling
In social phobia there is fear and not simply shyness.
- Sweating
- Fear of vomiting
During a mental state examination, they may seem relaxed as the phobic stimulus is not present.
😷 Presentation
- Behavioural avoidance
- Anticipatory anxiety - catastrophic thoughts and fears of being unable to cope.
- Nausea
- Dizziness
- Tachycardia
- Bradycardia, hypotension, syncope - with exposure to phobic stimulus.
- Hyperventilation
- Disgust
🔍 Investigations
- History and mental state examination.
- We can rate the patient on the scales of anxiety: Beck Anxiety Inventory and the Hospital anxiety and depression scale (HAD).
- Social and occupational assessments - to assess the effect on their quality of life
🧰 Management
- 🥇 Cognitive behavioural therapy - first-line management of choice.
- Exposure techniques - these aim to desensitise the individual form their phobia.
- Flooding - direct exposure to the phobic stimulus (e.g. taking a person with fear of heights to a tower).
- Modelling - observing therapist engaging with the phobic stimulus.
- Pharmacological therapies may also be tried:
- 🥈 SSRIs and MAOIs - these are 2nd line after CBT for agoraphobia.
- TCAs - useful if there is a depressive component.
- BDZs - can be effective to calm the individual prior to phobic exposure.
- ß-blockers - can also be useful prior to phobic exposure.
Obsessive compulsive disorder (OCD) is the disorder characterised by having obsessions (intrusive thoughts or urges that may be overt or covert [repeating a phrase in one’s mind]) and/or compulsions (repetitive behaviours that you feel driven to perform). They can be time consuming and cause significant distress and social impairment.
Approximately 1-3% of the population have OCD.
⚠️ Risk factors
- Family history
- Age - peak onset is 10-20 years old.
- Pregnancy/post-natal period
- History of abuse, bullying and neglect
- Male sex
😷 Presentation
- Obsessions - common obsessions include fear of contamination, need for symmetry and exactness, fear of causing harm to someone, sexual obsessions, religious obsessions, fear of behaving unacceptably, fear of making mistakes.
- Compulsions - cleaning, hand washing, checking, ordering and arranging, hoarding, seeking reassurance from others.
- Mental compulsions include counting, repeating words silently, ruminating, neutralising thoughts.
- Sensory phenomena - uncomfortable feelings, including bodily sensations, sense of inner tension, “just-right” perceptions, feelings of incompleteness which have been described to precede, trigger or accompany repetitive behaviours in individuals with OCD.
🔍 Investigations
Diagnosis in a clinical setting is determined through unstructured clinical interviewing with DSM-5-TR criteria:
- Presence of obsessions, compulsions or both
- Obsessions/compulsions are time consuming or cause clinically significant distress or impairment in social, occupational or other important areas of functioning.
- The obsessive-compulsive symptoms are not attributable to the physiological effects of a substance
- The disturbance is not better explained by the symptoms of another mental disorder.
🔢 Classification
NICE recommends classifying the level of impairment using the Yale-Brown Obsessive Compulsive scale:
- 0 - 7: subclinical/asymptomatic
- 8 - 15: mild symptoms
- 16 - 23: moderate symptoms
- 24 - 31: severe symptoms
- 32 - 40: extremely severe
🧰 Management
Mild functional impairment
- Low-intensity CBT + exposure and response prevention (ERP)
- ERP involves exposing a patient to an anxiety provoking situation and stopping them from engaging in their safety behaviours (e.g dirtying someone with OCD’s hands and not allowing them to wash it). It helps them confront their anxiety and the habituations leads to extinction of the safety response.
- If insufficient → SSRI or more intensive CBT + ERP
Moderate functional impairment
- SSRI or more intensive CBT + ERP
- Clomipramine (a TCA) may be used and alternative first-line drug treatment to SSRIs if they have used it before and benefitted or are contraindicated from SSRIs.
Severe functional impairment
- Refer to secondary care mental health team for assessment
- Offer combination SSRI + CBT with ERP while waiting assessment.
Panic disorders are characterised by recurring, unexpected panic attacks over a 1 month period. Individuals with panic disorder are always concerned about having another panic attack and/or about the consequences of another attack. They may also change their behaviour in an attempt to avoid panic attacks (avoidance behaviours and safety-related behaviours).
🏘️ Epidemiology
It affects 1-2% of the population.
It is 2-3x more common in females.
Bimodal peak incidence - 20 years old and again at 50 years old.
30-50% of patients have associated agoraphobia.
If they have co-morbid depression, alcohol misuse or substance misuse, their risk of attempted suicide increases.
⚠️ Risk factors
- Family history
- Female sex
- Comorbid anxiety, mood disorders and substance-use disorders
- Major life events - seen in 80% of patients
- Asthma
- Smoking
- Caffeine
- Stress
😷 Presentation
- Breathing difficulties
- Chest discomfort
- Palpitations
- Nausea and vomiting
- Tingling or numbness in hands, feet or around mouth
- Shaking, sweating and dizziness
- Depersonalisation/derealisation
- Fear
🔍 Investigations
It is a clinical diagnosis. Self-reporting, clinical interview and behavioural observations are sufficient to establish the diagnosis.
🧰 Management
Reassuring and educating the patient is very important.
- Step 1 - recognition and diagnosis.
- Step 2 - treatment in primary care
- 🥇 NICE recommends CBT OR SSRIs. CBT is preferred over SSRIs as only 50-60% have remission with medication while 80-100% remit with CBT.
- Clomipramine or imipramine are alternative first-line options if SSRIs are contraindicated.
- Step 3 - review and consider alternative treatments.
- Step 4 - review and refer to specialist mental health services.
- Step 5 - treatment in specialist mental health services.