SPECIFIC PHOBIAS/PHOBIAS- DR. GEETANJALI PAREEK
SPECIFIC PHOBIA
The
term phobia refers to an excessive fear of a
specific object, circumstance, or a situation. The diagnosis of specific phobia
requires the development of intense anxiety, to the point of being panic, when
exposed to the feared object. Persons with specific phobias anticipate harm,
such as being bitten by a dog, or might panic at the thought of losing control;
for instance, being in an elevator, they might also worry about getting
unconscious/fainting after the door closes.
Example
is Mr. X who was fearful of seeing any red object on the road/street on seeing
it he would scared and stand there and start praying especially, Hauman Chalisa
to ward of any negative energy associated with it. Because of this he would
reach his office late and would often get scold from his boss. His thoughts
were associated with intense fear and numerous somatic symptoms, including a
racing heart, nausea, and sweating etc. He understood the effect his phobia was
having on his personal, social and vocational life. But he was unable to get
rid of his fears.
EPIDEMIOLOGY
According
to DSM-5 the 12-month prevalence rate for
specific phobia in the United States, is approximately 7 to 9%. Prevalence
rates in European countries is about 6%, however rates are generally lower in
Asian, African, and Latin American countries i.e. 2 to 4%.
Prevalence
rates in children are approximately 5% and for adolescents it is approximately
16%. Prevalence rates are lower in older individuals (about 3 to 5%), possibly
reflecting diminishing severity to subclinical levels. Females are more
frequently affected than males, at a rate of approximately 2:1, although rates
vary across different phobic stimuli. That is, animal, natural environment, and
situational specific phobias are predominantly experienced by females, whereas
blood-injection-injury phobia is experienced nearly equally by both genders.
The
peak age of onset for the natural environment
type phobia and the blood-injection-injury
type is in the range of 5 to 9 years, although onset also occurs at older ages.
In contrast, the peak age of onset for the situational type (except fear of
heights) is higher, in the mid-20s, which is closer to the age of onset for agoraphobia. The feared objects and situations in
specific phobias (in descending frequency of appearance) are:
·
animals,
·
storms,
·
heights,
·
illness,
·
injury and
·
death.
COMORBIDITY
Reports
of comorbidity in specific phobia range from 50 to
80 percent and include anxiety, mood, and substance-related disorders.
ETIOLOGY
General
Principles of Phobias
1.
BEHAVIOURAL FACTORS:
In 1920, John
B. Watson wrote an article called “Conditioned Emotional Reactions,” in which
he recounted his experiences with Little Albert, an infant with a fear of rats
and rabbits. Little Albert’s fear of rats and rabbits was the direct consequence
of the scientific experiments conducted on him by two psychologists, to induce
conditioned responses in him. Unlike Freud’s case of Little Hans, who had phobic
symptoms (of horses) during natural course of his maturation. Watson’s hypothesized
the traditional pavlovian stimulus–response model to account for the creation
of the phobia.
Operant
conditioning theory provides a model to explain this phenomenon, according to
which anxiety is a drive that motivates
the organism to do whatever it can to avert a painful affect. In the
course of its random behaviour, the organism learns that certain actions enable
it to avoid the anxiety-provoking stimulus. These avoidance patterns remain stable
for long periods as a result of the reinforcement they receive from their
capacity to diminish anxiety. This model is readily applicable to phobias in
that avoidance of the anxiety provoking object or situation plays a central
part.
2.
PSYCHOANALYTIC FACTORS:
Freud
hypothesized that the major function of anxiety is to signal the ego that a
forbidden unconscious drive is pushing for conscious expression and to alert
the ego to strengthen and organize its defenses against the threatening
instinctual force. Freud viewed the phobia-anxiety hysteria
(as he called it) as a result of conflicts centered on an unresolved childhood oedipal
situation. Because sex drives continue to have a strong incestuous colouring in
adults, sexual arousal can kindle an anxiety that is characteristically a fear of
castration. When repression fails to be entirely successful, the ego must call
on auxiliary defenses. In patients with phobias, the primary defense involved
is displacement;
that is, the sexual conflict is displaced from the person who evokes the conflict
to a seemingly unimportant, irrelevant object or situation, which then has the power
to arouse a constellation of affects, one of which is called signal anxiety.
The phobic object or situation may have a direct associative connection with
the primary source of the conflict and thus symbolizes it. Furthermore, the
situation or the object is usually one that the person can avoid; with the
additional defense mechanism of avoidance, the person can escape suffering
serious anxiety. The end result is that the three combined defenses (repression,
displacement, and symbolization) may eliminate the anxiety. However the
anxiety is controlled at the cost of creating a phobic
neurosis. Psychiatrists who followed Freud’s thought that phobias
resulted from castration anxiety. However recent psychoanalytic theorists have
suggested that other types of anxiety may also be involved, for e.g. in
agoraphobia, separation anxiety clearly plays a leading role, and in
erythrophobia (a fear of red that can be manifested as a fear of blushing), the
element of shame implies the involvement of superego anxiety. Clinical
observations have led to the view that anxiety associated with phobias has a
variety of sources and colourings.
3.
GENETIC FACTORS.
Specific phobia tends to run in families for e.g. the injury blood-injection type
has a particularly high familial tendency. Studies have reported that two-thirds
to three-fourths of affected people have at least one first-degree relative
with specific phobia of the same type.
DIAGNOSIS
The
DSM-5 includes 5 distinctive types of specific phobia:
1.
Animal type,
2.
Natural environment
type (e.g., storms),
3.
Blood-injection-injury
type (e.g., needles),
4.
Situational type
(e.g., cars, elevators, planes),
5.
and other type
(for specific phobias that do not fit into the previous four types).
The
key feature of each type of phobia is that fear symptoms occur only in the
presence of a specific object. The blood injection-injury
type is differentiated from the others in that bradycardia
and hypotension often follow the initial tachycardia that is common to all phobias. The blood-injection-injury
type of specific phobia is particularly likely to affect many members and
generations of a family. One type of phobia of recently reported phobia is space phobia, in which persons fear falling when
there is no nearby support, such as a wall or a chair. Some data indicate that
affected persons may have abnormal right hemisphere
function, possibly resulting in visual-spatial
impairment. Balance disorders should be ruled out in such patients.
Phobias
have traditionally been classified according to specific fear by means of Greek
or Latin prefixes, like:
·
Acrophobia-Fear
of heights
·
Cynophobia-
Fear of Dogs
·
Pyrophobia-
Fear of Fire, etc.
Other phobias that are related to changes in
the society are the fear of electromagnetic fields, of microwaves, and of
society as a whole (amaxophobia).
CLINICAL
FEATURES
Phobias
are characterized by the arousal of severe anxiety when patients are exposed to
specific situations or objects or when patients even anticipate exposure to the
situations or objects. Exposure to the phobic stimulus or anticipation of it almost
invariably results in a panic attack in a person who is susceptible to them.
Persons
with phobias, by definition, try to avoid the phobic stimulus; some go to great
trouble to avoid anxiety-provoking situations. Perhaps as another way to avoid
the stress of the phobic stimulus, many patients have substance-related
disorders, particularly alcohol use disorders. Moreover, an estimated one-third
of patients with social phobia have major depressive disorder.
The
major finding on the mental status examination
is the presence of an irrational and ego-dystonic fear of a specific situation,
activity, or object; patients are able to describe how they avoid contact with
the phobia. Depression is commonly found on the mental status examination and
may be present in as many as one-third of
all patients with phobia.
Diagnostic
Criteria according to DSM-5
A.
Marked fear or anxiety about a specific object or situation (e.g., flying,
heights, animals, receiving an injection, seeing blood).
Note:
In children, the fear or anxiety may be expressed by crying, tantrums,
freezing, or clinging.
B.
The phobic object or situation almost always provokes immediate fear or
anxiety.
C.
The phobic object or situation is actively avoided or endured with intense fear
or anxiety.
D.
The fear or anxiety is out of proportion to the actual danger posed by the
specific object or situation and to the sociocultural context.
E.
The fear, anxiety, or avoidance is persistent, typically lasting for 6 months
or more.
F.
The fear, anxiety, or avoidance causes clinically significant distress or
impairment in social, occupational, or other important areas of functioning.
G.
The disturbance is not better explained by the symptoms of another mental
disorder, including fear, anxiety, and avoidance of situations associated with
panic-like symptoms or other incapacitating symptoms (as in agoraphobia):
objects or situations related to obsessions (as in obsessive-compulsive
disorder); reminders of traumatic events (as in posttraumatic stress disorder);
separation from home or attachment figures (as in separation anxiety disorder);
or social situations (as in social anxiety disorder).
SPECIFIERS
It
is common to have multiple specific phobias. The average individual with specific
phobia fears three objects or situations, and approximately 75% of individuals with specific phobia fear more
than one situation or object. In such cases, multiple specific phobia diagnoses,
each with its own diagnostic code reflecting the phobic stimulus, would need to
be given. For example, if an individual fears thunderstorms and flying, then
two diagnoses would be given: specific phobia, natural environment, and
specific phobia, situational.
DIFFERENTIAL
DIAGNOSIS
Non
psychiatric medical conditions that can result in the development of a phobia include
the use
of substances (particularly hallucinogens and sympathomimetics), CNS tumors, and cerebrovascular
diseases. Phobic symptoms in these instances are unlikely in the absence
of additional suggestive findings on physical, neurological, and mental status
examinations. Schizophrenia is also in the
differential diagnosis of specific phobia because patients with schizophrenia
can have phobic symptoms as part of their psychoses. Unlike patients with
schizophrenia, however, patients with phobia have insight into the
irrationality of their fears and lack the bizarre quality and other psychotic
symptoms that accompany schizophrenia.
In
the differential diagnosis of specific phobia, clinicians must consider panic disorder, agoraphobia, and avoidant personality
disorder. In general, however, patients with specific phobia tend to
experience anxiety immediately when presented with the phobic stimulus.
Furthermore, the anxiety or panic is limited to the identified situation;
patients are not abnormally anxious when they are neither confronted with the
phobic stimulus nor caused to anticipate the stimulus.
Other
diagnoses to consider in the differential diagnosis of specific phobia are hypochondriasis, OCD, and paranoid personality disorder.
Whereas hypochondriasis is the fear of
having a disease, specific phobia of the illness type is the fear of
contracting the disease. Some patients with OCD manifest
behaviour indistinguishable from that of a patient with specific phobia. For
example, whereas patients with OCD may avoid knives because they have
compulsive thoughts about killing their children or any person in general,
patients with specific phobia about knives may avoid them for fear of cutting
themselves. Patients with paranoid personality
disorder have generalized fear that distinguishes them from those with
specific phobia.
COURSE
AND PROGNOSIS
A. DEVELOPMENT AND COURSE
Specific
phobia exhibits a bimodal age of onset, with
a
1.
Childhood
peak for animal phobia, natural environment phobia, and blood-injection-injury
phobia and
2.
Early
adulthood peak for other phobias, such as
situational phobia.
Specific
phobia sometimes develops:
1.
Following a
traumatic event (e.g., being attacked by an animal or stuck in an elevator),
2.
Observation of
others going through a traumatic event (e.g., watching someone drown),
3.
An unexpected
panic attack in the, to be feared situation (e.g., an unexpected panic attack
while on the subway),
4.
Informational
transmission (e.g., extensive media coverage of a plane crash).
5.
However, many
individuals with specific phobia are unable to recall the specific reason for
the onset of their phobias.
Specific
phobia usually develops in early childhood, with the majority of cases
developing prior to age 10 years.
Situational
specific phobias tend to have a later age of onset than, natural environment,
animal, or blood-injection-injury specific phobias. Specific phobias that
develop in childhood and adolescence are likely to wax and wane during that
period. However, phobias that do persist into adulthood are unlikely to remit
for the majority of individuals.
Although
the prevalence of specific phobia is lower in older populations, it remains one
of the more commonly experienced, disorders in late life. Several issues should
be considered when diagnosing specific phobia in older populations.
1.
Older individuals
may be more likely to endorse natural environment specific phobias, as well as
phobias of falling.
2.
Specific phobia
(like all anxiety disorders) tends to co-occur with medical concerns in older
individuals, including coronary heart disease and chronic obstructive pulmonary
disease.
3.
Older individuals
may be more likely to attribute the symptoms of anxiety to medical conditions.
4.
Older individuals
may be more likely to manifest anxiety in an atypical manner (e.g., involving
symptoms of both anxiety and depression) and thus be more likely to warrant a
diagnosis of unspecified anxiety disorder. Additionally, the presence of
specific phobia in older adults is associated with decreased quality of life
and may serve as a risk factor for major neurocognitive disorder.
B. RISK AND PROGNOSTIC
FACTORS
1.
Temperamental:
Temperamental risk factors for specific phobia, such as negative affectivity
(neuroticism) or behavioural inhibition.
2.
Environmental:
Environmental risk factors for specific phobias, such as:
a) parental
over protectiveness,
b) parental
loss and separation,
c) and
physical and sexual abuse.
As noted earlier, negative or traumatic
encounters with the feared object or situation sometimes (but not always)
precede the development of specific phobia.
3.
Genetic and physiological:
There may be a genetic susceptibility to a certain category of specific phobia.
Individuals with blood-injection-injury phobia show a unique propensity to
vasovagal syncope (fainting) in the presence of the phobic stimulus.
FUNCTIONAL
CONSEQUENCES OF SPECIFIC PHOBIA
Individuals
with specific phobia show similar patterns of impairment in psychosocial functioning
and decreased quality of life as individuals with other anxiety disorders and alcohol
and substance use disorders, including impairments in occupational and
interpersonal functioning.
In
older adults, impairment may be seen in care giving duties and volunteer
activities. Also, fear of falling in older adults can lead to reduced mobility
and reduced physical and social functioning, and may lead to receiving formal
or informal home support.
The
distress and impairment caused by specific phobias tend to increase with the
number of feared objects and situations. Thus, an individual who fears four
objects or situations is likely to have more impairment in his or her
occupational and social roles and a lower quality of life than an individual
who fears only one object or situation. Individuals with blood-injection-injury
specific phobia are often reluctant to obtain medical care even when a medical
concern is present. Additionally, fear of vomiting and choking may
substantially reduce dietary intake.
TREATMENT
1.
BEHAVIOUR THERAPY:
The most studied and most effective treatment for phobias is probably behaviour
therapy. A variety of behavioural treatment techniques have been used, the most
common being systematic desensitization. Other behavioural techniques that have
been used are flooding.
2.
INSIGHT-ORIENTED PSYCHOTHERAPY:
Insight-oriented therapy enables patients to understand the origin of the
phobia, the phenomenon of secondary gain, and the role of resistance and
enables them to seek healthy ways of dealing with anxiety-provoking stimuli.
3.
VIRTUAL THERAPY:
A number of computer-generated simulations of phobic disorders have been
developed. Patients are exposed to or interact with the phobic object or situation
on the computer screen.
4.
OTHER THERAPEUTIC MODALITIES:
Hypnosis,
supportive therapy, and family therapy may be useful in the treatment of
phobic disorders. Hypnosis is used to enhance the therapist’s suggestion that the
phobic object is not dangerous, and self-hypnosis can be taught to the patient
as a method of relaxation when confronted with the phobic object. Supportive
psychotherapy and family therapy are often useful in helping the patient
actively confront the phobic object during treatment. Not only can family therapy
enlist the aid of the family in treating the patient, but it may also help the family
understand the nature of the patient’s problem.
A
common treatment for specific phobia is exposure therapy. In this method, therapists
desensitize patients by using a series of gradual, self-paced exposures to the
phobic stimuli, and they teach patients various techniques to deal with
anxiety, including relaxation, breathing control, and cognitive approaches.
The cognitive-behavioural
approaches include reinforcing the realization that the phobic situation is, in
fact, safe.
5.
PHARMACOTHERAPY:
In pharmacotherapy benzodiazepines are most commonly used.
REFERENCES:
·
Diagnostic
and Statistical Manual of Mental Disorders (DSM-5)
·
KAPLAN
& SADOCK S Synopsis of Psychiatry Behavioral Sciences/Clinical Psychiatry
eleventh edition ISBN 978-1-60913-971-1
·
Niraj Ahuja 2011, A Short
Textbook of PSYCHIATRY Seventh Edition Published by Jaypee Brothers Medical Publishers (P) Ltd
·
Passer, Michael W. and Ronald E. Smith: Psychology: the science of mind
and behavior (4th ed.), Published by McGraw-Hill 2009
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