Topic: Specific and Social Phobia

Submitted by: Fatima Sheraz

Roll no: 35
Batch E
Submitted to: Prof. Dr. Muhammad Masood Khokhar

Learning Objectives:
 Define specific and special phobias
 Explain the etiology of specific and special phobias
 Describe the prevalence, age and gender distribution
 Enlist the diagnostic criteria according to ICD 10 guidelines
 Discuss the differential investigations
 Discuss the management plan

Specific phobias

DEFINITION:
A specific phobia is an intense, irrational fear of something that poses little or no actual danger.
Although adults with phobias may realize that these fears are irrational, even thinking about
facing the feared object or situation brings on severe anxiety symptoms. Typically, the dread is
relatively greater than the real risk or danger. People with specific phobias are highly distressed
about having the fear, and often will take extraordinary measures to avoid the object or situation
in question. These phobias are long lasting and result in severe physical and psychological
reactions, specific phobias can also occur along with other types of anxiety disorders. It affects
the normal daily life activities at home and at work. Common categories of specific phobias are
a fear of situations, such as airplanes, enclose spaces or going to school. Nature such as
thunder storm or heights. Animals or insects such as dog or spiders. Blood injection or injury
such as needles accidents or medical procedures other such as choking, vomiting, loud noises
or clowns. Each specific phobia is named by its own terms (acrophobia, animal phobias,
claustrophobia, examination phobia and simple phobia).
No matter what specific phobia you have, it's likely to produce these types of reactions:
 An immediate feeling of intense fear, anxiety and panic when exposed to or even
thinking about the source of your fear
 Worsening anxiety as the situation or object gets closer to you in time or physical
proximity
 Doing everything possible to avoid the object or situation or enduring it with
intense anxiety or fear
 Difficulty functioning normally because of your fear
 Physical reactions and sensations, including sweating, rapid heartbeat, tight
chest or difficulty breathing
  Feeling nauseated, dizzy or fainting around blood or injuries

ETIOLOGY:
Specific phobias emerge in childhood or early adult life and they persist for a longer time.
The causes may include any negative experience or panic attack related to a specific object or
situation, changes in the brain functions, due to genetics or learned behaviors.

PREVALENCE:
In a recent study, it is estimated to be 9.1% prevalent in the past year with specific phobias
being 12.2% prevalent in females and 5.8% in males.

DIAGNOSTIC CRITERIA ICD-10:

The following should be fulfilled for a definitive diagnosis according to ICD.10

1) Psychological or autonomic symptoms must be the primary manifestation of anxiety, and not
secondary to symptoms such as delusion or obsessional thoughts.
2) The anxiety must be confined to the presence of a particular phobic object or situation.
3) The phobic situation is avoided whenever possible.
• Blood-injury phobia differs from others in leading to bradycardia and/or syncope, rather than
tachycardia.
• Fears of specific diseases such as cancer, heart disease or venereal infection should be
classified under hypochondriacal disorder (unless they relate to specific situations where the
disease might be acquired). Dysmorphophobia (believing that you have an abnormality or
disfigurement of a specific bodily part which is not objectively noticed) should also be
categorized under hypochondriacal disorder. If the conviction of disease reaches delusional
intensity, then diagnosis should be of delusional disorder.

DIFFERENTIAL DIAGNOSIS:

Specific phobias need to be differentiated from:

1). Generalized anxiety disorder (constant feelings of apprehension and other symptoms of
anxiety not restricted to any phobic object or situation).
2). Agoraphobia
3). Delusional disorder (a psychotic disorder)
4). Dysmorphophobia (individuals believe that they have a disfigured body part).
5). Panic disorder (in which the symptoms are episodic but not restricted to any particular
situation)
6). Social phobia
7). Post-Traumatic Stress Disorder (fear related to a specific past traumatic event and
involves flashbacks and recurrent nightmares along with other symptoms of anxiety).
Investigations:
Diagnosis of specific phobias is based on a thorough clinical interview and diagnostic
guidelines

TREATMENT:
NON-PHARMACOLOGICAL:
Psychotherapy

Talking with a mental health professional can help you manage your specific phobia. Exposure
therapy and cognitive behavioral therapy are the most effective treatments.

 Exposure therapy focuses on changing your response to the object or situation that you
fear. Gradual, repeated exposure to the source of your specific phobia and the related
thoughts, feelings and sensations may help you learn to manage your anxiety. For
example, if you're afraid of elevators, your therapy may progress from simply thinking
about getting into an elevator, to looking at pictures of elevators, to going near an
elevator, to stepping into an elevator. Next, you may take a one-floor ride, then ride
several floors, and then ride in a crowded elevator.
 Cognitive behavioral therapy (CBT) involves exposure combined with other
techniques to learn ways to view and cope with the feared object or situation differently.
You learn alternative beliefs about your fears and bodily sensations and the impact
they've had on your life. CBT emphasizes learning to develop a sense of mastery and
confidence with your thoughts and feelings rather than feeling overwhelmed by them.

PHARMACOLOGICAL:

Following medications can be used:

•(SSRIs)

1).Sertraline
(SERT)
(25mg-50mg)
Side effects:
•headache, nausea, constipation and dry mouth.
• pregnancy: category c
contraindicated:
•in patients with known hypersensitivity
 2.) Fluoxetine
(Prozac)
(20mg)
Side effects:
•nervousness, insomnia, nausea, dry mouth, heartburn
•It is unsafe in pregnancy and lactation
contraindicated in:
•diabetic patients and patients having SIADH(Syndrome of inappropriate antidiuretic
hormone secretion (SIADH) is a condition in which the body makes too much
antidiuretic hormone (ADH)

• Beta blockers:
for short term relief to block the stimulating effects of adrenaline, such as increased heart rate,
elevated blood pressure, pounding heart, and shaking voice and limbs that are caused by
anxiety.

1).Propranolol
(INDERAL)
(40 to 320mg) (safe in pregnancy)

•Benzodiazepines:
to reduce the amount of anxiety to help you relax.

Alprazolam:
(XANAX)
Dose: 0.5mg.
Contraindicated in depression and alcoholics.
Side effects include cognitive dysfunction, depression.
It is not safe in pregnancy and lactation.

SOCIAL PHOBIA

DEFINITION:

•Social phobia is one of the common anxiety disorders that cause severe fear and anxiety in
social settings. People have difficulty conversing with and meeting people and they start to
abstain from going to any sort of gatherings involving crowding. This fear can be discrete
which implies that they have a fear of eating in public or just speaking in public or it can be a
diffuse which means that they have a fear in every kind of social situation outside their family
circle. These people have low self-esteem, low confidence. They have a feeling of dread
toward being condemned. Whenever they go to social gatherings they have the symptoms
like nausea, hand tremors, blushing and these can later on progress to panic attacks. They
avoid gatherings and that can lead to complete social isolation.
Age and gender prevalence:
This starts in adolescence.
Social anxiety has an average age of onset of 13 years with more prevalence in women with
the lifetime prevalence of 5.67% than men who have a lifetime prevalence of 4.20%.

Etiology:
The exact cause of social phobia is unknown. But following are some of the known causes of
social phobias;
•Negative experiences (bullying, family conflict, sexual abuse).
•Physical abnormalities (Serotonin imbalance may contribute to this condition).
•An overactive amygdala may also cause these disorders.
•Anxiety disorders can run in families.
•Children can also develop anxiety disorders as a result of being raised in controlling or
overprotective environments.

There are two forms of the condition:

1. Generalized social anxiety which is the diffuse type and affects most if not all areas of life
and it’s the most common type affecting 70% of those who suffer from social phobia.

2. Performance social anxiety where these feelings only occur in a few specific situations such
as public speaking, eating in public or dealing with figures of authority.

Diagnostic criteria ICD-10:

All the following criteria should be fulfilled for a definitive diagnosis:
(a) The psychological, behavioral or autonomic symptoms must be primary manifestations of
anxiety and not secondary to other symptoms such as delusions or obsession of thoughts.
(b) The anxiety must be restricted to or predominate in particular social situations.
(c) The phobic situation is avoided whenever possible.

Differential diagnosis:
1. Agoraphobia (fear of being in places or circumstances that prove to be difficult to escape)
2. Specific phobia (fear of some specific object)
3. panic disorder (involves unexpected recurrent panic attacks without being triggered by a
phobic object)
4. Generalized anxiety disorder (constant feelings of apprehension and other symptoms of
anxiety not restricted to any phobic object or situation).
5. Post-Traumatic Stress Disorder (fear related to a specific past traumatic event and involves
flashbacks and recurrent nightmares along with other symptoms of anxiety).
Investigations:
The National Institute for Health and Care Excellence (NICE) recommends the use of the 3-
item Mini-Social Phobia Inventory (Mini-SPIN) for screening for social anxiety disorder.
Treatment;

NON-PHARMACOLOGICAL
PSYCHOLOGICAL AND SOCIAL:

Cognitive behavioral therapy

This helps to learn how to control anxiety through relaxation and breathing and how to replace
negative thoughts with positive ones.
Exposure therapy
This helps you to gradually face social situations, rather than avoiding them.
Group therapy
This helps to learn social skills and techniques to interact with people in social settings.
Avoid caffeine
Get plenty of sleep

PHARMACOLOGICAL:

Selective serotonin reuptake inhibitors(SSRIs) including

SERTRALINE
(SERT)
(25-50mg)
side effects:
•difficulty falling asleep, nausea, constipation and dry mouth.
•It is safe in pregnancy
contraindicated in:
•patients with known hypersensitivity
.

CITALOPRAM
(CELEXA)

(10mg)
side effects:
•rash, nausea, dry mouth ,urticaria
•Safe in pregnancy.

• Beta blockers:
for short term relief to block the stimulating effects of adrenaline, such as increased heart rate,
elevated blood pressure, pounding heart, and shaking voice and limbs that are caused by
anxiety.
1).Propranolol
INDERAL-PROPRANOLOL
(40 to 320mg) (safe in pregnancy)

•Benzodiazepines:
to reduce the amount of anxiety to help you relax.
Alprazolam:
XANAX-ALORAM
Dose: 0.5mg.
Contraindicated in depression and alcoholics.
Side effects include cognitive dysfunction, depression.
It is not safe in pregnancy and lactation.

References:

 The ICD 10 Classification of Mental and Behavioural disorders

 https://www.mayoclinic.org/diseases-conditions/social-anxiety-
 https://www.drugs.com/condition/social-anxiety-disorder.html
 https://www.nimh.nih.gov/health/statistics/specific-
phobia#:~:text=Specific%20phobia%20is%20an%20intense,brings%20on%20sev
ere%20anxiety%20symptoms.