Phobic Disorder
- Phobic disorders are anxiety disorders characterised by excessive, irrational fear of specific objects, situations, or activities, leading to avoidance behaviours and distress.
- Three main types:
- Specific Phobias: Fear of particular objects or situations (e.g., spiders, heights, flying).
- Social Anxiety Disorder (Social Phobia): Fear of social situations due to worry about embarrassment or scrutiny.
Agoraphobia: Fear of places or situations where escape might be difficult (e.g., crowded areas, open spaces).
Causes & Risk Factors
- Hyperactivity of the Amygdala → Exaggerated Fear Response.
- Dysfunctional Prefrontal Cortex Regulation → Inability to Rationalise Fear.
Classical Conditioning → Learned Fear Response (e.g., traumatic event → phobia formation).
Risk Factors for Phobic Disorder
|
Risk Factor |
Description |
|
Genetic Predisposition |
Higher Incidence in First-Degree Relatives. |
|
Previous Traumatic Experiences |
Conditioned Fear Response from Past Trauma. |
|
Parental Modelling |
Observing Parental Fear Can Reinforce Phobias. |
|
Overprotective or Anxious Parenting |
Increased Risk of Anxiety Disorders. |
|
Comorbid Anxiety or Depression |
Higher Risk of Phobia Development. |
🔹 Genetics, learned behaviour, and traumatic experiences contribute to phobia development.
Clinical Features
Symptoms of Phobic Disorders
|
Category |
Common Symptoms |
|
Emotional Symptoms |
Intense Fear, Panic, Irrational Thoughts. |
|
Cognitive Symptoms |
Anticipatory Anxiety, Catastrophic Thinking. |
|
Physical Symptoms (Autonomic Arousal) |
Palpitations, Sweating, Trembling, Dry Mouth. |
|
Avoidance Behaviour |
Actively Avoiding Triggers, Social Withdrawal. |
Signs on Examination
|
Feature |
Description |
|
Visible Anxiety Symptoms |
Shaking, Sweating, Rapid Breathing. |
|
Avoidant Behaviour |
Patient Avoids Discussing or Facing Triggers. |
|
Increased Startle Response |
Sensitive to Sudden Noises or Movements. |
🔹 Anticipatory anxiety, autonomic overactivity, and avoidance are hallmark signs.
Referral Criteria (NICE Guidelines)
Urgent Referral (If Severe Symptoms or Risk to Self/Others)
- Suicidal Ideation or Self-Harm.
- Severe Functional Impairment (Unable to Work, Socially Isolated).
- Comorbid Severe Depression or Panic Disorder.
Routine Referral (If Symptoms Persist or Affect Functioning)
- Failure of First-Line Psychological or Pharmacological Therapy.
- Severe Agoraphobia Preventing Leaving Home.
- Phobia Interfering with Work, Education, or Relationships.
🔹 Severe impairment requires psychiatric referral, while mild cases are managed in primary care.
Diagnosis
Clinical Diagnosis (DSM-5/ICD-10 Criteria)
|
Criterion |
Description |
|
Persistent & Excessive Fear of a Specific Object or Situation |
Disproportionate to Actual Danger. |
|
Immediate Anxiety Response on Exposure |
Autonomic Arousal (Palpitations, Sweating). |
|
Avoidance or Endurance with Intense Anxiety |
Patient Actively Avoids or Struggles Through Situations. |
|
Significant Distress or Functional Impairment |
Interferes with Daily Life. |
|
Duration ≥6 Months |
To Differentiate from Temporary Fears. |
|
Not Due to Another Mental or Medical Condition |
Exclude Panic Disorder, PTSD, or Hyperthyroidism. |
Differential Diagnosis
|
Condition |
Key Differences |
|
Generalised Anxiety Disorder (GAD) |
Excessive Worry About Multiple Situations (Not Just One Specific Phobia). |
|
Panic Disorder |
Sudden Panic Attacks Without a Specific Trigger. |
|
Obsessive-Compulsive Disorder (OCD) |
Compulsions & Intrusive Thoughts. |
|
Social Anxiety Disorder |
Fear of Social Judgement (Not General Avoidance). |
🔹 Diagnosis is clinical; psychological screening tools (e.g., Fear Survey Schedule) can help.
Management (NICE Guidelines)
Stepwise Approach to Phobic Disorder Management
|
Step |
Intervention |
|
Step 1 (Low-Intensity Psychological Therapy – First-Line for Mild Cases) |
Psychoeducation, Self-Help, Online CBT. |
|
Step 2 (Cognitive Behavioural Therapy – First-Line for Moderate-Severe Phobias) |
Exposure Therapy (Systematic Desensitisation). |
|
Step 3 (Pharmacological Therapy – If Psychological Therapy Insufficient) |
SSRI (Sertraline First-Line). |
|
Step 4 (Specialist Referral – If Severe or Treatment-Resistant) |
Psychiatry, Specialist CBT. |
Exposure Therapy (First-Line Psychological Treatment)
|
Technique |
Description |
|
Systematic Desensitisation |
Gradual Exposure to Phobia While Practicing Relaxation. |
|
Flooding (Less Common) |
Rapid, Intense Exposure (Risk of High Distress). |
|
Cognitive Reframing |
Changing Negative Thoughts About the Phobic Object/Situation. |
🔹 CBT with graded exposure is the most effective treatment for phobias.
First-Line Pharmacological Treatment (If Needed)
|
Drug |
Mechanism |
Considerations |
|
Sertraline (SSRI, First-Line for Social Phobia & Agoraphobia) |
Increases Serotonin Levels. |
Takes 4-6 Weeks to Work, Start Low & Increase. |
|
Alternative SSRIs (Escitalopram, Paroxetine) |
Same as Sertraline. |
Consider If Sertraline Not Tolerated. |
|
Beta-Blockers (Propranolol – For Performance Anxiety) |
Reduces Autonomic Symptoms (Palpitations, Tremors). |
Does Not Treat Psychological Symptoms. |
|
Benzodiazepines (Short-Term Use Only) |
Enhances GABA (Rapid Anxiolytic). |
Avoid Long-Term Due to Dependence Risk. |
🔹 CBT is first-line, with SSRIs for social anxiety and severe phobias.
Prognosis & Complications
Complications of Phobic Disorders
|
Complication |
Features |
|
Social Isolation (Especially in Social Phobia & Agoraphobia) |
Avoidance of Work, Relationships. |
|
Depression & Anxiety Disorders |
Common Comorbidities. |
|
Substance Abuse |
Alcohol or Drugs Used to Cope With Anxiety. |
|
Suicidal Ideation |
Risk in Severe Cases. |
🔹 Early treatment prevents worsening avoidance behaviours and associated complications.
UKMLA Key Points
- Best first-line treatment for phobias: Exposure Therapy (CBT).
- Best first-line pharmacological treatment: Sertraline (SSRI) – For Social Anxiety & Agoraphobia.
- Best medication for performance anxiety: Propranolol (Beta-Blocker).
- When to refer urgently: Suicidal ideation, severe functional impairment.
- When to use benzodiazepines: Short-term use only, avoid long-term dependence.