Phobias

Agoraphobia

Clinical Features and Diagnosis

DSM-5 criteria for agoraphobia, ALL must be met: ^[Ref]

1. Marked fear or anxiety about at least 2 of the following situations
   • Using public transportation
   • Being in open spaces
   • Being in enclosed spaces (e.g., shops, theatres, cinemas)
   • Standing in line or being in a crowd
   • Being outside the home alone
2. The situations are avoided (e.g. travel is restricted) or else are endured with marked distress or with anxiety about having a panic attack or panic-like symptoms, or require the presence of a companion
3. The agoraphobic situations almost always provoke fear or anxiety
4. The fear or anxiety is out of proportion to the actual danger posed by the agoraphobic situations and to the sociocultural context
5. The fear, anxiety, or avoidance is persistent, typically lasting ≥6 months
6. The fear, anxiety, or avoidance causes clinically significant distress or impairment in important areas of functioning
7. The anxiety or phobic avoidance is not better accounted for by another mental disorder

Differential Diagnoses / Closely Related Conditions

Agoraphobia and panic disorder

• Agoraphobia and panic disorder commonly coexist, but are separate diagnoses
• Agoraphobia may occur with or without panic attacks

See the Panic Disorder article for more information.

Agoraphobia vs claustrophobia

• Agoraphobia and claustrophobia can both involve fear of enclosed spaces, but the underlying fear is different
• Agoraphobia = fear / anxiety about multiple situations where escape may be difficult or help unavailable
  • Examples: public transport, crowds, open spaces, enclosed spaces, or being outside home alone
  • Key thought: “What if I panic or become unwell and can’t get out / get help?”
• Claustrophobia = a specific phobia of enclosed spaces
  • Examples: lifts, tunnels and MRI scanners
  • Key thought: “I’m terrified of being in this enclosed space”

Management

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• 1st line: psychotherapy, options include
  • CBT with graded exposure to feared situations
  • Applied relaxation
  • Education and self-help strategies
  • Guided self-help for milder symptoms
• Consider SSRIs if symptoms are more severe or psychotherapy is not effective

Social Anxiety Disorder (Social Phobia)

Clinical Features and Diagnosis

DSM-5 criteria for social anxiety disorder (social phobia), ALL must be met: ^[Ref]

1. Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others.
   • Examples include social interactions (e.g. having a conversation, meeting unfamiliar people), being observed (e.g. eating or drinking), and performing in front of others (e.g. giving a speech)
   • In children, the anxiety must occur in peer settings and not just during interactions with adults
   • The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated (i.e. will be humiliating or embarrassing; will lead to rejection or offend others)
2. The fear or anxiety is out of proportion to the actual threat posed by the social situation and to the sociocultural context
3. The social situations almost always provoke fear or anxiety.
4. The social situations are avoided or endured with intense fear or anxiety
5. Duration: persistent, typically ≥6 months
6. Presence of clinically significant distress or impairment in social, occupational, or other important areas of functioning
7. The fear, anxiety, or avoidance is not attributable to, or explained by
   • Physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition
   • Symptoms of another mental disorder, such as panic disorder, body dysmorphic disorder, or autism spectrum disorder
8. If another medical condition (e.g. Parkinson’s disease, obesity, disfigurement from burns or injury) is present, the fear, anxiety, or avoidance is clearly unrelated or is excessive

Differential Diagnosis / Related Conditions

Social anxiety disorder (social phobia) vs avoidant personality disorder

• Social anxiety disorder (social phobia) = fear is centred on particular social situations because of concern about being negatively evaluated, judged, embarrassed or humiliated by others, e.g. presentations, meeting strangers or eating in public
• Avoidant personality disorder = a broader, longstanding pattern across social life and relationships, with social inhibition, low self-esteem/feelings of inadequacy and marked sensitivity to criticism or rejection, affecting friendships, intimacy and everyday interactions rather than only particular feared situations

Management

• 1st line: individual CBT
• 2nd line: CBT-based supported self-help
• If the patient prefers medication or declines CBT: SSRI (sertraline or escitalopram)

If the patient declines both CBT and medications, consider short-term psychodynamic psychotherapy

Specific Phobias

Shared Definition

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• Marked fear or anxiety about a specific object or situation
• Exposure almost always provokes immediate fear / anxiety, leading to avoidance or marked distress
• The fear is disproportionate to the actual danger and causes significant distress or functional impairment
• Persistent duration: ≥6 months

Specific Phobias

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Management

1st line: CBT-based exposure therapy ^[Ref]

• Graded exposure / systematic desensitisation = gradual, stepwise exposure to increasingly feared situations, often using a fear hierarchy (utilises the principles of classical conditioning)
• Flooding (implosion) = direct exposure to a highly feared stimulus or situation without gradual progression

References