Phobias

Contributed Dr James Briscoe, medical director and consultant psychiatrist, Woodbourne Priory Hospital, Edgbaston, Birmingham

1. Epidemiology and aetiology

Phobias are anxiety disorders involving emotional and physical reactions to feared objects or situations that vary in severity among sufferers.

Some patients will be able to avoid the subject of their fear, some will have panic attacks with disabling symptoms and others will be unable to lead normal lives.

Epidemiology

Approximately one in 10 people will have troublesome anxiety or phobias at some point in their lives; most will understand that their fear is out of proportion to the stimulus, but facing their fear, or even thinking about it, can bring on a either a panic attack or severe anxiety.

Unfortunately, most individuals affected do not seek treatment from their GP either because they donit understand that phobias are real, albeit very treatable, illnesses, or because of the stigma which surrounds mental health problems.

A common phobia is fear of dentists and according to a study from the British Psychological Society one in 10 people avoid going to a dentist.

According to the National Phobics Society, anxiety disorders are commonplace and an estimated 13 per cent of the adult population will develop a specific phobia at some point in their lives (see table right).

Aetiology

Recent research suggests that heredity, genetics and brain chemistry combine with life experience to lead to the development of phobias.

Some researchers highlight biological, dispositional, learning and psychodynamic theories. It is possible for an individual to develop a phobia over anything; most phobias start in teenage and adult years and some may run in families, with women twice as likely to suffer from phobias as men.

Classification

Phobias have been defined and classified by both the updated DSM-IV and ICD-10 criteria under anxiety disorders such as social phobias, agoraphobias and specific phobias.

Social phobias are very common and can be extremely debilitating.

Cultural differences as well as age might explain under-reporting and delay in seeking medical opinion. There is a high prevalence of comorbidities, and in some cases a high risk of suicide.

PHOBIA PREVALENCE IN THE UK
Type of anxiety/phobia
Prevalence

1. Panic attacks and panic disorder

2. Social phobia/social anxiety

3. Generalised anxiety disorder (GAD)

4. Agoraphobia

5. Obsessive compulsive disorder (OCD)

6. Irritable bowel syndrome (IBS)

7. Vomit phobia (emetophobia)

8. Post traumatic stress phobia

9. Body dysmorphic disorder (BDD)

10. Blushing phobia (erythrophobia)

11. Tranquilliser issues (withdrawal/addiction)

12. Driving phobia

13. Illness phobia (nosemaphobia)

14. Flying phobia (aerophobia)

15. Spiders (arachnophobia)

16. Animal phobia (zoophobia)

17. Confined spaces (claustrophobia)

18. Hospital phobia

19. Injection phobia (trypanophobia)

20. Choking and swallowing phobia (globus hystericus)

0.2%

17.2%

16.8%

9.9%

7.3%

6.3%

2.6%

2.5%

1.4%

1.2%

1.1%

1.06%

0.8%

0.75%

0.75%

0.66%

0.57%

0.57%

0.57%

0.44%

Source: National Phobics Society survey 2005/6 

2.Types of phobias

Most specific phobias spring from a trigger event, generally a traumatic experience at an early age. Most patients will report an immediate response of uncontrolled anxiety when exposed to the object of their fear or, in extreme cases, when anticipating this event.

Specific phobias relate to distinct objects or situations such as black cats. While the presentation is straightforward, it is important to exclude physical problems like hyperthyroidism and to be alert to the concomitant use of alcohol as a coping strategy.

Clinical features

Mental symptoms include feeling worried all the time, feeling tired, inability to concentrate, irritableness and disrupted sleep patterns. Physical symptoms include palpitations, sweating, muscle tension and pain, heavy breathing, dizziness, indigestion, diarrhoea and feeling faint.

Social phobias

These occur after puberty, peak after 30 and affect 1-2 per cent of men and 2-3 per cent of women. Social phobias relate to a specific situation, and generalised social phobias involve fear of a variety of situations.

Agoraphobia

Agoraphobia develops between the ages of 18 and 35 with either a sudden or gradual onset; two thirds of sufferers are women. Most people develop agoraphobia after a spontaneous panic attack. The randomness of panic attacks Ètrainsi sufferers to anticipate future attacks and to fear situations in which an attack may occur. It is the most disabling phobia and treatment is difficult.

3. Treatment in primary care

A treatment package that enables patients to control behavioural and somatic symptoms is highly beneficial. GPs should be aware that patients might experience heightened degrees of anxiety when pharmacological interventions are begun.

To offset this, a short course of low-dose benzodiazepines might be useful; if patients donit respond to a particular antidepressant, the dosage should be increased.

Pharmacological interventions

Medication can control both the anticipatory anxiety and the panic experienced during a phobic situation and is often used for social phobia and agoraphobia.

In low doses, beta-blockers like propranolol and atenolol can control the physical shaking of anxiety that may be a symptom of social phobia, and may also be helpful for patients whose anxiety interferes with performance.

SSRIs like fluoxetine, paroxetine and sertraline can also be used. SSRIs in conjunction with behaviour therapy are increasingly popular in the treatment of social phobia because the antidepressant action helps patients who suffer from depression in addition to social phobia.

Tricyclic antidepressants such as imipramine have been effective in treating panic disorders as have MAOIs like phenelzine and tranylcypromine. Alprazolam and diazepam are commonly used to treat acute anxiety but should only be prescribed for short periods of time.

Behaviour therapy

Treatment options are not mutually exclusive and multiple treatments may be required to achieve the best results.

Cognitive behavioural therapy helps patients to understand their negative thought patterns and how to change them. Desensitisation involves slowly exposing the patient to the object or situation they fear until the fear begins to fade.

Flooding immerses the patient in the fear reflex until the fear dissipates; the key is to keep patients in the feared situation long enough so that they can see that the predicted consequences do not materialise. Counter-conditioning teaches patients to substitute a relaxation response for the fear response when confronted by a phobic stimulus. Additionally, systemic desensitisation can be paired with modelling to achieve successful outcomes.

In mild cases, posthypnotic suggestions can be used to help patients control their breathing and heart rate and create a relaxed state of mind that enables them to calmly and rationally overcome their fear.

Just 20 per cent of phobias go away on their own, making early diagnosis and treatment essential. If phobias are caught early they are extremely responsive and rewarding to treat; most patients who seek treatment make rapid, long-lasting progress.

When to refer

If patients fail to respond to primary care treatment, or if their phobia is part of a complex presentation involving symptoms of depression or other problematic illnesses, they should refer them to a consultant psychiatrist to receive specialist treatment.

Key points

  • Phobias affect one in 10 people.
  • Phobias usually start in teenage and adult years.
  • Most specific phobias have a trigger event.
  • Agoraphobia usually develops after a panic attack.

Resources

  • National Phobics Society, Zion Community Resource Centre, 339 Stretford Road, Hulme, Manchester M15 4ZY; telephone: 0870 122 2325.
  • Triumph over Phobia, TOP UK, Box 3760, Bath BA2 3WY; telephone: 0845 600 9601.

Have you registered with us yet?

Register now to enjoy more articles and free email bulletins

Register

Already registered?

Sign in

Follow Us:

Just published

The healthcare crisis in Myanmar - how UK GPs can help

The healthcare crisis in Myanmar - how UK GPs can help

Dr Jim Brockbank from Myanmar UK GP Health Action provides an update on how the military...

GPs warn of 'open floodgates' as 84% say e-consultations have driven up workload

GPs warn of 'open floodgates' as 84% say e-consultations have driven up workload

More than four fifths of GPs say e-consultation systems adopted in the pandemic have...

Map: Which CCGs have the highest COVID-19 vaccine coverage?

Map: Which CCGs have the highest COVID-19 vaccine coverage?

Tens of millions of COVID-19 jabs have been administered across England, but how...

Podcast: Greener practice, sharing patient data and additional roles

Podcast: Greener practice, sharing patient data and additional roles

In this episode we look at data extraction from GP records, ask whether the additional...

Red flag symptoms: Loss of consciousness

Red flag symptoms: Loss of consciousness

Red flag symptoms to look out for in presentations of loss of consciousness, including...

£20m fund to speed up second jabs as CCGs told to limit pressure on practices

£20m fund to speed up second jabs as CCGs told to limit pressure on practices

NHS England has announced £20m in funding to help local COVID-19 vaccination sites...