Phobia


According to the DSM-5, the two types of phobia are social phobia and specific phobia. Social phobia (also known as social anxiety disorder) is characterized by an individual having a marked and persistent fear of social or performance situations; the exposure inevitably provokes anxiety that can take the form of a panic attack.4 People who have social phobia commonly are hypersensitive to criticism from others, have low self-esteem, and display inadequate social skills.


A general avoidance of public speaking is common; less common fears include drinking or eating in public. Again, the drug treatment class of choice for social phobia is the SSRIs (eg, paroxetine, 20-40 mg/d; sertraline, 50-100 mg/d). Venlafaxine can also be used, as well as benzodiazepines, if antidepressants are not effective. Other agents that are approved for treatment of social anxiety disorder that are not FDA-approved include mirtazapine, anticonvulsants, β-blockers, and monoamine oxidase inhibitors (which are reserved for treatment resistance). 


Specific phobia is defined by a marked and persistent fear that is excessive with the types of phobias pertaining to animal, natural environment, blood-injection injury, or situational phobias (eg, airplanes, elevators, or enclosed spaces). Exposure to these specific feared stimuli can provoke a sudden anxiety response that can possibly take the form of a panic attack.3 Although the primary treatment for specific phobia is behavioral therapy, drug treatment, with agents such as β-blockers, can be taken prior to encountering the specific feared stimuli or situation to calm an individual. 



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Assessment and treatment of anxiety disorders


The challenge associated with the assessment process for all of these anxiety disorders is that the clinical features of one disorder can closely mimic or resemble those of another; through the use of clinical judgment and paying close attention to the criteria of the DSM-5, one can make a distinction. The commonality of most of the anxiety disorders is the fear component, a sense of loss of control that can lead to significant impairments in a person’s way of life. When it comes to the assessment process, it is important to focus on the clinical features that set one anxiety disorder apart from another. For example, with GAD, the prominent feature of chronic worry for at least 6 months is a distinguishing characteristic of the mental disorder, whereas with a panic disorder the features of the disorder are immediate within 10 minutes.4

With regard to differential diagnosis, it is important for a clinician to always rule out the presence of a heart attack or other cardiac condition before an individual is diagnosed with an anxiety disorder. The features of palpitations, increased heart rate, and chest pain can be signs of a serious medical condition, so a formal work-up must be performed on any person with these complaints. With regard to an initial work-up to determine whether a person has an anxiety disorder, it is important to include serum glucose, calcium, and phosphate level measurement, an electrocardiogram, and thyroid studies.4 Also, people with more psychotic disorders can present with marked anxiety; therefore, it is important that the diagnosis of a particular anxiety disorder is only made if the anxiety is unrelated to other conditions or disorders. 


With regard to use of psychopharmacologic treatment, most of the anxiety disorders that have been discussed in this article use the same type of drug treatments; the use of SSRIs is considered first-line therapy.5 If SSRI treatment fails, antidepressants from other drug classes, or benzodiazepines, can be used in acute situations. In some cases, the long-term effect of benzodiazepines may be needed but should only be reserved for those individuals who have failed to respond to SSRIs, venlafaxine, buspirone, or other antidepressants, or in those who are unable to tolerate any of these medication classes.


Abimbola Farinde, PharmD, is a professor at Columbia Southern University in Orange Beach, Ala.


References


  1. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: American Psychiatric Association; 2013. 

  2. Robins LN, Regier DA, eds. Psychiatric Disorders in America: the Epidemiologic Catchment Area Study. New York, NY: The Free Press; 1991. 

  3. Hersen M, Turner S, Beidel D, eds. Adult Psychopathology and Diagnosis. 5th ed. Hoboken, NJ: John Wiley & Sons; 2007.

  4. Hahn RK, Albers LJ, Reist C, eds. Psychiatry. Blue Jay, CA: Current Clinical Strategies Publishing; 2008

  5. Schatzberg AF, Cole JO, DeBattista C, eds. Manual of Clinical Psychopharmacology. 7th ed. Washington, DC: American Psychiatric Publishing, Inc.; 2010.