Phobic disorders consist of persistent, unreasonable, intense fears (phobias) of situations, circumstances, or objects. The fears provoke anxiety and avoidance. Phobic disorders are classified as general (agoraphobia and social phobia) or specific. The causes of phobias are unknown. Phobic disorders are diagnosed based on history. Treatment for agoraphobia and social phobia is drug therapy, psychotherapy (eg, exposure therapy, cognitive-behavioral therapy), or both. Some phobias, including specific phobias, are treated mainly with exposure therapy.
Symptoms and Signs
Symptoms depend on the type of phobic disorder, which is classified as general (agoraphobia and social phobia) or specific.
Agoraphobia is fear of and anticipatory anxiety about being trapped in situations or places without a way to escape easily and without help if intense anxiety develops. The situations are avoided or they may be endured but with substantial anxiety. Agoraphobia can occur alone or as part of panic disorder.
Agoraphobia without panic disorder affects about 4% of women and 2% of men during any 12-mo period. Peak age at onset is the early 20s; first appearance after age 40 is unusual.
Common examples of situations or places that create fear and anxiety include standing in line at a bank or at a supermarket checkout, sitting in the middle of a long row in a theater or classroom, and using public transportation, such as a bus or an airplane. Some people develop agoraphobia after a panic attack in a typical agoraphobic situation. Others simply feel uncomfortable in such a situation and may never or only later have panic attacks there. Agoraphobia often interferes with function and, if severe enough, can cause people to become housebound.
Social phobia (social anxiety disorder):
Social phobia is fear of and anxiety about being exposed to certain social or performance situations. These situations are avoided or endured with substantial anxiety. People with social phobia recognize that their fear is unreasonable and excessive.
Social phobia affects about 9% of women and 7% of men during any 12-mo period, but the lifetime prevalence may be at least 13%. Men are more likely than women to have the most severe form of social anxiety, avoidant personality disorder (see Avoidant personality disorder).
Fear and anxiety in people with social phobia often centers on being embarrassed or humiliated if they fail to meet expectations. Often the concern is that their anxiety will be apparent through sweating, blushing, vomiting, or trembling (sometimes as a quavering voice) or that the ability to keep a train of thought or find words to express themselves will be lost. Usually, the same activity done alone causes no anxiety. Situations in which social phobia is common include public speaking, acting in a theatrical performance, and playing a musical instrument. Other potential situations include eating with others, signing their name before witnesses, or using public bathrooms.
A more generalized type of social phobia causes anxiety in a broad array of social situations.
A specific phobia is fear of and anxiety about a particular situation or object (see Table 4: Some Common Phobias*). The situation or object is usually avoided when possible, but if exposure occurs, anxiety quickly develops. The anxiety may intensify to the level of a panic attack. People with specific phobias typically recognize that their fear is unreasonable and excessive.
Specific phobias are the most common anxiety disorders. Among the most frequent are fear of animals (zoophobia), heights (acrophobia), and thunderstorms (astraphobia or brontophobia). Specific phobias affect about 13% of women and 4% of men during any 12-mo period. Some cause little inconvenience—eg, fear of snakes (ophidiophobia) in city dwellers, unless they are asked to hike in an area where snakes are found. However, other phobias interfere severely with functioning—eg, fear of closed places (claustrophobia), such as elevators, in people who must work on an upper floor of a skyscraper. Phobia of blood (hemophobia), injections (trypanophobia), needles or other sharp objects (belonephobia), or injury (traumatophobia) occurs to some degree in at least 5% of the population. People with a phobia of blood, needles, or injury, unlike those with other phobias or anxiety disorders, can actually faint because an excessive vasovagal reflex causes bradycardia and orthostatic hypotension.
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Diagnosis is clinical based on criteria in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Text Revision (DSM-IV-TR).
If untreated, agoraphobia usually waxes and wanes in severity. Agoraphobia may disappear without formal treatment, possibly because some affected people conduct their own form of exposure therapy. But if agoraphobia interferes with functioning, treatment is needed.
Social phobia is almost always chronic, and treatment is needed.
The prognosis for specific phobias is more variable when untreated because it may be easy to avoid the situation or object that causes fear and anxiety.
Because many phobic disorders involve avoidance, exposure therapy, a specific psychotherapy, is the treatment of choice. With structure and support from a clinician who prescribes exposure homework, patients seek out, confront, and remain in contact with what they fear and avoid until their anxiety is gradually relieved through a process called habituation. Exposure therapy helps > 90% of those who carry it out faithfully and is almost always the only treatment needed for specific phobias. Cognitive-behavioral therapy is effective for agoraphobia and social phobia. Cognitive-behavioral therapy involves teaching patients to recognize and control their distorted thinking and false beliefs as well as instructing them on exposure therapy. For example, patients who describe acceleration of their heart rate or shortness of breath in certain situations or places learn by being repeatedly exposed to those situations that their worries about having a heart attack are unfounded and are taught to respond instead with slow, controlled breathing or other methods that promote relaxation.
Short-term therapy with a benzodiazepine (eg, lorazepam 0.5 to 1.0 mg po) or a β-blocker (propranolol is generally preferred—10 to 40 mg po), ideally about 1 to 2 h before the exposure, is occasionally useful when exposure to an object or situation cannot be avoided (eg, when a person who has a phobia of flying must fly on short notice) or when cognitive-behavioral therapy is either unwanted or has not been successful.
Many people with agoraphobia also have panic disorder, and many of them benefit from drug therapy with an SSRI. SSRIs and benzodiazepines are effective for social phobia, but SSRIs are probably preferable in most cases because, unlike benzodiazepines, they are unlikely to interfere with cognitive-behavioral therapy. β-Blockers are useful for phobias related to public performance.
Last full review/revision July 2012 by John H. Greist, MD
Content last modified November 2013