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Phobic disorders • fear • Unpleasurable emotional state consisting of psychophysiological changes in response to a realistic threat or danger. Compare with anxiety. • phobia • Persistent, pathological, unrealistic, intense fear of an object or situation; the phobic person may realize that the fear is irrational but, nonetheless, cannot dispel it. • • • • 3 types of phobia 1- agarophobia (crowd of people). 2- social phobia. 3- simple phobia. Agoraphobia1 • Essence )(جوهر الموضوع • Symptoms of anxiety (psychological and/or autonomic) are not secondary delusional or obsessive thoughts and are restricted to places or situations where escape may be difficult or embarrassing, leading to avoidance (e.g. of crowds, public places, travelling away from home or alone). • Epidemiology • The lifetime prevalence of agoraphobia is somewhat more controversial, varying between 2 to 6 percent across studies • Aetiology Genetic • Both genetic and environmental factors appear to play a role. The predisposition towards overly interpreting situations as dangerous may be genetic, and some commentators suggest an ethological factor involving an evolutionarily determined vulnerability to unfamiliar territory2. • First-degree relatives also have an increased prevalence of other anxiety and related disorders (e.g. social phobia), alcohol misuse, and depressive disorders. Psychoanalytical Unconscious conflicts are repressed and may be transformed by displacement into phobic symptoms. Learning theory Conditioned fear responses lead to learned avoidance. • Comorbidity • Panic disorder, depressive disorder, other anxiety and related disorders (e.g. 55% also have social phobia), alcohol and substance misuse • Differential diagnosis • Other anxiety and related disorders (esp. generalised anxiety disorder, social phobia, OCD), depressive disorders, secondary avoidance due to delusional ideas in psychotic disorders. • Management • Pharmacological Antidepressants As for panic disorder. BDZs short-term use only (may reinforce avoidance)—most evidence for alprazolam/clonazepam. • Psychological Behavioural methods Exposure techniques (focused on particular situations or places), relaxation training, and anxiety management. Cognitive methods Teaching about bodily responses associated with anxiety/education about panic attacks, modification of thinking errors. Simple or specific phobias • Essence • Recurring excessive and unreasonable psychological or autonomic symptoms of anxiety, in the (anticipated) presence of a specific feared object or situation leading, whenever possible, to avoidance. DSM-IV distinguishes 5 subtypes: animals, aspects of the natural environment, blood/injection/injury, situational • Epidemiology • Prevalence: lifetime 11.3% • animal/situational phobias may be more common; occurrence mainly in childhood/adolescence (mean 15yrs): animal phobias -7yrs, claustrophobia -20yrs. • Aetiology Genetic • Both genetic and environmental factors play a role. MZ:DZ = 25.9%:11.0%1 for animal phobia, situational phobia roughly equal suggesting stronger role for the environment. Psychoanalytical The manifest fear is the symbolic representation of an unconscious conflict, which has been repressed and displaced into phobic symptoms. • Learning theory Regarded as a conditioned fear response related to a traumatic situation, with learned avoidance (the trigger to the conditioned fear response may be a reminder of the original situation). • Observational learning also appears to be important, and the preparedness theory (Marks2) suggests that fear of certain objects may be evolutionarily adaptive (related to survival of the individual or species), selectively acquired, and difficult to extinguish as this is a non-cognitive process. • Comorbidity • The lifetime risk for patients with specific phobias experiencing at least one other lifetime psychiatric disorder is reportedly over 80% (NCS), particularly other anxiety disorders (panic, social phobia) and mood disorders (mania, depression, dysthymia). However, rates of substance misuse are considerably less than in other anxiety disorders. • Differential diagnosis • Panic disorder (fear of having further panic attack), agoraphobia, social phobia, hypochondriasis (fear of having a specific serious illness), OCD (avoidance/fear of an object or situation due to obsessional thoughts, ideas, or ruminations), psychosis (avoidance due to delusional idea of threat, fears tend to be overly excessive). • Management • Psychological • Behavioural therapy: treatment of choice: methods aim to reduce the fear response e.g. Wolpe's systematic desensitisation3 with relaxation and graded exposure (either imaginary or in vivo). Other techniques: reciprocal inhibition, flooding (not better than graded exposure), and modelling. Cognitive methods: education/anxiety management, coping skills/strategies may enhance long-term outcomes. • Pharmacological • Generally not used, except in severe cases to reduce fearavoidance (with BDZs e.g. diazepam) and allow the patient to engage in exposure techniques (B-blockers may be helpful, but benefit is not sustained). Clear depression may require an antidepressant. • Course • Without treatment, tend to run a chronic course. However, individuals may not present unless life changes force them to confront the feared object or situation. لالطالع Accidents Dystychiphobia Animals Zoophobia Ants( )نملMyrmecophobia Automobi Amaxophobia, motorphobia les Bees Apiphobia, melissophobia Birds Ornithophobia Blood Haemophobia لالطالع Bridges Gephyrophobia Cats Felinophobia Choking/ Anginaphobia, pnigophobia, pnigerophobia being smothere d Contamin Molysomophobia, mysophobia ation, dirt, or infection Creepy, crawly things Herpetophobia Crossing Agyrophobia streets Darkness Nyctophobia, scotophobia Dentists Dentophobia, Odontophobia Depth Bathophobia Doctors Iatrophobia لالطالع Dogs or Cynophobia rabies Everyth Panophobia, panphobia, pamphobia ing Feather Pteronophobia s Flying Aviophobia Forests, Nyctohylophobia at night Frogs Batrachophobia Hair, Chaetophobia, Trichophobia, doraphobia fur, or animal skins لالطالع Horses Equinophobia, hippophobia Hospitals Nosocomephobia Injections Trypanophobia Jumping Catapedaphobia Lightning Brontophobia, karaunophobia and thunder Moths Mottephobia Needles Aichmophobia, belonephobia Open Aeroacrophobia high places OperationTomophobia s: surgical لالطالع Place: Claustrophobia enclosed Railways/ Siderodromophobia trains Rain Rats Reptiles Snakes Spiders Vomiting X-rays Ombrophobia, Pluviophobia Zemmiphobia Herpetophobia Ophidiophobia Arachnophobia. Emetophobia Radiophobia Social phobia • Essence • Symptoms of incapacitating anxiety (psychological and/or autonomic) are not secondary delusional or obsessive thoughts and are restricted to particular social situations, leading to a desire for escape or avoidance (which may reinforce the strongly held belief of social inadequacy). • Epidemiology • Lifetime rates vary from 2.4% to 13.3% • Aetiology • Both genetic and environmental factors play a role. MZ:DZ = 24.4%:15.3%1. The predisposition towards overly interpreting situations as dangerous may be genetic, whereas individual interpretations of social cues may be environmentally determined2 (i.e. the particular trigger for the conditioned fear response depends on the social situation in which first episode of anxiety experienced). • Symptoms/signs • Somatic symptoms include blushing, trembling, dry mouth, perspiration when exposed to the feared situation, with excessive fear (which is recognised as such by the patient) of humiliation, embarrassment, or others noticing how anxious they are. • Individuals are often characteristically selfcritical and perfectionistic. Avoidance of situations may lead to difficulty in maintaining social/sexual relationships, educational problems (difficulties in interactions with other students/oral presentations), or vocational problems (work in less demanding jobs, well below their abilities). Thoughts of suicide are relatively common. • Comorbidity • There is a high level of psychiatric comorbidity with the most common disorders including simple phobia, agoraphobia, panic disorder, generalised anxiety disorder, PTSD, depression/dysthymia, and substance misuse • Differential diagnosis • Other anxiety and related disorders (esp. generalised anxiety disorder, agoraphobia, OCD), poor social skills, anxious/avoidant personality traits, depressive disorders, secondary avoidance due to delusional ideas in psychotic disorders, and substance misuse. • Management • Psychological CBT, in either an individual or group setting, should be considered as a first-line therapy (along with SSRIs/MAOIs) and may be better at preventing relapse. Components of this approach include relaxation training/anxiety management (for autonomic arousal), social skills training, and integrated exposure methods (modelling and graded exposure). • Pharmacological • B-blockers (e.g. atenolol) may reduce autonomic arousal, particularly for specific social phobia (e.g. performance anxiety). For more generalised social anxiety, both SSRIs (e.g. fluoxetine, paroxetine, sertraline) and MAOIs (e.g. phenelzine) are significantly more effective. Other treatment possibilities include RIMAs (e.g. moclobemide) or the addition of a BDZ (e.g. clonazepam, alprazolam) or buspirone. • Course • Without treatment, social phobia may be a chronic lifelong condition. • With treatment, response rates may be up to 90%, especially with combined approaches. • Medication best regarded as long-term, as relapse rates are high on discontinuation.