PHOBIA

PHOBIAS

 The term “Phobia” is derived from Greek word, Phoboc

means fear, phobia is also used in a non-medical sense
for aversions of all sorts. It describes negative attitudes
or prejudices towards the named subjects.
DEFINITION:

 Persistent avoidance behaviour secondary to irrational fear of a

specific object, activity or situation.
(Lalitha, K 2007)

 Fear cued by the presence or anticipation of a specific object or

situation, exposure to which almost invariably provokes an
immediate anxiety response or panic attack even though the subject
recognizes that the fear is excessive or unreasonable. The phobic
stimulus is avoided with marked distress.
(Shahrokh&Hales,2003)

 “ Exaggerated pathological fear of a specific type of stimuli or

situation.”
(Bimla kapoor, 2002)
EPIDEMIOLOGY
 Phobias are most common form of anxiety disorders.
 The prevalence estimates 6.7% for agoraphobia,11.3%
for simple phobia, and 13.3% for social phobia.
 Social phobia: 50% is common in 11 years of age and
80% in 20 years of age.
 Most common mental illness among women in all age
groups and the second most common illness among men,
older than 25 years.
 Severe fear are present in 10-15 percent of children.

 Specific phobias are found in 5percent of children.

COMORBIDITY

 Person with social phobia may have a history of other

anxiety disorders, mood disorders, substance-related
disorder and bulimia nervosa.
 Avoidant personality disorder frequently occurs in
persons with generalized social phobia.
 Comorbidity in specific phobia range from 50-80percent.
Common comorbid disorders with specific phobia
include anxiety, mood and substance-related disorders.
PREDISPOSING FACTORS
 PSYCHOANALYTICAL THEORY: Freud believed
that phobias developed when a child, feeling normal
incestual feeling toward the opposite –sex parent
(oedipal/ Electra complex) and fears aggression from the
same-sex parent (castration anxiety). To protect
themselves these children repress this fear of hostility
from the same sex parent, and displace it onto something
safer and more neutral, which becomes the phobic
stimulus. The phobic stimulus becomes the symbol for
the parents but the child does not realize this.
2.LEARNING THEORY:
 Classic conditioning in the case of phobias may be
explained as follows: A stressful
stimulus produces a “unconditioned” response of fear.
When the stressful stimulus is repeatedly paired with a
harmless object alone produces a conditioned response:
fear. This becomes a phobia when the individual
consciously avoids the harmless object to escape fear.
 Some theorists hold that fears are conditioned responses
and thus they are learned by imposing rewards for
appropriate behaviors. In the intense of phobias, when
the individual avoids the phobic object, he/she escapes
fear, which is indeed a powerful reward.
3.COGNITIVE THEORY:
 Cognitive theorists espouse that anxiety is the product of faulty
cognitions or anxiety-inducing self-instructions. There are two types of
faulty thinking , negative self-statements and irrational beliefs.
 Cognitive theorists believe that some individuals engage in negative and
irrational thinking that produces anxiety reactions. The individual begins
to seek out avoidance behaviours to prevent the anxiety reactions and
phobias result.
 Johnson and Sarason (1978) suggested that individuals with internal
locus of control and those with external locus of control might respond
differently to life change. These researchers proposed that locus of
control orientation may be an important variable in the development of
phobias. Individuals with an external control orientation experiencing
anxiety attacks in a stressful period are likely to mislabel the anxiety and
attribute it to external sources(eg, crowded areas) or to a disease(eg,
heart attack). They may perceive the experienced anxiety as being
outside of their control.
BIOLOGICAL ASPECTS

 Temperament: More than 50% of children experience normal fars and

anxieties before they are 18years old.
 Most infants are afraid of loud noises

 Common fears of toddlers and preschloors include strangers, animals,

darkness, and fears of being separated from parents or attachment figures.
 During the school age years there is fear of death and anxiety about
school achievements.
 Fear of social rejection and sexual anxieties are common among
adolescents.
 Innate fears usually do not reach phobic intensity but may have the
capacity for such development of reinforced by invents in later life.
 For ex: a 4 years old girl is afraid of dogs. By age 5 she has overcome her
fear and plays with her own dog and the neighbors dogs without fear.
Then when she is 19 she is bitten by a stray dog and develops the fear of
dog.
LIFE EXPERIENCES
 Certain early experiences may set the stage for phobic
reactions later in life. Some researchers believe that
phobias, particularly specific phobias, are symbolic of
original anxiety-producing objects or situations that have
been repressed. For eg:
 A child who is punished by being locked in a closet
develops a phobia for elevators or other closed places.
 A child who falls down a flight of stairs develops a
phobia for high places.
 A young woman who, has a child, survived a plane crash
in which both her parents were killed has a phobia of air
planes.
CLASSIFICATION:
 It can be classified mainly into three:
 Social phobia

 Agora phobia

 Specific phobia

 Social phobia: irrational fear of activities or social interaction,

characterized by an irrational fear of performing activities in the presence
of other people or interacting with others. The patient is afraid of his/ her
own actions being viewed by others critically, resulting in embarrassment
or humiliation. For example: speaking or eating in public places, fear of
using a public restroom, fear of writing in the presence of others.
Exposure to feared social situation invariably provokes anxiety, which
may take the form of a situational predisposed panic attack.
 The avoidance, anxious, anticipation, or distress in the feared situation
interferes significantly with the person’s normal occupational, social, or
interpersonal functioning or there is marked distress about having phobia.
 Agoraphobia: in this disorder there is a fear of being in places
or situations from which escape might be difficult or in which
help might not be available if a limited symptom attack or
panic like symptoms should occur. It is possible that individual
may have experienced the symptoms in the past and is
preoccupied with fears of their recurrence.
 Specific phobia: specific phobia are formerly called simple
phobia. The essential features of this disorder is a marked,
persistent, and excessive or unreasonable fear when
anticipating an encounter with a specific object or situation.
The specific phobia are of following types:
 Animal type (fear of dog, spider, snake and other animals)

 Natural environment type (height, water, storm)

 Blood injection/ injury type

 Situational type (planes, elevators, enclosed spaces)

 Other (fear of noises, driving)

 CLASSIFICATION OF PHOBIAS
 Acrophobia height
 Algiophobia pain
 Anthophobia flower
 Aquaphobia water
 Cynophobia dog
 Murophobia mice
 Nyctophpbia darkness
 Zoophobia animals
 arachnophobia Spiders
 claustrophobia Closed spaces
 herpatophobia Lizards & reptile
 murophobia Mice
 ophidiophobia Snakes
 pyrophobia Fire
 thanatophobia Death
 xenophobia Strangers
 astraphobia lightening
DIAGNOSTIC CRITERIA FOR SPECIFIC PHOBIA

 Individual experiences excessive and persistent fear of a

specific object or situation and has feelings of anxiety,
fear, or panic right when encountering it
 The person knows that their reaction of fear is
unreasonable
 Individual’s fear, anxiety, or avoidance causes significant
distress or it interferes with the person’s day to day life
 In children younger than 18 years old, the problem must
be present for at least six months before diagnosing a
specific phobia
 The person’s fear, panic, and avoidance aren’t better
explained by another disorder .
TYPES
 Animal- fear of animals
 Natural Environment- fear of heights, storms and being
near water
 Blood-Injection/Injury- fear of seeing blood, having a
blood test or injection, watching medical procedures
 Situational- driving, flying, elevators, and enclosed
places
 Other- other specific fears
DIAGNOSTIC CRITERIA FOR SOCIAL PHOBIA

 Individual experiences a marked and persistent fear of one or

more social or performance situations in which the person is
exposed to unfamiliar people or to possible scrutiny by others. The
individual fears that he or she will act in a way that will be
humiliating or embarrassing.
 In children, there must be evidence of the capacity for age-
appropriate social relationships with familiar people, and anxiety
must occur in peer settings, not just in interactions with adults.
 In children, anxiety may be expressed by crying, tantrums freezing
or shrinking from social situations with unfamiliar people.
 Individual recognizes that fear is excessive or unreasonable.

 In individuals under age 18years,the duration is at least 6 months.

 The fear or avoidance is not due to the direct physiological effects

of a substance.
DIAGNOSTIC CRITERIA FOR AGORAPHOBIA

 The presence of agoraphobia related to fear of developing panic

like symptoms.
 Agoraphobia is the fear of being in places or situations from
which escape might be difficult or in which help might not be
available in the event of suddenly developing a symptoms that
could be incapacitating or extremely embarrassing. Examples
include: dizziness or falling, depersonalization or derealization,
loss of bladder or bowel control,vomiting or cardiac distress.
 The person either restricts travel, needs a companion when
away from home.
 Common agrophobic situations include being outside the home
alone, being in a crowd or standing in a line, being on a
bridge, .and travelling in a bus/car.
LABORATORY STUDIES

 To rule out anxiety secondary to medical conditions, the

following tests are helpful.
 Thyroid function test: hypothyroidism or
hyperthyroidism
 Fasting glucose- Hypoglycemia

 Calcium-Hyperparathyroidism

 Electrocardiogram and cardiac enzyme test- Myocardial

infarct.
SIGN AND SYMPTOMS:

 Anxiety is most common feature of phobic disorders.

Others are:
 Elevated heart rate

 Elevated blood pressure

 Tremor

 Palpitations

 Diarrhea

 Sweating

 Dyspnea

 Dizziness
TREATMENT:
 Pharmacotherapy:
 The drug used in the treatment of phobia are:

 Benzodiazepines are useful in reducing the anticipatory

anxiety.
 Alprazolam is stated to have anti phobic, anti panic, and
anti anxiety properties.
 Clonazepam

 Diazepam

 SSRI with paroxethine. SSRIs like fluoxitine, and

sertraline.
 Antidepressants e.g. imipramine & phenelzine by
decreasing the distress.
 Psychotherapy: psychodynamically oriented psychotherapy is
not usually helpful in trearment of phobias. This approach is
however indicated when there are characterological or
personality difficulties as well.
 Behavior therapy: if properly planned this mode of treatment is usually
successful. This involves:
a) Systematic desensitization: it is a technique for assisting individuals to
overcome their fear of a phobic stimulus. It is “systematic” in that there
is hierarchy of anxiety producing events through which the individual
progresses during the therapy.An example of a hierarchy of events
associated with a fear of elevators may be as follows:
 Discuss riding an elevator with the therapist.

 Look at picture of elevator.

 See the elevator.

 Push the button of elevator.

 Walk into the elevator with the trusted person, disembark before the
doors close.
 Walk into the elevator with the trusted person, allow doors to close, then
open the doors and walk out.
 Ride one floor with trusted person, and then walk back into the stairs.

 Ride one floor with trusted person, and ride the elevator back down.

 Ride the elevator alone.

b) Flooding: the individual is flooded with a continuous
presentation (through mental imagenary) of the phobic
stimulus until it no longer elicits anxiety. It is contraindicated
with the client for whom intense anxiety would be hazardous
e.g. individuals with hear disease.
c) Modeling: it refers to the learning of new behaviours by
imitating the behavior in others. Role model are individuals
who have qualities or skills that a person admires and wishes to
imitate. Children imitate the behavior patterns of their parents ,
teachers, friends and others.
 It can also occur in therapy sessions in which the client
watches a model demonstrate appropriate behaviours in a role
play of client’s problem. The client is then instructed to imitate
the model’s behaviours in a similar role play and is positively
reinforced for appropriate imitation.
d) Cognitive behavioural therapy: For some people with social
phobias, the best treatment is cognitive behavioural therapy
(CBT). This involves exercises to alter the inappropriate
patterns of thinking you have developed and the behaviour that
stems from them. For more information, see Related topics. It
can be used to break the anxiety pattern in phobic disorders. It
is usual to combine CBT with behavioural therapy.
e) Supportive therapy: it is helpful adjunct to behaviour therapy
and drug treatment. The main aim of giving this therapy in
phobias is to prevent the emotional breakdown and teaching
new coping skills.
PROGNOSIS:
 The outlook is very good for people with specific phobia or
social phobia.
 According to the U.S. National Institute of Mental Health,
about 75% of people with specific phobias overcome their
fears through cognitive-behavioral therapy, while 80% of
those with social phobia find relief from medication,
cognitive-behavioral therapy or a combination.
 When agoraphobia occurs with panic disorder, the prognosis
is also good. With appropriate treatment, 30% to 40% of
patients become free of symptoms for extended periods,
while another 50% continue to experience only mild
symptoms that do not significantly affect daily life.
DIFFERENTIAL DIAGNOSIS:
 When Social Anxiety Disorder / Social Phobia attacks take on major proportions,
panic becomes quite similar to Panic Disorder. The fundamental difference may be
found in the clinical history.
 Four aspects must be carefully observed regarding the mistakes with Panic Disorder:
 1. Predictability of the Crises – In Panic Disorder, the panic attacks are
unpredictable, with no association with any type of exposition.
 2. Feelings Well Defined – In the attack of Panic Disorder the person has the
feeling that he is going to faint or go crazy or die from a heart attack. In panic from
Social Anxiety this does not occur, but the person has an urgent need to go away
from the situation.
 3. Differences in Evolution of the Panic Attacks – In Panic Disorder, it's common
for the person to go on feeling bad for a long time. In Social Anxiety Disorder it's
common for the person to recover quickly his habitual emotional condition.
 4. Social Phobia Added to Panic Disorder - The person begins with typical Panic
Disorder crises and associates them with places or situations he is in. These places
or situations trigger high anxiety. The person then avoids them because they "signal"
the possibility of anxiety attack.
 Common medicines used for treatment of phobia
 Buspirone 15-60mg POqd/bd

 Alprazolam(Xanax)0.5-4mg qd

 Lorazepam 2-6mg

 Atenolol 50mg

 Imipramine 50-100mg/d
NURSING MANAGEMENT:

  ASSESSMENT:
 1. Take the history from the patient.

 2. Assess the predisposing factors.

 3. Assess the age appropriate social relationship with

familiar people.
 4. Assess the previous history in the family.
NURSING DIAGNOSIS

  Fear R/T to causing embarrassment to self in front of

others, or a specific stimulus.
 Social isolation R/T fears of being in a place from which
one is unable to escape. face them rather than suppress
them.
  

Author’s Name Lisa M. Fisher, G. Terence Wilson  A study of the

psychology of agoraphobia
This study investigated the psychological characteristics of agoraphobics
seeking treatment. The personality characteristics, level of autonomic
arousal, cueing and attributional processes, marital satisfaction and
responses to marital conflict of agoraphobics were compared to those of
nonagoraphobics in a laboratory analysis.

The agoraphobics were more anxious, more depressed, less assertive and
reported feeling more powerless and helpless than non agora phobics. The
two groups did not differ in attention to internal cues, but the agoraphobics
mislabeled cues to a greater extent and reported different attributions from
the non agora phobics. There was no difference in reported marital
satisfaction, although the agoraphobics responded in a significantly
different manner to a videotaped scene of marital conflict. Differences were
noted between agoraphobics of short and long duration, respectively. 
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