Dr. M.J. Bazos, Patient Handout
PHOBIAS

About Your Diagnosis
In simple terms, a phobia is a fear of some behavior or some event. This fear is often accompanied by physical signs such as rapid heart rate, shortness of breath, feeling of a lump in the throat, tightness in the chest, and diarrhea. Individuals will often go to great lengths to avoid the stimulus that causes their fear or phobia, if that is possible. It is only when such fears become so intense that they interfere with social and occupational functioning that the attention of a psychiatrist is sought. In social phobia, there is a significant and long-lasting fear of one or more social situations in which individuals might be exposed to unfamiliar people or to possible scrutiny by others.

Living With Your Diagnosis
Individuals with a social phobia have a fear that they will act in a humiliating or embarrassing way. Such activities as writing a check in public, eating in a restaurant, and using a public restroom facility are examples of behavior that individuals with social phobia will try to avoid. If, however, these situations cannot be avoided, exposure to them almost always creates significant anxiety, which may even lead to a panic attack. Individuals with social phobia realize that the fear they are experiencing is unreasonable and excessive, but they are still unable to control it. Their only relief comes from avoiding the specific activity that they fear. An individuals’ occupation may enhance exposure to the phobic event, such as individuals who work in a bank, or who are accountants or secretaries, where writing in full view of others may be part of the job. In that case, there can be a significant impairment in their occupational functioning. The most common phobias are the specific phobias. Individuals with specific phobias have a marked, long-lasting fear which is excessive or unreasonable that is caused by the presence of a specific object or situation. The most common objects r situations that provoke specific phobias are fear of flying, fear of heights (acrophobia), fear of spiders (arachniphobia), fear of strangers (xenophobia), or fear of receiving an injection, fear of seeing blood, and fear of being in small spaces (claustrophobia). Exposure to one of these events or situations causes significant anxiety that can escalate into a full-blown panic attack. Therefore individuals try to avoid whatever might be causing the fear or phobia. In some situations, this is fairly easy. For those individuals who fear snakes, being a city dweller will greatly minimize their exposure to snakes. Therefore, avoidance of them will be easy. Other situations obviously are hard to avoid. Individuals who have a fear of closed in places often cannot ride an elevator, and cannot have certain procedures done that involve closed in areas, such as a magnetic resonance imaging (MRI) scan. These individuals will have more trouble avoiding phobic situations than those who have a specific fear of animals or blood. Phobias are among the most common of all psychiatric disorders. The specific phobias are more common in women than in men, although there are some differences in terms of types of phobia in each group. The incidence of social phobias in males and
females is about the same. Most phobias begin in the middle-to-late teenage years, but often phobias of animals, blood, storms, and water begin in early childhood. Phobias of height tend to begin in the teens, whereas situational phobias such as claustrophobia begin in the late teens to middle 20s. If the occurrence rates of specific phobias in males and females are compared, we find that women are much more likely than men to have a fear of (1) spiders, bugs, mice, and snakes; (2) public transportation, such as buses and planes; (3) elevators; (4)water (being in a swimming pool or lake); (5) storms; and (6) closed places. Males and females are equally fearful of heights. Men and women are equally affected by a fear of speaking to strangers or meeting new people, and by a fear of eating in front of others. Women are only slightly more likely to have a fear of public speaking. There is no specific factor that may cause a phobia, although there probably is a genetic component because these disorders tend to run in families. Some phobias begin after a traumatic event, but many patients cannot recall the specific onset of their phobia. The onset of the phobia or fear can be sudden or gradual.

Treatment
In the treatment of phobia, the main goal is to decrease fear to a level that no longer causes significant distress, and to minimize the need to avoid the object or situation the patient fears, so that the ability to function is no longer impaired. Treatment also serves to improve some of the skills that phobic avoidance may have prevented the individual from obtaining or developing adequately, such as driving or social skills. Typically, an effective treatment for social phobia lasts several months, although the treatment of some specific social phobias, such as public speaking, may take less time. Specific phobias can be treated relatively quickly. In fact, the vast majority of individuals with phobias of animals, blood, or injections are able to overcome their phobias in one session of behavioral treatment. Phobias can be effectively treated by using medications, behavioral techniques, or both. There is a marked difference in the response of social phobia and specific phobias to medication. Medication has generally been ineffective for the specific phobias. If medications are used, they are generally used to treat the consequences of the phobia, such as panic disorder, in which case the antidepressant imipramine and the serotonin drugs Paxil and Prozac are used. Therefore, medications that are effective for panic disorder may prove to be effective for situational phobias as well. In contrast to the specific phobias, the social phobias have been treated successfully with medication. The monoamine oxidase (MAO) inhibitor antidepressants, such as phenelzine (Nardil), are very effective for many patients with social phobias. The benzodiazepines such as clonazepam (Klonopin) and alprazolam (Xanax) have also shown some beneficial effects, as have the beta-blockers such as Atenolol and Inderal, which are used extensively for performance anxiety. Often, Inderal or Atenolol will be given to individuals who are stage performers just before their activity. These drugs decrease significantly some of the signs of anxiety, especially tachycardia or a sense of the heart pounding. In contrast to drug therapy, numerous studies have shown that exposure-based treatments are effective for treating patients with specific phobias, including fear of blood, injections, dentists, animals, enclosed places, flying, heights, and choking. Also, the way in which individuals are exposed to these specific fears may make a difference in how well they respond to treatment. Exposure seems to work best when sessions are spaced close together, and prolonged exposure seems to be more effective than exposure for a short duration. During exposure to the object that is feared, patients should be discouraged from engaging in avoidance techniques such as distraction or thinking of something else, or overuse of different safety techniques such as being accompanied by someone during exposure. Gradual exposure to the feared object is the most common behavioral treatment for phobias and is very effective for the specific phobias. For instance, an individual with a fear of driving may initially spend some time washing a car, staying in the garage with a car, and then gradually advance to sitting in the car in the garage, sitting in the car in the driveway,
backing the car out of the driveway, and so on. This gradual exposure to the feared event can offer the individual ways of dealing with the anxiety that comes from being near the feared object. Biofeedback often is helpful in helping the individual control his heart rate and breathing when exposed to
the object.

In summary, there are three basic types of phobias: (1) agoraphobia, (2) social phobias, and (3) specific phobias. Agoraphobia is a fear of wide open spaces and the fear of being trapped without being able to return home. Social phobias are fears of performing certain activities in public or areas where the activity may be witnessed; for example, writing checks in public or eating in public. Specific phobias are fears of specific objects or situations, such as a fear of flying, fear of driving, fear of animals, fear of snakes, fear of strangers, fear of heights, and fear of closed places. It seems that the social phobias respond very well to medication, in particular to such drugs as the MAO inhibitor, Nardil. In contrast, the specific phobias respond much better to behavioral techniques, such as gradual exposure to the object and rating the anxiety produced by that, and then using biofeedback, hypnosis, or some other technique to diminish the anxiety. There are side effects that can result from the medications used to treat phobias. In particular, patients who are taking the MAO inhibitor, Nardil, must follow certain dietary restrictions as well as avoid certain medications. Such patients cannot eat aged cheeses or fava beans and cannot drink red wine, especially Chianti wine. Also, patients should avoid the use of medications such as Demerol, any epinephrine-containing compounds, and cocaine while taking the MAO inhibitor. Patients must also avoid using any other antidepressants such as imipramine, Elavil, or Prozac within 2 weeks of being on the MAO inhibitor. If these dietary and medication restrictions are not followed, the MAO inhibitor may cause a severe hypertensive crisis. There-fore, patients who already have high blood pressure should not take this medication. Of course, the benzodiazepines such as Klonopin and Ativan can decrease respirations, so they should not be used in patients who have serious lung disease. They also tend to produce sedation, which may impair driving or activity that requires delicate machinery. The benzodiazepines have the additional problem of being potentially addictive. The tricyclic antidepressants such as imipramine can cause blurred vision, dry mouth, possible constipation, rapid heartbeat, and in some cases oversedation.

The DOs
If you do have a phobic disorder, it is very important to report this condition to your physician. Many individuals, especially some males, are embarrassed to admit their fear to certain objects. Specific phobias, however, can be successfully treated, often in a single session. Because phobias are anxiety disorders, it is important to avoid undo stress. It is also important to minimize the use of stimulants, including caffeine and sugar in your diet. Getting plenty of exercise often provides an outlet for the anxiety associated with phobias, as well as relieving some of the consequences of phobias. If you do have a phobia of specific objects that can be successfully avoided without significant impairment of your functioning, such as snakes, then you should do so.

The DON’Ts
You should not take any medications without consulting with your physician. Many over-thecounter (OTC) medications have some stimulant properties and can increase the anxiety associated with phobias. Such OTC drugs as Valerian Root may interact with antidepressants.

When to Call Your Doctor
You should call your physician if you notice phobic attacks occurring more often, if you have physical complications from increased anxiety, or if you become depressed and suicidal because of a phobic condition.

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