Specific Phobia

Anxiety disorders

Clinicals - History

Fact Explanation
Marked and persistent fear that is excessive and unreasonable cued by a specific object or situation. Specific phobias are classified into five major types. 1) animal (insects, snakes, dogs), 2)natural environment (darkness, storms, heights), 3)situational (enclosed spaces, elevators, flying), 4)blood-injection-injury (seeing blood, receiving shots or injections), 5)other (choking, loud sounds, costumed characters). Marked and persistent fear that is excessive and unreasonable cued by a specific object or situation.
Specific phobias are classified into five major types. 1) animal (insects, snakes, dogs), 2)natural environment (darkness, storms, heights), 3)situational (enclosed spaces, elevators, flying), 4)blood-injection-injury (seeing blood, receiving shots or injections), 5)other (choking, loud sounds, costumed characters).
Exposure to the phobic object or situation will invariably provokes an anxiety attack. It may take the form of a situationally provoked panic attack. Exposure to the phobic object or situation will invariably provokes an anxiety attack.
It may take the form of a situationally provoked panic attack.
The person recognizes the fear is excessive or unreasonable. Although adults recognize that the fear is unreasonable, children may not. The person recognizes the fear is excessive or unreasonable.
Although adults recognize that the fear is unreasonable, children may not.
The phobic situation is avoided or endured with difficulty. The person is anxious in the presence of the object or the situation and has the anticipatory anxiety which creates the urge to avoid the encounter. The phobic situation is avoided or endured with difficulty.
The person is anxious in the presence of the object or the situation and has the anticipatory anxiety which creates the urge to avoid the encounter.
Anxiety, anxious anticipation or distress in the feared situation interferes with the person's day to day life. The person's occupational , social life is face with interference and person is distresses due to the anxiety and the effects it is having on his /her life. Anxiety, anxious anticipation or distress in the feared situation interferes with the person's day to day life.
The person's occupational , social life is face with interference and person is distresses due to the anxiety and the effects it is having on his /her life.
In individuals who are less than 18 years, the symptoms prevails at least for 6 months. Specific phobias are early on onset when compared to other anxiety disorders. In individuals who are less than 18 years, the symptoms prevails at least for 6 months.
Specific phobias are early on onset when compared to other anxiety disorders.
The anxiety, panic attacks or phobic avoidance is not better accounted for by another mental disorder. Obsessive-compulsive disorder, Post traumatic stress disorder, Separation anxiety disorder, Social phobia, Panic disorder with
agoraphobia or Agoraphobia without history of panic disorder.
The anxiety, panic attacks or phobic avoidance is not better accounted for by another mental disorder.
Obsessive-compulsive disorder, Post traumatic stress disorder, Separation anxiety disorder, Social phobia, Panic disorder with
agoraphobia or Agoraphobia without history of panic disorder.

Clinicals - Examination

Fact Explanation
Cardiovascular examination Symptoms of anxiety are seen in patients with ischemic heart disease and arrhythmia. Therefore a detailed examination of the cardiovascular system should be performed. Possible findings include: tachycardia, irregular pulse, tachypnoea. Cardiovascular examination
Symptoms of anxiety are seen in patients with ischemic heart disease and arrhythmia. Therefore a detailed examination of the cardiovascular system should be performed. Possible findings include: tachycardia, irregular pulse, tachypnoea.
Signs of hyperthyroidism Tachycardia, irregularly irregular pulse, tachypnoea, lid retraction, sweaty palms, hand tremors , restlessness can be seen in both hyperthyroidism and anxiety disorder. Thyroid goiter, exophthalmos, opthalmoplegia, fine hair due to hair loss, are specific to thyroid disease. Signs of hyperthyroidism
Tachycardia, irregularly irregular pulse, tachypnoea, lid retraction, sweaty palms, hand tremors , restlessness can be seen in both hyperthyroidism and anxiety disorder. Thyroid goiter, exophthalmos, opthalmoplegia, fine hair due to hair loss, are specific to thyroid disease.
Mental State Examination: Appearance Anxiety features are seen in particular situations only.Patient is free of anxiety in most of the times. But if the circumstances occur more frequently, patient will be anxious for most of the time.
The face looks strained,with furrowed brow. Posture is tensed tremors and sweating may be seen in the hands and the patient is restless. Also exclude co-morbid conditions like depression, where vertical furrows in the brow can be seen.
Mental State Examination: Appearance
Anxiety features are seen in particular situations only.Patient is free of anxiety in most of the times. But if the circumstances occur more frequently, patient will be anxious for most of the time.
The face looks strained,with furrowed brow. Posture is tensed tremors and sweating may be seen in the hands and the patient is restless. Also exclude co-morbid conditions like depression, where vertical furrows in the brow can be seen.
Mental State Examination: Speech Normal. May speak slowly if the patient has co morbid depression. Mental State Examination: Speech
Normal. May speak slowly if the patient has co morbid depression.
Mental State Examination: Mood. Associated symptoms like palpitations, dry mouth, tremor when faced with a feared situation. Mental State Examination: Mood.
Associated symptoms like palpitations, dry mouth, tremor when faced with a feared situation.
Mental State Examination: Thoughts Preoccupations of reasons for anxiety and fear of a catastrophic event may prolong the disorder. Patient may also show anticipatory anxiety when in the possibility of facing a feared situation in the foreseeable future. Mental State Examination: Thoughts
Preoccupations of reasons for anxiety and fear of a catastrophic event may prolong the disorder. Patient may also show anticipatory anxiety when in the possibility of facing a feared situation in the foreseeable future.
Mental State Examination: Perception. They do not have any illusions or hallucinations. Mental State Examination: Perception.
They do not have any illusions or hallucinations.
Mental State Examination: Depersonalization/ Derealization Depersonalization can occur during an anxiety attack. The patient will feel detached from their own body, and will experience a sense of 'unreality' about themselves. Mental State Examination: Depersonalization/ Derealization
Depersonalization can occur during an anxiety attack. The patient will feel detached from their own body, and will experience a sense of 'unreality' about themselves.
Mental State Examination: Cognitive function. Normal. Mental State Examination: Cognitive function.
Normal.
Mental State Examination: Insight Insight is preserved. Mental State Examination: Insight
Insight is preserved.

Investigations - Diagnosis

Fact Explanation
ECG and echocardiogram To exclude any underlying cardiac disease. Conditions like arrhythmia and supra ventricular tachycardia. ECG and echocardiogram
To exclude any underlying cardiac disease. Conditions like arrhythmia and supra ventricular tachycardia.
Thyroid Function Tests. TSH and free T4 levels. To exclude thyroid disease giving rise to anxiety episodes. Thyroid Function Tests.
TSH and free T4 levels. To exclude thyroid disease giving rise to anxiety episodes.

Management - Supportive

Fact Explanation
Exclude co- morbid depressive disorder. Anxiety symptoms can be present in depressive disorder or patients with an anxiety disorder can be depressed due to their condition. If depressive symptoms are present, treatment for depression should be started. Exclude co- morbid depressive disorder.
Anxiety symptoms can be present in depressive disorder or patients with an anxiety disorder can be depressed due to their condition. If depressive symptoms are present, treatment for depression should be started.
Assess the severity of the phobia and the interference in person's life due to the phobia. Amount of interference of daily life, work , in the relationships and person's occupational, social and academic impairment due to the condition. Assess the severity of the phobia and the interference in person's life due to the phobia.
Amount of interference of daily life, work , in the relationships and person's occupational, social and academic impairment due to the condition.
Explain the management plan to the patient and agree to a clear plan. Anxiety is prolonged by the uncertainty. A clear management plan will reduce it. Explain the management plan to the patient and agree to a clear plan.
Anxiety is prolonged by the uncertainty. A clear management plan will reduce it.
Provide and discuss information with the patient and the family members of the patient. To reduce or eliminate the fears about the nature of the symptoms and the consequence of the symptoms. And explain about the vicious cycle of anxiety. (e.g : when a person fears heights, the anxiety reaction of the person when face with such a situation heightens the fear of the person when he faced with the same situation next time). Provide and discuss information with the patient and the family members of the patient.
To reduce or eliminate the fears about the nature of the symptoms and the consequence of the symptoms. And explain about the vicious cycle of anxiety. (e.g : when a person fears heights, the anxiety reaction of the person when face with such a situation heightens the fear of the person when he faced with the same situation next time).

Management - Specific

Fact Explanation
Self help methods Make a list of feared situations and objects and arrange them in to the ascending order of the amount of fear. Encourage the patients to enter into situations that they have avoided, repeatedly, starting with those which provoke least fear.
The presence of a trusted and understanding companion will be a help in the initial period.
Self help methods
Make a list of feared situations and objects and arrange them in to the ascending order of the amount of fear. Encourage the patients to enter into situations that they have avoided, repeatedly, starting with those which provoke least fear.
The presence of a trusted and understanding companion will be a help in the initial period.
Pharmacotherapy - Anxiolytics - Benzodiazepines alprazolam
For the short term use only.
For immediate relief of symptoms when a well known phobia to the patient makes it difficult to face a particular task or an occasion.
If taken regularly dependence may occur. Adverse effects of benzodiazepines-physiological and psychological dependence, potential fatalities upon withdrawal, impaired cognition and coordination, a potentially lethal overdose when they are mixed with alcohol or opioids, inhibition of memory encoding, which can interfere with the efficacy of concomitant psychotherapy.
Pharmacotherapy - Anxiolytics - Benzodiazepines
alprazolam
For the short term use only.
For immediate relief of symptoms when a well known phobia to the patient makes it difficult to face a particular task or an occasion.
If taken regularly dependence may occur. Adverse effects of benzodiazepines-physiological and psychological dependence, potential fatalities upon withdrawal, impaired cognition and coordination, a potentially lethal overdose when they are mixed with alcohol or opioids, inhibition of memory encoding, which can interfere with the efficacy of concomitant psychotherapy.
Cognitive behavioral therapy (CBT) - Relaxation techniques Teach the patient relaxation techniques to use when faced with a feared situation or an object.
Relaxing muscle groups one by one, breathing slowly, clearing the mind on worrying thoughts by concentrating on calming things, situations.
Cognitive behavioral therapy (CBT) - Relaxation techniques
Teach the patient relaxation techniques to use when faced with a feared situation or an object.
Relaxing muscle groups one by one, breathing slowly, clearing the mind on worrying thoughts by concentrating on calming things, situations.
Cognitive behavioral therapy (CBT) - Graded exposure The treatment of choice for specific phobia is exposure techniques.
Exposure therapies are designed to encourage the individual to enter feared situations and to try to remain in those situations.
It is by Graded Exposure.
The situations to try are selected by an individually-tailored fear hierarchy that starts with situations that are only mildly anxiety-provoking and builds up to the most feared situations.
For an example, for a patient who is afraid of dogs, the graded exposure can start with giving the patient several pictures of dogs to look at, and then to proceed to watching videos of dogs and then to watch a real dog from a distance. When he/she c
an face those situations without the anxiety they can try petting a dog and to giving a dog a treat.
Cognitive behavioral therapy (CBT) - Graded exposure
The treatment of choice for specific phobia is exposure techniques.
Exposure therapies are designed to encourage the individual to enter feared situations and to try to remain in those situations.
It is by Graded Exposure.
The situations to try are selected by an individually-tailored fear hierarchy that starts with situations that are only mildly anxiety-provoking and builds up to the most feared situations.
For an example, for a patient who is afraid of dogs, the graded exposure can start with giving the patient several pictures of dogs to look at, and then to proceed to watching videos of dogs and then to watch a real dog from a distance. When he/she c
an face those situations without the anxiety they can try petting a dog and to giving a dog a treat.

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