AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

A phobia is defined as an irrational fear that produces a conscious avoidance of the feared subject, activity, or situation. The affected person usually recognizes that the reaction is excessive. Phobic disorders can be divided into 3 types: social phobia, specific phobias, and agoraphobia.

The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)¹ and its subsequent Text Revision (DSM-IV-TR) defines social phobia is a strong, persisting fear of an interpersonal situation in which embarrassment can occur and specific phobia as a strong, persisting fear of an object or situation. Agoraphobia is defined as the fear of being alone in public places (e.g., a supermarket), particularly places from which a rapid exit would be difficult in the course of a panic attack. At least 75% of patients with agoraphobia experience panic disorder as well.

Social phobia has been described as far back as Hippocrates as erythrophobia, which is a fear of blushing in front of others, and is now considered as a disorder distinct from other phobias. In the first two versions of DSM, social phobia was not conceptualized as a stand alone diagnosis but starting with DSM-III-R, the disorder could be diagnosed separately in the presence of multiple social fears and other comorbid conditions.

Specific phobia is more common than social phobia. The following types of specific phobia are described:

• Animal type (fear of dogs, spiders, snakes, or other animals)
• Natural environment type (e.g., height, water, storm)
• Blood injection/injury type
• Situational type (e.g., planes, elevators, enclosed spaces)
• Other

Collectively, these disorders are the most common forms of psychiatric illness, surpassing rates of mood disorders and substance abuse. Anxiety linked to a specific object or situation is the most common subtype. Severity can range from mild and unobtrusive to severe and can result in incapacity to work, travel, or interact with others.

Pathophysiology

Sympathetic nervous system activation is common in the phobic disorders, resulting in elevations in heart rate and blood pressure, as well as symptoms such as tremor, palpitations, sweating, dyspnea, dizziness, and/or paresthesias. Cognitive distortions, such as fear of scrutiny by others or fear that one is trapped without escape, also are common.

Several theories are postulated for the biological etiology of phobic disorders, most focusing on the dysregulation of endogenous biogenic amines. Genetic factors also play a role in both social phobia and specific phobia, especially blood-injection-injury type, where two thirds to three fourths of patients have at least one affected first-degree relative.

Psychological theories range from explaining anxiety as a displacement of an intrapsychic conflict (psychodynamic models) to conditioning (learned) paradigms (the cognitive-behavior models). Many of these theories capture portions of the disorder. A psychoanalyst would likely conceptualize social anxiety as a symptom of a deeper conflict—for instance, low self-esteem or unresolved conflicts with internal objects. The treatment uses exploration with the goal of understanding the underlying conflict. A behaviorist would see phobia as an learned conditioned response, resulting from a past association with a situation with negative emotional valence at the time of association. E.g., social situations are avoided because intense anxiety was originally experienced in that setting. Even if there is no danger in most social encounters, an avoidance response has been linked to these situations. Treatment from this perspective aims to weaken and eventually separate the specificresponse from the stimulus.

Frequency

United States

The National Comorbidity Survey reported the following lifetime (and 30-day) prevalence estimates: 6.7% (and 2.3%) for agoraphobia, 11.3% (and 5.5%) for simple phobia, and 13.3% (and 4.5%) for social phobia². Social phobia is the most common anxiety disorder; it has an early age of onset -by age 11 years in about 50% and by age 20 years in about 80% of individuals that have the diagnosis -and it is a risk factor for subsequent depressive illness and substance abuse³.

Phobias are highly comorbid. Most comorbid simple and social phobias are temporally primary, while most comorbid agoraphobia is temporally secondary. Comorbid phobias are generally more severe than pure phobias. Despite evidence of role impairment in phobia, only a minority of individuals with phobia ever seek professional treatment

International

European data generally are similar to those of the United States.

Mortality/Morbidity

Controversy exists whether anxiety disorders in general and phobias in particular are independently associated (i.e., after adjusting for comorbid mental disorders) with suicidal ideation and suicide attempts. New evidence suggests that even after adjusting for socio-demographic factors and other mental disorders baseline presence of any anxiety disorder, including agoraphobia, social phobia and specific phobias, is significantly associated with suicidal ideation and suicide attempts. Additionally, the presence of any anxiety disorder, phobias included,  in combination with a mood disorder appears to increase likelihood of suicide attempts in comparison with a mood disorder alone⁴.

Significant morbidity is possible in terms of work and relationships, especially in social phobia and agoraphobia.

Race

The occurrence of phobias appears equally distributed among races.

Sex

• Specific phobia has a female-to-male ratio of 2:1.
• Social phobia is more common in women, but more men seek treatment due to career issues.
• Agoraphobia has a female-to-male ratio of 2-3:1.

Age

Most anxiety disorders appear earlier in life. Animal phobias are most common at the elementary school level. Earlier median ages at illness onset are reported for simple (15 years of age) and social (16 years of age) phobias than for agoraphobia (29 years of age)².

• Specific phobia: Age of onset depends on the phobia. In general, specific phobia appears earlier than social phobia or agoraphobia. Examples include the following: Animal phobia appears at a mean age of 7 years. Blood phobia appears at a mean age of 9 years. Dental phobia appears at a mean age of 12 years. Claustrophobia appears at a mean age of 20 years. Most simple phobias develop during childhood and eventually disappear. Those that persist into adulthood rarely go away without treatment.
• Social phobia: Most social phobias begin before age 20 years.
• Agoraphobia: Agoraphobia usually begins in late adolescence to early adulthood.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

• Social phobia: Ask the patient about any difficulties in social situations, such as speaking in public, eating in a restaurant, or using public washrooms. Fear of scrutiny by others or of being embarrassed or humiliated is described commonly by people with social phobia.
• Agoraphobia: Inquire about any intense anxiety reactions that occur when the patient is exposed to specific situations such as heights, animals, small spaces, or storms. Other areas of inquiry should include fear of being trapped without escape (e.g., being outside the home and alone; in a crowd of unfamiliar people; on a bridge, in a tunnel, in a moving vehicle.
• Specific phobias: If specific phobias are suspected specific questions about irrational and out of proportion fear to specific situations (e.g., animals, insects, blood, needles, flying, heights) need to be asked.
• Phobias can be disabling and cause severe emotional distress, leading to other anxiety disorders, depression, suicidal ideation and substance-related disorders, especially alcohol abuse or dependence. The physician must inquire about these areas as well.

Physical

Anxiety is the most common feature in phobic disorders. Manifestations include the following (which should be asked about and examined):

• Elevated heart rate
• Elevated blood pressure
• Tremor
• Palpitations
• Diarrhea
• Sweating
• Dyspnea
• Paresthesias
• Dizziness

Causes

• Social phobia can be initiated by traumatic social experience (eg, embarrassment) or by social skills deficits that produce recurring negative experiences. A hypersensitivity to rejection, perhaps related to serotonergic or dopaminergic dysfunction, is present. Current thought is that social phobia appears to be an interaction between biological and genetic factors and environmental events.
• Specific phobia can be acquired by conditioning, modeling, traumatic experience, or even may have a genetic component (eg, blood-injury phobia).
• Agoraphobia may be the result of repeated, unexpected panic attacks, which, in turn, may be linked to cognitive distortions, conditioned responses, and/or abnormalities in noradrenergic, serotonergic, or gamma-aminobutyric acid (GABA)–related neurotransmission.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Depersonalization disorder
Seizure
Vertigo
Vestibular dysfunction

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

To rule out anxiety secondary to medical conditions:

• Thyroid function tests - Hypothyroidism or hyperthyroidism 
• Fasting glucose - Hypoglycemia
• Calcium - Hyperparathyroidism
• Electrocardiogram and cardiac enzyme tests - Myocardial infarct
• 24-hour urine for 5-hydroxyindoleacetic acid (5-HIAA) - Pheochromocytoma

To rule out substance induced anxiety:

• Drug screen 

Imaging Studies

• Imaging studies are limited to presentations where medical illness, such as a seizure disorder, is suspected.
• • Head CT scan - Suspected intracranial abnormality
  • MRI - Intracranial abnormality
  • Echocardiogram - Mitral valve prolapse

Other Tests

• ECG may be used to exclude arrhythmia and EEG may be used to exclude seizure disorder because these conditions may mimic anxiety.
• Provocation studies with carbon dioxide, sodium lactate, or yohimbine, as well as positron emission tomography (PET) studies, are reserved for research purposes at this point.

Procedures

Not applicable.

Histologic Findings

Not applicable.

Staging

Not applicable.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical Care

Treatment usually consists of a combination of pharmacotherapy (see Medication) and/or psychotherapy⁵. Behavioral therapy and cognitive behavioral therapy have demonstrated efficacy through controlled studies⁶. Psychodynamic therapy (or insight oriented therapy) is rarely indicated as an exclusive treatment ifor phobias and is now mostly used for cases of phobic disorders ovelapping with personality disorders. Deciding which treatment or combination of treatments to prescribe depends on a careful interview and assessment of the patient's goals and level of pathology.

Patient prognosis is determined by several factors, including:

• Severity of diagnosis
• Level of functioning prior to onset of symptoms
• Degree of motivation for treatment
• Level of support (e.g., family, friends, work, school)
• Ability to comply with medication and/or psychotherapeutic regimen

Surgical Care

Not applicable.

Consultations

Internal medicine or neurological consultation may be helpful to sort through the nonpsychiatric differential, especially if rare disorders, such as pheochromocytoma, are suspected.

Diet

Inquire about the amount of caffeine intake (including coffee, caffeinated teas or sodas). Considering the overall noradrenergic hyperdrive of this group of patients it is likely that even moderate amounts of coffee might exacerbate the anxiety response and symptoms. In a recent small, double blind, placebo controlled study a tryptophan rich diet was shown to have a positive effect on social anxiety⁷. Dietary restrictions (a tyramine free diet) are necessary for the patients taking an MAOI.

Activity

Activity should not be restricted. In fact, patients should be encouraged to confront anxiety-producing stimuli in the context of a behavior therapy treatment plan.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Specific phobia

Specific phobia usually responds to behavioral therapy treatment. No controlled studies to date demonstrate the efficacy of psychopharmacological intervention. Gradual desensitization is the most commonly used treatment for specific phobia. Other treatments include cognitive approaches, relaxation, and breathing control techniques.

Agoraphobia

Agoraphobia, specifically the panic attacks that usually occur, most often responds to treatment with a selective serotonin reuptake inhibitor (SSRI). Tricyclic antidepressants (TCAs) and monamine oxidase inhibitors (MAOIs) also have demonstrated efficacy in controlled trials. Benzodiazepines can be used either as an adjunct or as primary treatment. However, benzodiazepines usually are not chosen as a first-line treatment because of the potential for abuse, particularly if a previous history of substance dependence exists. Another effective form of treatment for panic disorder and agoraphobia is cognitive behavioral therapy. Family and group therapy also help.

Social phobia

Both pharmacotherapy and psychotherapy are useful in treating social phobia. Social phobia typically responds to either an SSRI or an MAOI. Failing this, patients sometimes respond to high-potency benzodiazepines. Beta-blockers, clonidine, and buspirone usually are not helpful for long-term treatment, although beta-blockers (eg, propranolol) may be useful for the circumscribed treatment of performance anxiety on a prn basis.

Drug Category: Antidepressant, Serotonin Reuptake Inhibitor

May require 2-6 weeks of daily use to become effective, usually not without side effects appearing first. Shown to be effective in controlled clinical trials. As a class, it tends to have the fewest adverse effects. However, these agents can produce drug-drug interactions through their inhibition of cytochrome P450 enzymes and by displacement of other drugs from protein binding sites.

SSRIs are greatly preferred over the other classes of antidepressants. Because the adverse effect profile of SSRIs is less prominent, improved compliance is promoted. SSRIs do not have the cardiac arrhythmia risk associated with tricyclic antidepressants. Arrhythmia risk is especially pertinent in overdose, and suicide risk must always be considered, particularly when treating a child or adolescent with mood disorder.

Physicians are advised to be aware of the following information and use appropriate caution when considering treatment with SSRIs in the pediatric population.

In December 2003, the UK Medicines and Healthcare Products Regulatory Agency (MHRA) issued an advisory that most SSRIs are not suitable for use by persons younger than 18 years for treatment of "depressive illness." After review, this agency decided that the risks to pediatric patients outweigh the benefits of treatment with SSRIs, except fluoxetine (Prozac), which appears to have a positive risk-benefit ratio in the treatment of depressive illness in patients younger than 18 years.

In October 2003, the US Food and Drug Administration (FDA) issued a public health advisory regarding reports of suicidality in pediatric patients being treated with antidepressant medications for major depressive disorder. This advisory reported suicidality (both ideation and attempts) in clinical trials of various antidepressant drugs in pediatric patients. The FDA has asked that additional studies be performed because suicidality occurred in both treated and untreated patients with major depression and thus could not be definitively linked to drug treatment.

Drug Name	Sertraline (Zoloft)
Description	Selectively inhibits presynaptic serotonin reuptake. Shorter half-life than fluoxetine. Tends to have fewer drug-drug interactions from inhibition of the cytochrome P450 system.
Adult Dose	50-200 mg/d PO
Pediatric Dose	6-12 years: 25 mg qd 13-17 years: 50 mg qd
Contraindications	Documented hypersensitivity
Interactions	While less likely to do so compared to fluoxetine, it still increases toxicity of diazepam, tolbutamide, and warfarin; can cause a serotonin syndrome when used with MAOIs
Pregnancy	C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions	Caution in preexisting seizure disorders and in those that have experienced a recent myocardial infarction, have unstable heart disease, and hepatic or renal impairment

Drug Name	Paroxetine (Paxil)
Description	In addition to selective inhibition of serotonin reuptake, also has anticholinergic effect that may result in sedation or cardiovascular effects.
Adult Dose	10-20 mg/d initially, followed by a maintenance dose of 10-60 mg/d
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity; concurrent administration with MAOIs or administering within 14 d of discontinuing an MAOI
Interactions	Phenobarbital and phenytoin decrease effects of paroxetine; alcohol, cimetidine, sertraline, phenothiazines, and warfarin increase toxicity of paroxetine; a potent inhibitor of cytochrome P450 system and can cause serotonin syndrome with MAOIs
Pregnancy	C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions	Caution in history of seizures, mania, renal disease, and cardiac disease

Drug Name	Citalopram
Description	Enhances serotonin activity due to selective reuptake inhibition at the neuronal membrane. No head-to-head comparisons of SSRIs exist, although, based on metabolism and adverse effects, citalopram is considered SSRI of choice for patients with head injury. SSRIs are the antidepressants of choice due to minimal anticholinergic effects. All are equally efficacious. The choice depends on adverse effects and drug interactions.
Adult Dose	20-60 mg PO qd; 10 mg/d initially, titrate by 10 mg/wk
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity; concurrent MAOI therapy
Interactions	May be potentiated by azole antifungals, omeprazole, macrolides; serotonin syndrome may be induced by buspirone, tramadol, MAOI, nefazodone; serotonin syndrome (ie, myoclonus, rigidity, confusion, nausea, hyperthermia, autonomic instability, coma, eventual death) occurs with simultaneous use of other serotonergic agents (eg, anorectic agents, tramadol, buspirone, trazodone, clomipramine, nefazodone, tryptophan), discontinue other serotonergic agents at least 2 wk prior to SSRIs
Pregnancy	C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions	Caution in cirrhosis, suicidal tendencies, SIADH; DM, and breast-feeding; common side effects include fatigue and sexual dysfunction

Drug Name	Fluoxetine (Prozac)
Description	Selectively inhibits presynaptic serotonin reuptake with minimal or no effect in the reuptake of norepinephrine or dopamine. In this patient population, initial anxiogenic effects occur, so either start with lower doses or educate patients about adverse effects. Sexual dysfunction is common, which may impact long-term compliance.
Adult Dose	20-80 mg/d PO
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity; concurrently taking MAOIs or having taken them in the last 2 wk
Interactions	Increases toxicity of drugs such as diazepam and trazodone by decreasing clearance through its cytochrome P450 enzyme inhibition; also increases toxicity of highly protein bound drugs; causes a serotonin syndrome with fever, muscle fasciculations, shivering, and altered mental status when used with MAOIs
Pregnancy	C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions	Caution in hepatic impairment and history of seizures; MAOIs should be discontinued at least 14 d before initiating fluoxetine therapy

Drug Name	Escitalopram
Description	Selective serotonin reuptake inhibitor (SSRI) and S-enantiomer of citalopram. Used for the treatment of depression. Mechanism of action is thought to be potentiation of serotonergic activity in central nervous system resulting from inhibition of CNS neuronal reuptake of serotonin. Onset of depression relief may be obtained after 1-2 wk, which is sooner than other antidepressants.
Adult Dose	10 mg PO qd initially; if needed, may increase to 20 mg/d after 1 wk
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity; administration within 14 d of receiving MAOI
Interactions	Primarily metabolized by CYP450 3A4 and 2C19; coadministration with alcohol or other centrally acting drugs increases CNS depression; cimetidine increases AUC and maximum serum concentration; coadministration with sumatriptan and SSRIs has caused weakness and hyperreflexia
Pregnancy	C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions	Caution with history of seizures, mania, suicide; common adverse effects include insomnia, ejaculation disorder (primarily ejaculatory delay), nausea, sweating, fatigue, and somnolence

Drug Category: Antidepressant, Selective Serotonin/norepinephrine Reuptake Inhibitor (ssnri)

This class of medication can help prevent panic attacks and alleviate symptoms of anxiety and depression.

Drug Name	Venlafaxine (Effexor)
Description	Reuptake inhibitor of both serotonin and norepinephrine.
Adult Dose	Immediate release: 75 mg/d PO divided bid-tid with food; increase in 75-mg/d increments q4d to 225-375 mg/d Extended release: 75 mg PO qd with food; increase in 75-mg/d increments q4d to 225 mg/d
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity; patients taking MAOIs or have taken them within 14 d of initiating therapy
Interactions	Cimetidine, MAOIs, sertraline, fluoxetine class I-C antiarrhythmics, TCAs; phenothiazine may increase the effects
Pregnancy	C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions	Patients on this medication may experience hypertension; fatal reaction may occur if taken concurrently with an MAOI; exercise caution in patients with cardiovascular disorders

Drug Category: 5-HT1 Agonist

Drug Category: Benzodiazepines

This category of medication should not, in general, be prescribed to patients with a history of alcohol/drug abuse or emotional dependence. Some psychiatrists feel that the longer-acting benzodiazepines (eg, diazepam, clonazepam) have advantages such as less frequent dosing and more consistent levels throughout the day. Slowly taper benzodiazepines (usually after 6 mo) to avoid withdrawal and precipitating panic.

Drug Name	Lorazepam (Ativan)
Description	Sedative hypnotic with short onset of effects and relatively long half-life. By increasing the action of GABA, which is a major inhibitory neurotransmitter in the brain, may depress all levels of CNS, including limbic and reticular formation. When patient needs to be sedated for longer than 24-hour period, this medication is excellent. Not significantly metabolized by the liver. Can be prescribed IV/IM.
Adult Dose	2-6 mg qd PO bid/tid 0.05 mg/kg IV/IM (4 mg maximum IV dose)
Pediatric Dose	0.02-0.1 mg/kg per dose IV/PO q4-8h; maximum 2 mg per dose
Contraindications	Documented hypersensitivity; preexisting CNS depression; hypotension; narrow-angle glaucoma
Interactions	Toxicity of benzodiazepines in CNS increases when used concurrently with alcohol, phenothiazines, barbiturates, and other CNS depressants
Pregnancy	D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions	Caution in renal or hepatic impairment, myasthenia gravis, organic brain syndrome, or Parkinson disease

Drug Category: Antidepressant, Tricyclic

Long history of demonstrated efficacy, relatively inexpensive. However, due to their broad spectrum of action and their inhibition of multiple neurotransmitter systems, they result in more side effects, such as anticholinergic and cardiovascular side effects, and therefore present problems for long-term treatment. Treatment response occurs on the same order as the SSRIs, within 2-6 weeks.

Drug Name	Nortriptyline (Pamelor)
Description	Has demonstrated effectiveness in the treatment of chronic pain. By inhibiting the reuptake of serotonin and/or norepinephrine by the presynaptic neuronal membrane, this drug increases the synaptic concentration of these neurotransmitters in the central nervous system. Pharmacodynamic effects such as the desensitization of adenyl cyclase and down-regulation of beta-adrenergic receptors and serotonin receptors also appear to play a role in its mechanisms of action.
Adult Dose	60-150 mg/d PO (can divide dose if needed)
Pediatric Dose	Children: Not established Adolescents: 30-50 mg/d PO (divided tid/qid); maximum 150 mg/d
Contraindications	Documented hypersensitivity; narrow-angle glaucoma; do not administer to patients that have taken MAOIs in last 2 wk
Interactions	Cimetidine may increase nortriptyline levels when used concurrently; nortriptyline may increase prothrombin time in patients stabilized with warfarin; while less likely than imipramine, it can still cause anticholinergic and cardiovascular drug interactions; similar risk as imipramine with MAOIs(can inhibit antihypertensive effects of clonidine and cause serotonin syndrome with MAOIs)
Pregnancy	D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions	Caution in cardiac conduction disturbances and history of hyperthyroidism or renal or hepatic impairment; due to pronounced effects in cardiovascular system, best to avoid in elderly patients

Drug Category: Antidepressant, Tetracyclic

Drug Category: Monoamine oxidase inhibitors

MAOIs most commonly are prescribed for patients with social phobia. Advantages of MAOIs are low risk of dependence and less anticholinergic effect than TCAs. Disadvantages are the higher number of adverse effects, including sexual difficulty, hypotension, and weight gain. A diet low in tyramine must be followed to avoid a hypertensive crisis. Over-the-counter medications should be used with great caution.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Inpatient Care

• Indicated only for severe cases presenting with acute suicidal ideation and/or attempt. Also, inpatient treatment including detox and/or rehab may be recommended for treatment of secondary drug and/or alcohol abuse or dependence.

Further Outpatient Care

• Outpatient follow-up usually is needed through resolution of symptoms. After symptoms are resolved, physician can (1) attempt a taper of medication and therapy and (2) monitor for relapse.

In/Out Patient Meds

• Continue medication regimen for at least 6-12 months.
• If symptoms have resolved and the patient is not experiencing excessive stress, the physician can taper the patient off medication gradually.
• Psychotherapy usually helps make the transition off medication more successful.

Transfer

• Physicians without expertise in conducting behavioral therapy may want to consult with a psychiatric center specializing in treatment of anxiety disorders for guidance on developing a treatment plan or for referral (for more difficult cases).

Deterrence/Prevention

• Overwhelming exposure in early childhood (eg, a frightening experience with an aggressive dog) may predispose the child to the development of phobic symptoms. Intervention (psychotherapy or medication) in the early stages of symptom development may be beneficial in preventing worsening of symptoms.

Complications

• Left untreated, social phobia or agoraphobia can result in tremendous morbidity. The patient becomes restricted to the most familiar surroundings (eg, house) or most trusted people (eg, family member, spouse). Therefore, the ability to work and relate to other people is significantly impaired. Significant risk of substance abuse exists with this degree of isolation.
• Patients with specific phobia also may be limited by having to avoid buildings (in the case of acrophobia), elevators (in the case of claustrophobia), or even their own lawn (eg, fear of snakes). Usually, less impairment is observed in specific phobia than in social phobia or agoraphobia.

Prognosis

• Most patients respond to treatment, with good resolution of symptoms.
• Patients with specific phobia often recover to the highest level of functioning, while agoraphobics or social phobics either may have residual symptoms or run a greater risk of relapse even after successful treatment.
• Social phobics with extensive deficits in social skills may not respond well to treatment.

Patient Education

• The treating physician should begin a process of education, not only for the patient but also for family and friends who may be confused about the diagnosis and the need for treatment. Abilities that most people take for granted such as socializing at gatherings or riding in a small elevator may seem commonplace, but patients who experience phobias have tremendous difficulty in these areas and can be helped significantly by a caring support system. Family and friends can encourage the patient to confront fears, help the patient when necessary (with medication compliance or confronting fearful situations), and also can learn when to stay out of the way and allow the patient to venture forth on his own.
• • Numerous books and self-help groups are available. In addition, patient advocacy groups exist nationwide to provide patients with information, presentations, and conferences. The following Web sites are helpful:
  • Social Phobia/Social Anxiety Association
  • American Psychiatric Association
  • Anxiety Disorders Association of America
• For excellent patient education resources, visit eMedicine's Anxiety Center. Also, see eMedicine's patient education articles Anxiety, Panic Attacks, and Hyperventilation.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Patients with social phobia have substantial associated morbidity such as increased suicidal ideation, social isolation, and substance abuse.
• Patients with severe agoraphobia may be housebound and therefore unable to seek out medical attention when needed. Patients with concomitant panic attacks are at higher risk for substance abuse and suicide.
• Many anxiety attack symptoms resemble those found in life-threatening medical disorders, such as myocardial infarction, which must be ruled out first.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC:. American Psychiatric Association Press;1994.
2. Magee WJ, Eaton WW, Wittchen HU, McGonagle KA, Kessler RC. Agoraphobia, simple phobia, and social phobia in the National Comorbidity Survey.Arch Gen Psychiatry. Feb 1996;53(2):159-68. [Medline].
3. Stein MB, Stein DJ. Social anxiety disorder. Lancet. Mar 2008;371(9618):1115-25. [Medline].
4. Sareen J, Cox BJ, Afifi TO, de Graaf R, Asmundson GJ, ten Have M, et al. Anxiety disorders and risk for suicidal ideation and suicide attempts: a population-based longitudinal study of adults. Arch Gen Psychiatry. 62(11);2005 Nov:1249-57. [Medline].
5. de Beurs E, van Balkom AJ, Van Dyck R. Long-term outcome of pharmacological and psychological treatment for panic disorder with agoraphobia: a 2-year naturalistic follow-up. Acta Psychiatr Scand. Jan 1999;99(1):59-67. [Medline].
6. Shear MK, Beidel DC. Psychotherapy in the overall management strategy for social anxiety disorder. J Clin Psychiatry. 1998;59 Suppl 17:39-46. [Medline].
7. Hudson C, Hudson S, MacKenzie J. Protein-source tryptophan as an efficacious treatment for social anxiety disorder: a pilot study. Can J Physiol Pharmacol. Sep 2007;85(9):928-32. [Medline].
8. Allgulander C. Paroxetine in social anxiety disorder: a randomized placebo-controlled study. Acta Psychiatr Scand. Sep 1999;100(3):193-8. [Medline].
9. Balon R, Mufti R, Arfken CL. A survey of prescribing practices for monoamine oxidase inhibitors. Psychiatr Serv. Jul 1999;50(7):945-7. [Medline].
10. Charney DS. Discovering the neural basis of human social anxiety: a diagnostic and therapeutic imperative. Am J Psychiatry. Jan 2004;161(1):1-2. [Medline].
11. Gelder MG. Combined pharmacotherapy and cognitive behavior therapy in the treatment of panic disorder. J Clin Psychopharmacol. Dec 1998;18(6 Suppl 2):2S-5S. [Medline].
12. Heimberg RG, Liebowitz MR, Hope DA. Cognitive behavioral group therapy vs phenelzine therapy for social phobia: 12-week outcome. Arch Gen Psychiatry. Dec 1998;55(12):1133-41. [Medline].
13. Kaplan HI, Sadock BJ. Comprehensive Textbook of Psychiatry. 6th ed. Philadelphia, Pa:. Lippincott Williams & Wilkins;1995.
14. Loerch B, Graf-Morgenstern M, Hautzinger M. Randomised placebo-controlled trial of moclobemide, cognitive-behavioural therapy and their combination in panic disorder with agoraphobia. Br J Psychiatry. Mar 1999;174:205-12. [Medline].
15. Lydiard RB. The role of drug therapy in social phobia. J Affect Disord. Sep 1998;50 Suppl 1:S35-9. [Medline].
16. Marcourakis T, Gorenstein C, Ramos RT. Serum levels of clomipramine and desmethylclomipramine and clinical improvement in panic disorder. J Psychopharmacol. 1999;13(1):40-4. [Medline].
17. Michelson D, Lydiard RB, Pollack MH. Outcome assessment and clinical improvement in panic disorder: evidence from a randomized controlled trial of fluoxetine and placebo. The Fluoxetine Panic Disorder Study Group. Am J Psychiatry. Nov 1998;155(11):1570-7. [Medline].
18. Otto MW, Pollack MH, Penava SJ. Group cognitive-behavior therapy for patients failing to respond to pharmacotherapy for panic disorder: a clinical case series. Behav Res Ther. Aug 1999;37(8):763-70. [Medline].
19. Pohl RB, Wolkow RM, Clary CM. Sertraline in the treatment of panic disorder: a double-blind multicenter trial. Am J Psychiatry. Sep 1998;155(9):1189-95. [Medline].
20. Stein MB, Fyer AJ, Davidson JR. Fluvoxamine treatment of social phobia (social anxiety disorder): a double-blind, placebo-controlled study. Am J Psychiatry. May 1999;156(5):756-60. [Medline].
21. Uhlenhuth EH, Balter MB, Ban TA. International study of expert judgment on therapeutic use of benzodiazepines and other psychotherapeutic medications: VI. Trends in recommendations for the pharmacotherapy of anxiety disorders, 1992-1997. - Yang K. 1999;rends in recommendations for the pharmacotherapy of anxiety disorders, 1992-199:107-16. [Medline].
22. Van Ameringen M, Allgulander C, Bandelow B. WCA recommendations for the long-term treatment of social phobia. CNS Spectr. Aug 2003;8(8 Suppl 1):40-52. [Medline].
23. Wittchen HU, Stein MB, Kessler RC. Social fears and social phobia in a community sample of adolescents and young adults: prevalence, risk factors and co-morbidity. Psychol Med. Mar 1999;29(2):309-23. [Medline].
24. Yudofsky SC, Hales RE. What''s new in neuropsychiatry [editorial]. J Neuropsychiatry Clin Neurosci. Winter 1999;11(1):1-4. [Medline].

Article Last Updated: Feb 25, 2005