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). [1]
Exposure to the phobic object or situation will invariably provokes an anxiety attack. It may take the form of a situationally provoked panic attack. [1]
The person recognizes the fear is excessive or unreasonable. Although adults recognize that the fear is unreasonable, children may not. [1]
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. [1]
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. [2]
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. [2]
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. [1]
References
  1. OLLENDICK TH, RAISHEVICH N, DAVIS TE III, SIRBU C, ÖST LG. Specific Phobia in Youth: Phenomenology and Psychological Characteristics Behav Ther [online] 2010 Mar, 41(1):133-141 [viewed 19 June 2014] Available from: doi:10.1016/j.beth.2009.02.002
  2. BURSTEIN M, GEORGIADES K, HE JP, SCHMITZ A, FEIG E, KHAZANOV GK, MERIKANGAS K. Specific Phobia among U.S. Adolescents: Phenomenology and Typology Depress Anxiety [online] 2012 Dec, 29(12):1072-1082 [viewed 19 June 2014] Available from: doi:10.1002/da.22008

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. [1]
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. [2]
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. [3]
Mental State Examination: Speech Normal. May speak slowly if the patient has co morbid depression. [3]
Mental State Examination: Mood. Associated symptoms like palpitations, dry mouth, tremor when faced with a feared situation. [3]
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. [3]
Mental State Examination: Perception. They do not have any illusions or hallucinations. [3]
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. [3]
Mental State Examination: Cognitive function. Normal. [3]
Mental State Examination: Insight Insight is preserved. [3]
References
  1. WATKINS LL, BLUMENTHAL JA, BABYAK MA, DAVIDSON JR, MCCANTS CB JR, O’CONNOR C, SKETCH MH JR. Prospective association between phobic anxiety and cardiac mortality in individuals with coronary heart disease Psychosom Med [online] 2010 Sep, 72(7):664-671 [viewed 19 June 2014] Available from: doi:10.1097/PSY.0b013e3181e9f357
  2. BYSTRITSKY A, KHALSA SS, CAMERON ME, SCHIFFMAN J. Current Diagnosis and Treatment of Anxiety Disorders P T [online] 2013 Jan, 38(1):30-57 [viewed 19 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3628173
  3. BURSTEIN M, GEORGIADES K, HE JP, SCHMITZ A, FEIG E, KHAZANOV GK, MERIKANGAS K. Specific Phobia among U.S. Adolescents: Phenomenology and Typology Depress Anxiety [online] 2012 Dec, 29(12):1072-1082 [viewed 19 June 2014] Available from: doi:10.1002/da.22008

Differential Diagnoses

Fact Explanation
Panic disorder with agoraphobia. They have a more pervasive type of anxiety, unlike in person's with specific phobia whose anxiety features are present only when faced with a specific object or a situation. And panic disorder with agoraphobia is characterized by the initial experience of panic attacks and subsequent avoidance of such situations. Where as in specific phobias the anxiety attacks are born due to situations. [1]
Social phobia Differentiated by the focus of the fears. [2]
Post traumatic stress disorder can identify a life threatening stressor and features like re experiencing trauma and restricted effect is present. [3]
Obsessive compulsive disorder The avoidance is associated with the content of the obsession. (E.g. avoiding dirt) [3]
Separation anxiety disorder. Avoidance behavior is exclusively limited to situations in which the person fears of being separated from the persons he or she attached. [4]
Hypochondriasis Avoidance of situations that may lead to contracting an illness. They are preoccupied with fears of already having a disease but individual with specific phobia fear contracting a disease. [3]
Anorexia nervosa and bulimia nervosa Avoidance behavior is exclusively limited top the avoidance of food and avoidance of food related cues. [4]
Schizophrenia or other psychotic disorders. May avoid certain activities in response to delusions. But does not recognize that the fear is excessive or unreasonable. [3]
References
  1. MCTEAGUE LM, LANG PJ, LAPLANTE MC, BRADLEY MM. Aversive imagery in panic disorder: Agoraphobia severity, comorbidity and defensive physiology Biol Psychiatry [online] 2011 Sep 1, 70(5):415-424 [viewed 19 June 2014] Available from: doi:10.1016/j.biopsych.2011.03.005
  2. LETAMENDI AM, CHAVIRA DA, STEIN MB. Issues in the Assessment of Social Phobia: A Review Isr J Psychiatry Relat Sci [online] 2009, 46(1):13-24 [viewed 19 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2925842
  3. BYSTRITSKY A, KHALSA SS, CAMERON ME, SCHIFFMAN J. Current Diagnosis and Treatment of Anxiety Disorders P T [online] 2013 Jan, 38(1):30-57 [viewed 19 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3628173
  4. BEESDO K, KNAPPE S, PINE DS. Anxiety and Anxiety Disorders in Children and Adolescents: Developmental Issues and Implications for DSM-V Psychiatr Clin North Am [online] 2009 Sep, 32(3):483-524 [viewed 19 June 2014] Available from: doi:10.1016/j.psc.2009.06.002

Investigations - for Diagnosis

Fact Explanation
ECG and echocardiogram To exclude any underlying cardiac disease. Conditions like arrhythmia and supra ventricular tachycardia. [1]
Thyroid Function Tests. TSH and free T4 levels. To exclude thyroid disease giving rise to anxiety episodes. [2]
References
  1. WATKINS LL, BLUMENTHAL JA, BABYAK MA, DAVIDSON JR, MCCANTS CB JR, O’CONNOR C, SKETCH MH JR. Prospective association between phobic anxiety and cardiac mortality in individuals with coronary heart disease Psychosom Med [online] 2010 Sep, 72(7):664-671 [viewed 19 June 2014] Available from: doi:10.1097/PSY.0b013e3181e9f357
  2. BYSTRITSKY A, KHALSA SS, CAMERON ME, SCHIFFMAN J. Current Diagnosis and Treatment of Anxiety Disorders P T [online] 2013 Jan, 38(1):30-57 [viewed 19 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3628173

Management - General Measures

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. [1]
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. [2]
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. [3]
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). [3]
References
  1. BURSTEIN M, GEORGIADES K, HE JP, SCHMITZ A, FEIG E, KHAZANOV GK, MERIKANGAS K. Specific Phobia among U.S. Adolescents: Phenomenology and Typology Depress Anxiety [online] 2012 Dec, 29(12):1072-1082 [viewed 19 June 2014] Available from: doi:10.1002/da.22008
  2. ARIKIAN SR, GORMAN JM. A Review of the Diagnosis, Pharmacologic Treatment, and Economic Aspects of Anxiety Disorders Prim Care Companion J Clin Psychiatry [online] 2001, 3(3):110-117 [viewed 19 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC181171
  3. COTTRAUX J. Nonpharmacological treatments for anxiety disorders Dialogues Clin Neurosci [online] 2002 Sep, 4(3):305-319 [viewed 19 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3181686

Management - Specific Treatments

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. [1]
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. [1]
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. [2]
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. [2]
References
  1. ARIKIAN SR, GORMAN JM. A Review of the Diagnosis, Pharmacologic Treatment, and Economic Aspects of Anxiety Disorders Prim Care Companion J Clin Psychiatry [online] 2001, 3(3):110-117 [viewed 19 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC181171
  2. PACHANA NA, WOODWARD RM, BYRNE GJ. Treatment of specific phobia in older adults Clin Interv Aging [online] 2007 Sep, 2(3):469-476 [viewed 19 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2685257