Psychiatry and Behavioral Health Rotation

Psychiatry EOR: Specific phobias

Patient will present as → a 21-year-old female who is nervous about an upcoming spring break extravaganza in Cabo San Lucas with her three best friends. She comes to your office requesting something to help her "make it through the flight." The last time she was scheduled to go on a plane she ended up canceling her flight and taking the bus instead. She knows her fear is excessive but no matter how hard she tries she just can't overcome it.

Key Points:

  • Marked and persistent (> 6 months) fear that is excessive or unreasonable
  • Cued by presence or anticipation of specific object or situation
  • Types: animal/insect, environment, blood/infections, situational (closed spaces), other

DSM-5 Diagnostic Criteria

  • Marked fear or anxiety about a specific object or situation (e.g., flying, heights, animals, receiving an injection, seeing blood). Note: In children, the fear or anxiety may be expressed by crying, tantrums, freezing, or clinging.
  • The phobic object or situation almost always provokes immediate fear or anxiety.
  • The phobic object or situation is actively avoided or endured with intense fear or anxiety.
  • The fear or anxiety is out of proportion to the actual danger posed by the specific object or situation and to the sociocultural context.
  • The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.
  • The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  • The disturbance is not better explained by the symptoms of another mental disorder, including fear, anxiety, and avoidance of situations associated with panic-like symptoms or other incapacitating symptoms (as in agoraphobia); objects or situations related to obsessions (as in obsessive-compulsive disorder); reminders of traumatic events (as in posttraumatic stress disorder); separation from home or attachment figures (as in separation anxiety disorder); or social situations (as in social anxiety disorder).

Code is based on specific phobia - 5 types

  1. Animal/insects
  2. Natural phenomena (storms, heights, water)
  3. Blood-injection injury (invasive procedures, blood, needles, contamination)
  4. Situational (bridges, flying, confined spaces)
  5. Other (vomiting, choking, becoming sick, death)

Treat with exposure therapy (first line), teach to relax and try to understand/overcome the fear

  • SSRI + CBT
  • Short acting benzodiazepines such as alprazolam (i.e prior to flying)
  • Treat agoraphobia just as GAD with SSRIs and CBT
Question 1
A phobia is an excessive fear of an object or place that leads to or can be preceded by:
A
panic attack
B
depression
C
hallucinations
D
delusions
E
confabulations
Question 1 Explanation: 
Patients who have a phobia realize it is an irrational fear and try to avoid whatever they have the fear of. In attempts to avoid the “problem,” patients can develop anxiety or panic attacks.
Question 2
A 50-year-old male presents to your clinic complaining of intense fear of snakes for 2 years. Whenever he sees a picture of snakes or hears someone talking about snakes, he gets diaphoretic, nervous, and has an intense sense of doom. Which of the following is the first-line treatment for his most likely diagnosis?
A
Benzodiazepines
Hint:
Benzodiazepines or beta-blockers may be used for short term, but they are not supposed to be used long term.
B
Propranolol
Hint:
Benzodiazepines or beta-blockers may be used for short term, but they are not supposed to be used long term.
C
Exposure therapy
D
SSRIs
Hint:
There is minimal evidence to support the use of selective serotonin reuptake inhibitors (SSRIs) for the treatment of specific phobias
Question 2 Explanation: 
Specific phobia is the most common psychiatric disorder in the United States. It is defined as persistent (>6 months) intense fear of a specific situation, object, or place that provokes a reaction, causes fear out of proportion to normal, and makes the person avoid the stimuli. Types of phobias include animals, natural environment, situational, or injury. For most patients newly diagnosed with specific phobia, first-line treatment is cognitive-behavioral therapy (CBT) which includes exposure therapy. Benzodiazepines or beta-blockers may be used for short term, but they are not supposed to be used long term.
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