PHOBIAS

INTRODUCTION

 The word is derived from the Greek phobos meaning extreme fear and flight. The ancient Greek god, Phobos, was believed to be able to reduce the enemies of the Greeks to a state of abject terror, making victory in battle more likely.

Fear, aversion, or the strong aversion tested by people of any age or any gender is generally named like phobia. It is an intensive, most of the time an unexplainable concern and a fear in certain specific situations or compared to certain specific objects which at the end carries out to the action to avoid with this situation or object.

Definition

Phobia is persistent avoidance behaviour secondary to irrational fear of a specific object, activity or situation.

Marks has defined phobia on the  following  four criteria:

1 The fear is out of proportion to the demands of the situation

2 It cannot be explained or reasoned away

3 It is beyond voluntary control

4 The fear leads to an avoidance of the feared situation.

Epidemiology

Phobias affects people of all the ages, all the long walks of the life, and in each place in world. The national institute of the mental health has disclosed that 5.1%-12.5% of Americans have phobias. Phobias forms the psychiatric disease commonest between the women of all the ages and is the second common disease between the men oldest of 25, according to NIMH statistic.

Aetiology

A Behavioural Factors

1Stimulus Response Model

Involves the traditional Pavlovian stimulus response model of the conditioned response to account for the creation of phobia. That is, anxiety is aroused by a naturally frightening  stimulus that occurs in contiguity with a second inherently neutral stimulus .As a result of the contiguity, especially when the two stimuli are paired on several occasions, the originally neutral stimulus  takes on the capacity to arouse anxiety by itself. The neutral stimulus, therefore, becomes a conditioned stimulus for anxiety production.

2 Operant Conditioning Theory

In the classic stimulus response theory, the conditioned stimulus gradually loses its potency to arouse a response, if it is not reinforced by a periodic repetition of the unconditioned stimulus. In the phobic symptoms the attenuation of the response to the phobic stimulus (that is reconditioning of stimulus) does not occur. The symptom may last for years without any apparent external reinforcement. The operant conditioning theory provides a model to explain that phenomenon .According to it, anxiety is a drive that motivates the organism to do what it can, to obviate the painful affect. In the course of its random behaviour, the organism learns that certain actions enable it to avoid the anxiety-provoking stimulus.Those avoidance patterns remains stable for long periods of time; as a result of the reinforcement they receive from their capacity to diminish activity.

   B Psychoanalytic Theories

According to the psychoanalytic theory, the major function of anxiety is a signal to the ego, that a forbidden unconscious drive is pushing for conscious expression, thus altering the ego to strengthen and marshal its defences against the threatening instinctual force.

 In social and specific phobia, the conflict is regarding sexual arousal, leading to castration anxiety. When repression fails to be entirely successful, the ego must call on auxiliary defences. These defences in social and specific phobia are of displacement, symbolization and avoidance .In agoraphobia, it is the separation anxiety playing a central role .

Regions of the brain associated with phobias

Neurobiology

Phobias are generally caused by an event recorded by the amygdala and hippocampus and labelled as deadly or dangerous; thus whenever a specific situation is approached again the body reacts as if the event were happening repeatedly afterward. Treatment comes in some way or another as a replacing of the memory and reaction to the previous event perceived as deadly with something more realistic and based more rationally. In reality most phobias are irrational, in that the subconscious association causes far more fear than is warranted based on the actual danger of the stimulus; a person with a phobia of water may admit that their physiological arousal is irrational and over-reactive, but this alone does not cure the phobia

Phobias are more often than not linked to the amygdala, an area of the brain located behind the pituitary gland in the limbic system. The amygdala may trigger secretion of hormones that affect fear and aggression. When the fear or aggression response is initiated, the amygdala may trigger the release of hormones into the body to put the human body into an "alert" state, in which they are ready to move, run, fight, etc. This defensive "alert" state and response is generally referred to in psychology as the fight-or-flight response.

Classification

According  to ICD-10

F40-48 Neurotic, Stress-Related and Somatoform Disorders

F40 Phobic Anxiety Disorders

F40.0 Agoraphobia

        .00 Without panic disorder

        .01 With panic disorder

F40.1Social phobias

F40.2 Specific (isolated) phobias

F40.8 Other Phobic anxiety disorders

F40.9 Phobic anxiety disorder, Unspecified

SIGNS AND SYMPTOMS

Specific phobia (formerly called simple phobias, most common in children)

Social Phobia

Agoraphobia

Specific Phobia

 It is an irrational fear of a specific object or stimulus. Simple phobias are common in childhood .By early teenage most of these fears are lost, but a few persist till adult life. Sometimes they may reappear after a symptom-free period. Exposure to the phobic object often results in panic attack.

 Common examples of specific phobias, which can begin at any age, include animal type, example fear of insects, snakes, and dogs; natural environment type example; high places; and open spaces, situational type example escalators, elevators, and bridges and other types

Signs &Symptoms

Irrational and persistent fear of object or situation

Immediate anxiety on contact with feared object or situation

Loss of control, fainting, or panic response.

Avoidance of activities involving feared stimulus.

Anxiety when thinking about stimulus.

Worry with anticipatory anxiety.

Possible impaired social or work functioning.

Social Phobia

  It is an irrational fear of performing activities in the presence of other people or interacting with others. The patient is afraid of his own actions being viewed by others critically, resulting in embarrassment or humiliation.

Social phobia is not the same as shyness. Shy people may feel uncomfortable with others, but they do not experience severe anxiety, they do not worry excessively about social situations beforehand, and they do not avoid events that make them feel self-conscious. On the other hand, people with social phobia may not be shy; they may feel perfectly comfortable with people except in specific situations. Social phobias may be only mildly irritating, or they may significantly interfere with daily life. It is not unusual for people with social phobia to turn down job offers or avoid relationships because of their fears.

Signs &Symptoms

Hyperventilation

Sweating, cold, and clammy hands

Blushing

Palpitations

Confusion

Gastrointestinal symptoms

Trembling hands and voice

Urinary urgency

Muscle tension

Anticipatory anxiety

Fear or embarrassment or ridicule

Agoraphobia

It is characterised by an irrational fear of being in places away from the familiar setting of home, in crowds, or in situations that the patient cannot leave easily.

Usually begins between ages 15 and 35 and affects three times as many women as men or approximately 3 percent of the population.

As the agoraphobia increases in severity, there is a gradual restriction in normal day-to-day activities. The activity may become severely restricted that the person becomes self imprisoned at home.

Signs &Symptoms

Overriding fear of open or public spaces (primary symptom)

Deep concern that help might not be available in such places.

Avoidance of public places and confinement to home.

When accompanied by panic disorder, fear that having panic attack in public will lead to embarrassment or inability to escape (for symptoms of a panic attack).

Differential features of common phobias

Agoraphobia	Anxiety about or avoidance of being trapped in situations or places with no way to escape easily if panic develops. Agoraphobia is more common than panic disorder. It affects 3.8% of women and 1.8% of men during any 6-mo period. Peak age of onset is the early 20s; first appearance after age 40 is unusual.
Specific Phobia	Clinically significant anxiety induced by exposure to a specific situation or object, often resulting in avoidance. Specific phobias are the most common anxiety disorders but are often less troubling than other anxiety disorders. They affect 7% of women and 4.3% of men during any 6-mo period.
Social Phobia	Clinically significant anxiety induced by exposure to certain social or performance situations, often resulting in avoidance. Social phobias affect 1.7% of women and 1.3% of men during any 6-mo period. However, more recent epidemiologic studies suggest a substantially higher lifetime prevalence of about 13%. Men are more likely than women to have the most severe form of social anxiety, avoidant personality disorder.

 

Facts and Tips about Phobic Disorders

1. Phobic Disorders is common form of anxiety disorder, having unreasonable fear of certain situations, conditions, or substance.
2. Phobic Disorders is further divided into three types such as agoraphobia, social phobia (social anxiety disorder) and specific phobias.
3. Agoraphobia includes fear of that places from where escape is difficult. Social phobia is fear of certain social or presentation situations and specific phobias includes fear about specific situation or object.
4. Patient is aware during this situation but cannot control it.
5. Distress, anxiety and avoidance of situation that causes fear, decreased attention and memory, travelling on buses, trains or planes are some symptoms of phobic disorders. 
6. Treatment for phobic disorders includes exposure therapy, cognitive-behavior therapy, antidepressant drugs therapy, facing situation systematically and social skills training.

KINDS OF PHOBIA AND THEIR MEANING

Phobia Feared Object or Situation

Acrophobia     - Heights
Aerophobia      - Flying
Agoraphobia    - Open spaces, public places
Aichmophobia   - Sharp pointed objects
Ailurophobia       - Cats
Amax phobia        - Vehicles, driving
Anthropophobia      - People
Aqua phobia             - Water
Arachnophobia       - Spiders
Astraphobia             - Lightning
Batrachophobia       - Frogs, amphibians
Blennophobia          - Slime
Brontophobia          - Thunder
Carcinophobia         - Cancer
Claustrophobia       - Closed spaces, confinement
Clinophobia           - Going to bed
Cynophobia           - Dogs
Dementophobia     - Insanity
Dromophobia         -Crossing streets
Emetophobia         - Vomiting
Entomophobia        - Insects
Genophobia             - Sex
Gephyrophobia       - Crossing bridges
Hematophobia          - Blood
Herpetophobia          - Reptiles
Homilophobia        -Sermons
Linonophobia         - String
Monophobia             -Being alone
Musophobia             - Mice
Mysophobia              -Dirt and germs
Nudophobia             - Nudity
Numerophobia         -Numbers
Nyctophobia             - Darkness, night
Ochlophobia            - Crowds
Ophidiophobia          -Snakes
Ornithophobia            - Birds
Phasmophobia           - Ghosts
Pnigophobia                - Choking
Pogonophobia              - Beards
Siderodromophobia      - Trains
Taphephobia                   - Being buried alive
Thanatophobia                 - Death
Trichophobia                    - Hair
Triskaidekaphobia           - The number 13
Trypanophobia                  - Injections
Zoophobia                         - Animals

Treatment

Psychotherapy

Behavior therapy

Pharmacotherapy

Supportive therapy

Insight-oriented Psychotherapy

Is superior to psychoanalytic psychotherapy. Insight-oriented psychotherapy enables the patient to understand the origin of the phobia, phenomena of secondary gain and the role of resistance, and enables the patient to seek healthy ways of dealing with anxiety provoking stimuli.

Behaviour therapy

Cognitive behaviour therapy and various techniques of behaviour therapy like desensitization; flooding and social skill training are used.

Desensitization is carried out entirely in imagination and geared around the hierarchy of anxiety provoking situations whereas in flooding most therapeutic effect is concentrated at the top of hierarchy. The therapist teaches the patient various techniques to deal with the anxiety , including relaxation, breathing control and cognitive approaches to situation.

One cognitive-behavioral therapy is desensitization (also known as exposure therapy), in which people are gradually exposed to the frightening object or event until they become used to it and their physical symptoms decrease

 For example, someone who is afraid of snakes might first be shown a photo of a snake. Once the person can look at a photo without anxiety, he might then be shown a video of a snake. Each step is repeated until the symptoms of fear (such as pounding heart and sweating palms) disappear. Eventually, the person might reach the point where he can actually touch a live snake. Three-fourths of affected people are significantly improved with this type of treatment

  Another, more dramatic, cognitive-behavioral approach is called flooding. It exposes the person immediately to the feared object or situation. The person remains in the situation until the anxiety lessens.

Social skill training includes such methods as modelling and role-playing.  All the three types of behaviour therapies are useful in the treatment

  The key aspects of successful behaviour therapy

The patient’s commitment to treatment

Clearly identified problems and objectives

Available alternative strategies for coping with the patient’s feelings.

Cognitive-behavioural treatment of social phobia includes imaginal exposure, in which patients visualize their own participation in phobic events, performance based exposure in which patients enacted simulated phobic situations during sessions, cognitive restricting, in which patient’s cognitions experienced during exposure situation and home work assignments involving confrontation of environmental events. Most patient gain significantly and improvement is maintained at 3 and 6 months.

Pharmacotherapy

For generalized  type or social phobia

Antidepressant -Phenelzine,imipramine,sertraline.  

 Benzodiazipines- clonazepam, alprazolam, lorazepam, diazepam and  SSRI have been found useful.

  Supportive therapy

The support afforded to patients by a positive relationship with their physicians has a beneficial effect.

Eye Movement Desensitization and Reprocessing (EMDR) has been demonstrated in peer-reviewed clinical trials to be effective in treating some phobias. Mainly used to treat Post-traumatic stress disorder, EMDR has been demonstrated as effective in easing phobia symptoms following a specific trauma, such as a fear of dogs following a dog bite. Hypnotherapy coupled with Neuro-linguistic programming can also be used to help remove the associations that trigger a phobic reaction. However, lack of research and scientific testing compromises its status as an effective treatment. These treatment options are not mutually exclusive. Often a therapist will suggest multiple treatments.

Prognosis

Phobias are among the most treatable mental health problems; depending on the severity of the condition and the type of phobia, most properly treated people can go on to lead normal lives. Research suggests that once a person overcomes the phobia, the problem may not return for many years, if it returns at all. Children most often outgrow their specific phobias, with or without treatment.
Untreated phobias are another matter. In adults, only about 20 percent of specific phobias go away without treatment, and agoraphobia gets worse with time if untreated. Social phobias tend to be chronic and are not likely go away without treatment. Moreover, untreated phobias can lead to other problems, including depression, alcoholism, and feelings of shame and low self-esteem. Therefore, specific phobias that persist into adolescence should receive professional treatment.
A group of researchers in Boston reported in 2003 that phobic anxiety appears to be a risk factor for Parkinson's disease (PD) in males, although as of 2004 it is not known whether phobias cause PD or simply share an underlying biological cause .While most specific phobias appear in childhood and subsequently fade away, those that remain in adulthood often need to be treated. Unfortunately, most people never get the help they need; only about 25 percent of people with phobias ever seek help for their condition.

Nursing management

Assessment

Focus on physical symptoms, precipitating factors, avoidance behavior associated with phobia, impact of anxiety on physical functioning, normal coping ability,thought content and social support systems.

Nursing diagnosis 1

Fear related to a specific stimulus or causing embarrassment to self in front of others, evidenced by behaviour directed towards avoidance of the feared object/situation.

Objective:

Patient will be able to function in the presence of a phobic object or situation without experiencing panic anxiety.

Nursing interventions

Reassure the patient that he is safe

Explore patient’s perception of the threat to physical integrity or threat to self concept.

Include patient in making decisions related to selection of alternative coping strategies.

If the patient elects to work on eliminating the fear, techniques of desensitization or implosion therapy may be employed.

Encourage patient to explore underlying feelings that may be contributing to irrational fears.

Nursing Diagnosis 2

Social isolation related to fear of being in a place from which one is unable to escape, evidenced by staying alone, refusing to leave the room/home.

 Objective:

Patient will voluntarily participate in group activities with peers.

Interventions

Convey an accepting attitude and unconditional positive regard.

 Make brief, frequent contacts.

 Be honest and keep all promises.

Attend group activities with the patient that may be frightening for him.

Administer anti-anxiety medications as ordered by physician, monitor for effectiveness and adverse effects.

 Discuss with the patient signs and symptoms of increasing anxiety and techniques to interrupt the response.

Give recognition and positive reinforcement for voluntary interactions with others.

Nursing diagnosis-3

Ineffective coping related to the fear attacks associated with disease condition

Nursing diagnosis -4

Ineffective communication pattern related to the fear associated with social gatherings

 Evaluation

Effectiveness of planned interventions will be demonstrated in the patient’s ability to recognize and deal with the anxiety producing factors .Relaxed participation in unit activities and reports longer periods of restful sleep indicates reduced anxiety.

Conclusion

Phobias vary in severity among individuals. Some individuals can simply avoid the subject of their fear and suffer relatively mild anxiety over that fear. Others suffer full-fledged panic attacks with all the associated disabling symptoms. Most individuals understand that they are suffering from an irrational fear, but they are powerless to override their initial panic reaction.

References

Ø  Kaplan Harold I, Sadock Benjamin J Cmprehensive text book of psychiatry vol.1,5^th edn Willliams&Wilkins 972-983

Ø  Dr.Lalitha K Mental  health and psychiatric nursing an Indian perspective,V.G.M book house 354-358

Ø  Sreevani R A guide to mental health& psychiatric nursing 3^rd edn Jaypee publishers 171-175

Ø  StuartGailW,LaraiaMicheleT.Principles and practice of Psychiatric nursing.8^th edn.Elsevier.272,276

Ø  www.nlm.nih.gov/medlineplus/phobias.html  retrieved on 17.6.2011 @ 7.30pm

Ø  http://www.depression-guide.com/phobic-disorder.htm retrieved on 30.6.2011@11pm