Specific Phobia

1. Anxiety disorders: (Simple phobia) Specific Phobia

2. A. Marked and persistent fear that is excessive or unreasonable, cued by the presence or anticipation of a specific object or situation (e.g., flying, heights, animals, receiving an injection, seeing blood). Definition:

3. B. Exposure to the phobic stimulus almost invariably provokes an immediate anxiety response, Note: In children, the anxiety may be expressed by crying, tantrums, freezing, or clinging. Definition:

4. C. The person recognizes that the fear is excessive or unreasonable.Note: In children, this feature may be absent. D. The phobic situation(s) is avoided Definition:

5. E. The avoidance, anxious anticipation, or distress in the feared situation(s) interferes significantly with the person's normal routine, occupational (or academic) functioning, or social activities or relationships, or there is marked distress about having the phobia. Definition:

6. F. In individuals under age 18 years, the duration is at least 6 months. G. The anxiety, panic attacks, or phobic avoidance associated with the specific object or situation are not better accounted for by another mental disorder, such as OCD(e.g., fear of dirt in someone with an obsession about contamination), PTSD(e.g., avoidance of stimuli associated with a severe stressor), SAD(e.g., avoidance of school), social phobia (e.g., avoidance of social situations because of fear of embarrassment), panic disorder with agoraphobia, or agoraphobia without history of panic disorder. Definition:

7. 1. Animal type 2 .Natural environment type(e.g., heights, . storms, water) 3 . Blood-injection-injury type 4 . Situational type (e.g., airplanes, elevators, . enclosed places) 5 . Other type(e.g., fear of choking, vomiting, . or contracting an illness; in children, fear . of loud sounds or costumed characters) Specify type::

8. Normal - abnormal barrier ? : “clinically significant” distress Impaired functioning ? Clinical judgment Organizing ideas: Empiricism/ E-B Medicine / Translational Science/ . Development Final diagnose:

9. Many people report subclinical fears of specific objects 12 month prevalence: 1/9 % in china to 8/7% in US Life time prevalence: 1/5 to 10/8 percent Boys: 1 - 7.7 Girls: 2 – 17.8 percent Bimodal age of onset: childhood peak for animal, natural, and blood -injury phobias Early adulthood peak for others (situational) epidemiology

10. Anxiety disorders: (social anxiety disorder) social Phobia

11. Life time prevalence of anxiety disorders in IRAN (CTP): agoraphobia: 0.7% social phobia: 0.8 GAD: 1.3% panic: 1.5% OCD: 1.8% All anxiety disorders : 8.4% Life time prevalence of social phobia in IRAN: 0/8% Mohammadi MR, Davidian H, Noorbala AA, Malekafzali H, Naghavi HR: An epidemiological survey of psychiatric disorders in Iran. Clinic PractEpidemioMent Health. 2005;26; 1:16. Mohammadi MR, Ghanizadeh, A, Mohammadi M, Mesgarpour B: Prevalene of social phobia and its comorbidity with psychiatric disorders in Iran. Depress Anxiety. 2006;23(7) : 405. epidemiology

12. Social phobia : 0.2 – 15% Highest prevalence in new zealand the lowest prevalence = Asian countries ( china & Korea= 0/2) more common in Female than men Boys: 2 – 8% Girls: 2 – 14% Onset: late childhood and early adulthood epidemiology

13. A-A marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. The individual fears will be humiliating or embarrassing.Note: In children, there must be evidence of the capacity for age-appropriate social relationships with familiar people and the anxiety must occur in peer settings, not just in interactions with adults. Definition:

14. B- Exposure to the feared social situation almost provokes anxiety, Note: In children, the anxiety may be expressed by crying, tantrums, freezing, or shrinking from social situations with unfamiliar people. C- The person recognizes that the fear is excessive or unreasonable.Note: In children, this feature may be absent. Definition:

15. D-The feared social or performance situations are avoided or else are endured with intense anxiety or distress. E-The avoidance, anxious anticipation, or distress in the feared social or performance situation(s) interferes significantly with the person's normal routine, occupational (academic) functioning, or social activities or relationships, or there is marked distress about having the phobia. Definition:

16. F-In individuals under age 18 years, the duration is at least 6 months. G-The fear or avoidance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition and is not better accounted for by another mental disorder (e.g., panic disorder with or without agoraphobia, separation anxiety disorder, body dysmorphic disorder, a pervasive developmental disorder, or schizoid personality disorder). Definition:

17. H-If a general medical condition or another mental disorder is present, the fear in Criterion A is unrelated to it (e.g., the fear is not of stuttering, trembling in Parkinson's disease, or exhibiting abnormal eating behavior in anorexia nervosa or bulimia nervosa). Specify if:   Generalized: if the fears include most social situations (also consider the additional diagnosis of avoidant personality disorder) Definition:

20. Behavioral factors: classic stimulus response theory operant conditioning theory Psychoanalytic factors: phobic neurosis/ signal anxiety ( id, separation, castration, superego) defense mechanisms: repression, displacement, symbolization, avoidance Environmental stressors: humiliation, criticism Etiology of phobias

21. Genetic factors: Specific phobia tends to run in families. The blood-injection-injury type has a particularly high familial tendency. First-degree relatives of social phobia are about three times more likely to be affected with social phobia. Monozygotic twins are more often concordant than are dizygotic twins Neurochemical Factors: peformance phobia : release more norepinephrine or epinephrine generalized social phobia: dopaminergic activity Etiology of phobias

22. First step: exclude medical illness ( asthma, hypoglycemia, cardiac problems and seizure, hyperthyroidism, pheochromocytoma, tumor, drug use or withdrawal In general, appropriate management initially involves pharmacotherapy & CBT Beta adrenergic antagonists : propranolol 20- 40 mg per dose & atenolol 25 – 50 mg per dose for performance anxiety or 30 – 60 minutes before performance situation. management

23. antidepressants: SSRIs & venlafaxine for general social anxiety : effective doses are the same for depression but to start with lower initial doses than in depression and titrate upward more slowly. Therapeutic response 8 -12 weeks at an optimized dose. management

24. Benzodiazepines: PRN basis in performance anxiety ( alprazolam / lorazepam / clonazepam) BNZ add to antidepressants for better effect in less than optimal response to antidep. Atypical antipsychotics:limited to augmentation of antidepressants- resistant anxiety Duration: 1 to 2 years thentapering: 10 to 25% every 1 to 2 months. CBT:exposure ( systematic Desensitization / vivo exposure / imaginal exposure) is the treatment of choice for specific phobia and social phobia. management

25. پسر كلاس اول دبستان. چپ دست / پدر كمرو / روابط اجتمايي محدود كلاس دوم راست دستش مي كنند در سالهاي بعدي:كمرو (خجالتي) دبيرستان: آشكار شدن فوبياي اجتمايي ورود به دانشگاه با تداوم فوبياي اجتمايي ورود به دوره دستياري : اقدام به درمان براي اولين بار: شناخت درماني + مواجهه سازي + ايندرال گزارش مورد

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