Three types: agoraphobia, social phobia, specific phobia

Aetiology

• Typically early onset
  • Agoraphobia - 50% presented by 20; 75% by early 30’s
  • Social and specific phobias - 80% by early adolescence; 75% by early 20’s

Pathophysiology

• Fear recognised by patient as irrational
• Typified by avoidance and anticipatory anxiety

Agoraphobia

• A fairly well-defined cluster of phobias embracing fears of leaving home, entering shops, crowds and public places, or travelling alone in trains, buses or planes
• Avoidance of the phobic situation is often prominent, and some people with agoraphobia experience little anxiety because they are able to avoid their phobic situations
• May be a primary disorder or, more often, secondary to other pathology (e.g. panic disorder or depression)

Clinical features

• Often involves other people, alcohol or technology to avoid anxiety
  • Others do shopping (for or with the patient)
  • Drink alcohol to overcome fear
  • Go shopping to 24 hour store at night (when quiet)
  • Internet shopping

ICD-11 criteria

• Fear of open spaces and associated factors like the presence of crowds or the perceived difficulty of immediate easy escape to a safe place, usually home (may occur with or without panic disorder)

Management

1. Self-help
2. CBT or SSRI if long standing or no benefit from CBT
3. Consider tricyclics e.g. clomipramine, desipramine if there is no improvement after 12 weeks and further medication is indicated

Specific phobia

• 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 or insects, receiving an injection or seeing blood