Diagnosis & Treatment of Phobias with Cognitive Restructuring Interventions

1. Epidemiology and aetiology
Phobias are anxiety disorders involving emotional and physical reactions to feared objects or situations that vary in severity among sufferers.

Some patients will be able to avoid the subject of their fear, some will have panic attacks with disabling symptoms and others will be unable to lead normal lives.

Epidemiology
Approximately one in 10 people will have troublesome anxiety or phobias at some point in their lives; most will understand that their fear is out of proportion to the stimulus, but facing their fear, or even thinking about it, can bring on a either a panic attack or severe anxiety. Unfortunately, most individuals affected do not seek treatment from their GP either because they don't understand that phobias are real, albeit very treatable, illnesses, or because of the stigma which surrounds mental health problems.

A common phobia is fear of dentists and according to a study from the British Psychological Society one in 10 people avoid going to a dentist.

According to the National Phobics Society, anxiety disorders are commonplace and an estimated 13 percent of the adult population will develop a specific phobia at some point in their lives (see table right).

Aetiology
Recent research suggests that heredity, genetics and brain chemistry combine with life experience to lead to the development of phobias.

Some researchers highlight biological, dispositional, learning and psychodynamic theories. It is possible for an individual to develop a phobia over anything; most phobias start in teenage and adult years and some may run in families, with women twice as likely to suffer from phobias as men.

Classification
Phobias have been defined and classified by both the updated DSM-IV and ICD-10 criteria under anxiety disorders such as social phobias, agoraphobias and specific phobias.

Social phobias are very common and can be extremely debilitating. Cultural differences as well as age might explain under-reporting and delay in seeking medical opinion. There is a high prevalence of comorbidities, and in some cases a high risk of suicide.

2.TYPES OF PHOBIAS
Most specific phobias spring from a trigger event, generally a traumatic experience at an early age. Most patients will report an immediate response of uncontrolled anxiety when exposed to the object of their fear or, in extreme cases, when anticipating this event.

Specific phobias relate to distinct objects or situations such as black cats. While the presentation is straightforward, it is important to exclude physical problems like hyperthyroidism and to be alert to the concomitant use of alcohol as a coping strategy.

Clinical features
Mental symptoms include feeling worried all the time, feeling tired, inability to concentrate, irritableness and disrupted sleep patterns. Physical symptoms include palpitations, sweating, muscle tension and pain, heavy breathing, dizziness, indigestion, diarrhoea and feeling faint.

Social phobias
These occur after puberty, peak after 30 and affect 1-2 percent of men and 2-3 percent of women. Social phobias relate to a specific situation, and generalised social phobias involve fear of a variety of situations.

Agoraphobia
Agoraphobia develops between the ages of 18 and 35 with either a sudden or gradual onset; two thirds of sufferers are women. Most people develop agoraphobia after a spontaneous panic attack. The randomness of panic attacks 'trains' sufferers to anticipate future attacks and to fear situations in which an attack may occur. It is the most disabling phobia and treatment is difficult.

Behaviour therapy
Treatment options are not mutually exclusive and multiple treatments may be required to achieve the best results.

Cognitive behavioural therapy helps patients to understand their negative thought patterns and how to change them. Desensitisation involves slowly exposing the patient to the object or situation they fear until the fear begins to fade.

Flooding immerses the patient in the fear reflex until the fear dissipates; the key is to keep patients in the feared situation long enough so that they can see that the predicted consequences do not materialise. Counter-conditioning teaches patients to substitute a relaxation response for the fear response when confronted by a phobic stimulus. Additionally, systemic desensitisation can be paired with modelling to achieve successful outcomes.

In mild cases, posthypnotic suggestions can be used to help patients control their breathing and heart rate and create a relaxed state of mind that enables them to calmly and rationally overcome their fear.

Just 20 percent of phobias go away on their own, making early diagnosis and treatment essential. If phobias are caught early they are extremely responsive and rewarding to treat; most patients who seek treatment make rapid, long-lasting progress.

When to refer
If patients fail to respond to primary care treatment, or if their phobia is part of a complex presentation involving symptoms of depression or other problematic illnesses, they should refer them to a consultant psychiatrist to receive specialist treatment.

KEY POINTS
•           Phobias affect one in 10 people.
•           Phobias usually start in teenage and adult years.
•           Most specific phobias have a trigger event.
•           Agoraphobia usually develops after a panic attack.

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Personal Reflection Exercise Explanation
The Goal of this Home Study Course is to create a learning experience that enhances your clinical skills. We encourage you to discuss the Personal Reflection Journaling Activities, found at the end of each Section, with your colleagues. Thus, you are provided with an opportunity for a Group Discussion experience. Case Study examples might include: family background, socio-economic status, education, occupation, social/emotional issues, legal/financial issues, death/dying/health, home management, parenting, etc. as you deem appropriate. A Case Study is to be approximately 225 words in length. However, since the content of these “Personal Reflection” Journaling Exercises is intended for your future reference, they may contain confidential information and are to be applied as a “work in progress.” You will not be required to provide us with these Journaling Activities.

Personal Reflection Exercise #1
The preceding section contained information about types of phobias. Write three case study examples regarding how you might use the content of this section in your practice.

Online Continuing Education QUESTION 15
What percentage of phobias disappear on their own? Record the letter of the correct answer the CEU Answer Booklet.