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Main features of diagnostic criteria for specific phobia in the DSM-IV-TR:
- 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).
- Exposure to the phobic stimulus almost invariably provokes an immediate anxiety response, which may take the form of a situationally bound or situationally predisposed panic attack. In children, the anxiety may be expressed by crying, tantrums, freezing, or clinging.
- The person recognizes that the fear is excessive or unreasonable. In children, this feature may be absent.
- The phobic situation(s) is avoided or else is endured with intense anxiety or distress.
Specific Phobia – DSM 5 Criteria
- Fear or anxiety about a specific object or situation (In children fear/anxiety can 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 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 symptoms of another mental disorder, including fear, anxiety, and avoidance of situations associated with panic-like symptoms or other incapacitating symptoms; objects or situations related to obsessions; reminders of traumatic events; separation from home or attachment figures; or social situations
ICD-10 defines social phobia as a fear of scrutiny by other people leading to avoidance of social situations. The anxiety symptoms may present as a complaint of blushing, hand tremor, nausea or urgency of micturition. Symptoms may progress to panic attacks.
Standardized rating scales such as the Social Phobia Inventory, the SPAI-B, Liebowitz Social Anxiety Scale, and the Social Interaction Anxiety Scale can be used to screen for social anxiety disorder and measure the severity of anxiety.
Most people who present to mental health specialists develop agoraphobia after the onset of panic disorder. Agoraphobia is best understood as an adverse behavioral outcome of repeated panic attacks and subsequent anxiety and preoccupation with these attacks that leads to an avoidance of situations where a panic attack could occur. Early treatment of panic disorder can often prevent agoraphobia. Agoraphobia is typically determined when symptoms are worse than panic disorder, but also do not meet the criteria for other anxiety disorders such as depression. In rare cases where agoraphobics do not meet the criteria used to diagnose panic disorder, the formal diagnosis of agoraphobia without history of panic disorder is used (primary agoraphobia).
According to the fourth revision of the "Diagnostic and Statistical Manual of Mental Disorders", phobias can be classified under the following general categories:
- Animal type – Fear of dogs, cats, rats and/or mice, pigs, cows, birds, spiders, or snakes.
- Natural environment type – Fear of water (aquaphobia), heights (acrophobia), lightning and thunderstorms (astraphobia), or aging (gerascophobia).
- Situational type – Fear of small confined spaces (claustrophobia), or the dark (nyctophobia).
- Blood/injection/injury type – this includes fear of medical procedures, including needles and injections (trypanophobia), fear of blood (hemophobia) and fear of getting injured.
- Other – children's fears of loud sounds or costumed characters.
As noted by Altman, McGoey & Sommer, it is important to observe the child, "in multiple contexts, on numerous occasions, and in their everyday environments (home, daycare, preschool)". It is beneficial to view parent and child interactions and behaviors that may contribute to SAD.
Dyadic Parent-Child Interaction Coding System and recently the Dyadic Parent-Child Interaction Coding System II (DPICS II) are methods used when observing parents and children interactions.
Separation Anxiety Daily Diaries (SADD) have also been used to “assess anxious behaviors along with their antecedents and consequences and may be particularly suited to SAD given its specific focus on parent–child separation” (Silverman & Ollendick, 2005). The diaries are carefully evaluated for validity.
This form of assessment should not be the sole basis of a SAD diagnosis. It is also important to verify that the child who is reporting on their experiences has the cognitive and communication skills appropriate to accurately comprehend and respond to these measurements.
An example of a self-report tool that has been tested is: The Separation Anxiety Assessment Scale for Children (SAAS-C). The scale contains 34 items and is divided into six dimensions. The dimensions in order are: Abandonment, Fear of Being Alone, Fear of Physical Illness, Worry about Calamitous Events, Frequency of Calamitous Events, and Safety Signal Index. The first five dimensions have a total of five items while the last one contains nine items. The scale goes beyond assessing symptoms; it focuses on individual cases and treatment planning.
The terms "distress" and "impairment" as defined by the "Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition" (DSM-IV-TR) should also take into account the context of the person's environment if attempting a diagnosis. The DSM-IV-TR states that if a feared stimulus, whether it be an object or a social situation, is absent entirely in an environment, a diagnosis cannot be made. An example of this situation would be an individual who has a fear of mice but lives in an area devoid of mice. Even though the concept of mice causes marked distress and impairment within the individual, because the individual does not usually encounter mice, no actual distress or impairment is ever experienced. Proximity to, and ability to escape from, the stimulus should also be considered. As the phobic person approaches a feared stimulus, anxiety levels increase, and the degree to which the person perceives they might escape from the stimulus affects the intensity of fear in instances such as riding an elevator (e.g. anxiety increases at the midway point between floors and decreases when the floor is reached and the doors open).
Prevention of anxiety disorders is one focus of research. Use of CBT and related techniques may decrease the number of children with social anxiety disorder following completion of prevention programs.
The diagnosis of an anxiety disorder requires first ruling out an underlying medical cause. Diseases that may present similar to an anxiety disorder, including certain endocrine diseases (hypo- and hyperthyroidism, hyperprolactinemia), metabolic disorders (diabetes), deficiency states (low levels of vitamin D, B2, B12, folic acid), gastrointestinal diseases (celiac disease, non-celiac gluten sensitivity, inflammatory bowel disease), heart diseases, blood diseases (anemia), and brain degenerative diseases (Parkinson's disease, dementia, multiple sclerosis, Huntington's disease).
Also, several drugs can cause or worsen anxiety, whether in intoxication, withdrawal, or from chronic use. These include alcohol, tobacco, cannabis, sedatives (including prescription benzodiazepines), opioids (including prescription pain killers and illicit drugs like heroin), stimulants (such as caffeine, cocaine and amphetamines), hallucinogens, and inhalants.
Cognitive behavioral therapy (CBT) is commonly used to treat social phobia.
Treatment of social phobia usually involves psychotherapy, medication, or both.
Anxiety disorders are often severe chronic conditions, which can be present from an early age or begin suddenly after a triggering event. They are prone to flare up at times of high stress and are frequently accompanied by physiological symptoms such as headache, sweating, muscle spasms, tachycardia, palpitations, and hypertension, which in some cases lead to fatigue.
In casual discourse the words "anxiety" and "fear" are often used interchangeably; in clinical usage, they have distinct meanings: "anxiety" is defined as an unpleasant emotional state for which the cause is either not readily identified or perceived to be uncontrollable or unavoidable, whereas "fear" is an emotional and physiological response to a recognized external threat. The term "anxiety disorder" includes fears (phobias) as well as anxieties.
The diagnosis of anxiety disorders is difficult because there are no objective biomarkers, it is based on symptoms, which typically need to be present at least six months, be more than would be expected for the situation, and decrease functioning. Several generic anxiety questionnaires can be used to detect anxiety symptoms, such as the State-Trait Anxiety Inventory (STAI), the Generalized Anxiety Disorder 7 (GAD-7), the Beck Anxiety Inventory (BAI), the Zung Self-Rating Anxiety Scale, and the Taylor Manifest Anxiety Scale. Other questionnaires combine anxiety and depression measurement, such as the Hamilton Anxiety Rating Scale, the Hospital Anxiety and Depression Scale (HADS), the Patient Health Questionnaire (PHQ), and the Patient-Reported Outcomes Measurement Information System (PROMIS). Examples of specific anxiety questionnaires include the Liebowitz Social Anxiety Scale (LSAS), the Social Interaction Anxiety Scale (SIAS), the Social Phobia Inventory (SPIN), the Social Phobia Scale (SPS), and the Social Anxiety Questionnaire (SAQ-A30).
Anxiety disorders often occur along with other mental disorders, in particular depression, which may occur in as many as 60% of people with anxiety disorders. The fact that there is considerable overlap between symptoms of anxiety and depression, and that the same environmental triggers can provoke symptoms in either condition, may help to explain this high rate of comorbidity.
Studies have also indicated that anxiety disorders are more likely among those with family history of anxiety disorders, especially certain types.
Sexual dysfunction often accompanies anxiety disorders, although it is difficult to determine whether anxiety causes the sexual dysfunction or whether they arise from a common cause. The most common manifestations in individuals with anxiety disorder are avoidance of intercourse, premature ejaculation or erectile dysfunction among men and pain during intercourse among women. Sexual dysfunction is particularly common among people affected by panic disorder (who may fear that a panic attack will occur during sexual arousal) and posttraumatic stress disorder.
The DSM-IV-TR diagnostic criteria for panic disorder require unexpected, recurrent panic attacks, followed in at least one instance by at least a month of a significant and related behavior change, a persistent concern of more attacks, or a worry about the attack's consequences. There are two types, one with and one without agoraphobia. Diagnosis is excluded by attacks due to a drug or medical condition, or by panic attacks that are better accounted for by other mental disorders.
The diagnostic criteria:
The essential feature is recurrent attacks of severe anxiety (panic), which are not restricted to any particular situation or set of circumstances and are therefore unpredictable.
The dominant symptoms include:
- sudden onset of palpitations
- chest pain
- choking sensations
- dizziness
- feelings of unreality (depersonalization or derealization)
- secondary fear of dying, losing control, or going mad
Panic disorder should not be given as the main diagnosis if the person has a depressive disorder at the time the attacks start; in these circumstances, the panic attacks are probably secondary to depression.
The Panic Disorder Severity Scale (PDSS) is a questionnaire for measuring the severity of panic disorder.
There are various methods used to treat phobias. These methods include systematic desensitization, progressive relaxation, virtual reality, modeling, medication and hypnotherapy.
There are two assessment tools used to diagnose emetophobia; the Specific Phobia of Vomiting inventory and the Emetophobia Questionnaire. The Specific Phobia of Vomiting Inventory and the Emetophobia Questionnaire are both self-report questionnaires that focus on a different range of symptoms.
There have been a limited number of studies in regard to emetophobia. Victims of the phobia usually experience fear before vomiting, but feel less afterwards. The fear comes again however, if the victim fears they will throw up again.
Systematic desensitization can provide lasting relief to the majority of patients with panic disorder and agoraphobia. Disappearance of residual and subclinical agoraphobic avoidance, and not simply of panic attacks, should be the aim of exposure therapy. Similarly, systematic desensitization may also be used. Many patients can deal with exposure easier if they are in the company of a friend on whom they can rely. Patients must remain in the situation until anxiety has abated, because if they leave the situation, the phobic response will not decrease and it may even rise.
A related exposure treatment is "in vivo" exposure, a Cognitive Behavioral Therapy method, that gradually exposes patients to the feared situations or objects. This treatment was largely effective with an effect size from "d =" 0.78 to "d =" 1.34, and these effects were shown to increase over time, proving that the treatment had long term efficacy (up to 12 months after treatment).
Psychological interventions in combination with pharmaceutical treatments were overall more effective than treatments simply involving either CBT or pharmaceuticals. Further research showed there was no significant effect between using group CBT versus individual CBT.
Cognitive restructuring has also proved useful in treating agoraphobia. This treatment involves coaching a participant through a dianoetic discussion, with the intent of replacing irrational, counterproductive beliefs with more factual and beneficial ones.
Relaxation techniques are often useful skills for the agoraphobic to develop, as they can be used to stop or prevent symptoms of anxiety and panic.
A problem with culture-bound syndromes is that they are resistant to Western-style medicine.} The standard Japanese treatment for taijin kyofusho is Morita therapy, developed by Shoma Morita in the 1910s as a treatment for the Japanese mental disorders taijin kyofusho and shinkeishitsu (nervousness). The original regimen involved patient isolation, enforced bed rest, diary writing, manual labor, and lectures on the importance of self-acceptance and positive endeavor. Since the 1930s, the treatment has been modified to include out-patient and group treatments. This modified version is known as neo-Morita therapy. Medications have also gained acceptance as a treatment option for taijin kyofusho. Other treatments include systematic desensitization, which includes slowly exposing one self to the fear, and learning relaxation skills, to extinguish fear and anxiety.
Milnacipran, a serotonin–norepinephrine reuptake inhibitor (SNRI), is currently used in the treatment of taijin kyofusho and has been shown to be efficacious for the related social anxiety disorder. The primary aspect of treating this disorder is getting patients to focus their attention on their body parts and sensations.
Phobias of this sort can usually be treated by different types of therapies, including: cognitive behavioral therapy (CBT), psychotherapy, behavior therapy and exposure therapy.
Practice may play an important part in overcoming fear. It may be helpful to sufferers to increase phone usage at a slow pace, starting with simple calls and gradually working their way up. For example, they may find it easier to start with automated calls, move on to conversations with family and friends, and then further extend both the length of conversations and the range of people with whom conversations are held.
Panic disorder is a serious health problem that in many cases can be successfully treated, although there is no known cure. Identification of treatments that engender as full a response as possible, and can minimize relapse, is imperative. Cognitive behavioural therapy and positive self-talk specific for panic are the treatment of choice for panic disorder. Several studies show that 85 to 90 percent of panic disorder patients treated with CBT recover completely from their panic attacks within 12 weeks. When cognitive behavioral therapy is not an option, pharmacotherapy can be used. SSRIs are considered a first-line pharmacotherapeutic option.
Coping strategies may consist of planning the conversation ahead of time and rehearsing, writing or noting down what needs to be said. This may be helped by having privacy in which to make a call.
Associated avoidance behavior may include asking others (e.g. relatives at home) to take phone calls and exclusively using answering machines. The rise in the use of electronic text-based communication (the Internet, email and text messaging) has given many sufferers alternative means of communication that they tend to find considerably less stressful than the phone. However, some individuals experience "textphobia", a fear or anxiety of texting or messaging, and also avoid those forms of communication.
Sufferers may find it helpful to explain the nature of the phobia to friends, so that a failure to respond to messages is not misinterpreted as rudeness or an unwillingness to communicate.
There are several options for treatment of scopophobia. With one option, desensitization, the patient is stared at for a prolonged period and then describes their feelings. The hope is that the individual will either be desensitized to being stared at or will discover the root of their scopophobia.
Exposure therapy, another treatment commonly prescribed, has five steps:
- Evaluation
- Feedback
- Developing a fear hierarchy
- Exposure
- Building
In the evaluation stage, the scopophobic individual would describe their fear to the therapist and try to find out when and why this fear developed. The feedback stage is when the therapist offers a way of treating the phobia. A fear hierarchy is then developed, where the individual creates a list of scenarios involving their fear, with each one becoming worse and worse. Exposure involves the individual being exposed to the scenarios and situations in their fear hierarchy. Finally, building is when the patient, comfortable with one step, moves on to the next.
As with many human health problems support groups exist for scopophobic individuals. Being around other people who face the same issues can often create a more comfortable environment.
Other suggested treatments for scopophobia include hypnotherapy, neuro-linguistic programming (NLP), and energy psychology. In extreme cases of scopophobia, it is possible for the subject to be prescribed anti–anxiety medications. Medications may include benzodiazepines, antidepressants, or beta-blockers.
Patients are typically sent to therapy for BII phobia in order to receive therapeutic treatments to calm their levels of anxiety and stress. Therapists use a combination of psychological and physical measures, such as applying muscle tension, in order to help the patient to be aware that there is certainly a needle in front of them.
A popular method of treatment for BII phobics is Cognitive-Behavior Therapy (CBT), which is a technique that allows the patient to become immune to their fear by being exposed to it. For BII phobics, patients are given pictures of needles or blood, they are also asked to draw pictures of these needles and speak about it. Afterwards, they are given an actual needle, and the goal is: by that point, that the patient is to be comfortable enough with their fear of needles and blood.
Some patients may refuse professional help for their phobia. Instead, a different type of treatment solely revolves around motivation and whether or not the patient is willing to undergo through treating their phobia with self-help. Similar to CBT, patients treat themselves by completing exercises to become immune to their fear. This requires no professional assistance and merely relies on the person.
Research on hypnotherapy has been looked upon to treat patients with BII phobia. Hypnotherapists are known for using relaxing therapies towards individuals with common anxiety issues. A form of therapy given to patients with BII phobia include the “Applied Tension” method, which was developed by Lars-Göran Öst and his colleagues at the University of Uppsala in Sweden. This “coping method involves creating tension on a person’s arms, legs, and chest until they start to feel their body temperature rising,” (Robertson) which usually occurs within 10 to 20 seconds. These sessions of muscle tension is repeated 5 times with 20 to 30 second breaks. Patients should complete this form of therapy over the course of 5 weeks. This helps to prevent the patient from fainting by applying tension to the body, the blood pressure steadily rises, preventing any sudden drop until their vaccination is complete. By using this treatment, there was a noticeable improvement by 90% of patients with BII phobia. Compared to patients that only used the relaxation methods, where only 60% showed noticeable improvement.
Along with muscle tension,there are several methods of physical maneuvers that can help with the treatment of BII phobia. Therapists suggest that while being injected, patients should perform movements, such as: leg crossing, muscle tensing, and holding in the breath. Patients are instructed by their therapist to perform these maneuvers simultaneously while being injected with a needle. It’s also recommended that the patient stays seated with their head lowered while performing these movements.
The most common treatment for serious cases is behavior therapy—specifically, systematic desensitization.
Several other self-help treatments exist, mainly involving exposure therapy and relaxation techniques while driving. Additional driving training and practice with a certified teacher also help many to become more confident and less likely to suffer from anxiety.
One of the emerging methods of treating this fear is through the use of virtual therapy.
With repeated exposure, all of the subjects displayed significantly less variance from normal in heart rate acceleration, depression readings, subjective distress, and post-traumatic stress disorder ratings.
Also noted in the emetophobia internet survey was information about medications. People were asked whether they would consider taking anxiety medication to potentially help their fear, and many in the study answered they wouldn't for fear that the drugs would make them nauseated. Others, however, stated that some psychotropic medications (such as benzodiazepines and antidepressants) did help with their phobia, and some said gastrointestinal medications were also beneficial.
Currently, scholarly accepted and empirically proven treatments are very limited due to its relatively new concept. However, promising treatments include cognitive-behavioral psychotherapy and combined with pharmacological interventions. Treatments using tranylcypromine and clonazepam were successful in reducing the effects of nomophobia.
Cognitive behavioral therapy seems to be effective by reinforcing autonomous behavior independent from technological influences, however, this form of treatment lacks randomized trails. Another possible treatment is "Reality Approach," or Reality therapy asking patient to focus behaviors away from cell phones. In extreme or severe cases, neuropsychopharmacology may be advantageous, ranging from benzodiazepines to antidepressants in usual doses. Patients were also successfully treated using tranylcypromine combined with clonazepam. However, it is important to note that these medications were designed to treat social anxiety disorder and not nomophobia directly. It may be rather difficult to treat nomophobia directly, but more plausible to investigate, identify, and treat any underlying mental disorders if any exist.
Even though nomophobia is a fairly new concept, there are validated psychometric scales available to help in the diagnostic, an example of one of these scales is the "Questionnaire of Dependence of Mobile Phone/Test of Mobile Phone Dependence (QDMP/TMPD)".