Specific phobia and social anxiety disorder (social phobia): Clinical sciences

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Introduction0:00–0:53

Specific phobia and social anxiety disorder are characterized by intense, irrational fear or anxiety triggered by a specific object, situation or activity that poses no inherent danger.
This heightened sensation of fear or anxiety often causes significant distress impacting daily life and function. Often, individuals develop avoidance behaviors of a known trigger to deter these feelings.
Common examples of specific phobias include arachnophobia, or fear of spiders; claustrophobia, or fear of confined spaces; and aerophobia, or fear of flying.
On the other hand, social phobia, also known as social anxiety disorder or SAD, is the persistent fear of being in a social situation and being scrutinized by others.
Alright, when a patient presents with a chief concern suggesting a phobia, your first step is to perform a focused history and physical examination including a mental status exam.

History & Physical0:53–1:35

On history, patients often report active avoidance of phobic stimulus, which can be an object, situation, or activity that provokes excessive fear and anxiety to a greater degree than in the general population.
The physical exam might be grossly normal, but the mental status exam can reveal anxious behavior, abnormal speech patterns, and a change in affect by the phobic stimulus.
The patient might also exhibit illogical thinking regarding the stimulus but have an insight into the exaggerated response.

Social Anxiety Disorder1:35–4:43

With these initial findings, your next step is to assess for social anxiety. When social anxiety is present, the patient will report fear of humiliation or embarrassment and anxiety in response to an anticipated social activity.
They might experience physical symptoms of sweating, trembling, or a shaky voice when exposed to the trigger, and thereby avoid social situations.
On mental status exam, the patient might display a depressed or anxious mood, soft speech with hesitancy, and normal thought content.
In severe cases, they might even have suicidal ideation. In this case, suspect social anxiety disorder and assess with the DSM-5 criteria to confirm the diagnosis.
To meet the criteria, your patient must report intense fear of being in a social situation due to being embarrassed or humiliated; avoidance of anxiety-producing social situations; excessive social anxiety out of proportion to the situation; and anxiety causing impairment in daily living.
These disturbances must have been present for at least six months and cannot be explained by other medical conditions, medication, or substance use.
If all these criteria are met, you can diagnose SAD. Here’s a high-yield fact!
Agoraphobia is similar but distinct from social phobia. Patients with agoraphobia express marked fear or anxiety in two or more situations like public transportation; open spaces like a parking lot; or enclosed spaces like a theater; standing in line or in a crowd; or being alone outside of their home.
Now, treatment for SAD includes cognitive behavioral therapy, exposure therapy, and pharmacotherapy. Cognitive behavioral therapy focuses on negative or inappropriate perceptions and thought processes in an effort to reduce or eliminate undesirable associated behavior patterns.
Exposure therapy, on the other hand, provides gradual exposure to phobic stimulus with the goal of reducing or eliminating the fear and avoidance response.
When it comes to pharmacotherapy, first line agents include selective serotonin reuptake inhibitors, or SSRIs, like paroxetine and sertraline; as well as serotonin-norepinephrine reuptake inhibitors, or SNRIs, like venlafaxine.
Time for a clinical pearl! If SSRIs or SNRIs prove ineffective or suboptimal in treating SAD, you can consider prescribing beta blockers, like propranolol; anticonvulsants, such as gabapentin and pregabalin; MAO inhibitors like phenelzine; or benzodiazepines such as clonazepam.
Keep in mind, MAO inhibitors can have multiple food and medication interactions leading to adverse effects. Additionally, benzodiazepines should only be prescribed short term, since chronic use can lead to tolerance, physical dependence, and addiction.
Okay, let’s go back to your initial assessment for social anxiety, and see how to make a decision when social anxiety is absent.

Specific Phobia4:43–6:15

If social anxiety is absent, your next step is to assess for specific fears; like animals, the natural environment, blood-injection-injury, or other common triggers.
If fear or anxiety response is absent, consider an alternative diagnosis and treat any associated medical conditions. On the other hand, if specific fears are present, you should suspect a specific phobia related to the trigger.
To confirm the diagnosis, assess with the DSM-5 criteria. To meet the criteria, the patient must show a marked fear of a situation or phobic object that provokes immediate anxiety, and avoidance of the phobic object or situation.
The fear should last greater than 6 months, be out of proportion to the danger posed, and cause impairment in areas of functioning.
These disturbances should not be explained by other mental health disorders. If all criteria are met, diagnose specific phobia.
Treatment options include cognitive behavioral therapy and exposure therapy. Here’s a clinical pearl!
The DSM-5 recommends specifying the type of phobia such as animals, natural environment, blood-injection-injury, situational, and other types which include avoidance of situations that lead to vomiting or contracting an illness.
Alright, as a quick recap… Specific phobia and social anxiety disorder cause fear and anxiety out of proportion of the triggering stimuli.

Review6:15–7:05

When assessing these patients start with history and physical exam, including a mental status exam. Then assess for social anxiety.
If it’s present, suspect social anxiety disorder and assess DSM-5 criteria to confirm the diagnosis. Once the diagnosis is made, start treatment with cognitive behavioral therapy, exposure therapy, or pharmacotherapy.
Now, if the patient doesn’t exhibit social anxiety but there are specific fears, suspect specific phobia and assess DSM-5 criteria to confirm.
Treatment options here include cognitive behavioral therapy and exposure