Second edition

20.qxd 3/10/08 9:58 AM Page 635
Interestingly, in many cases patients are able to temporarily
overcome their agoraphobia if they take their ‘safety’ with
them by travelling with a good and trusted friend.
Course
Agoraphobia is a chronic disorder and tends to gradually
worsen over long periods of time.
Etiology
In cases occurring secondary to panic disorder, the normal
anticipatory anxiety about having another panic attack
becomes so severe and pervasive that patients cannot bear
venturing into ‘unsafe’ situations. In those cases that occur
in the absence of panic disorder, patients, although
describing well the dread they feel over being in agoraphobic
situations, cannot clearly explain, either to themselves
or others, what it is they fear might happen, and the etiology
in these cases is simply not known.
Differential diagnosis
In social phobia of the generalized subtype (also known as
social anxiety disorder), patients may fear and avoid many
different situations. The difference here is that social phobics
fear that they will do something that embarrasses or
humiliates them, whereas agoraphobics fear that something
will happen to them, such as a panic attack.
In illnesses characterized by delusions of persecution,
patients may avoid going out for fear that people will talk
about them, spy on them, assault them, etc. This may be
seen in schizophrenia, schizoaffective disorder, the persecutory
subtype of delusional disorder, and depressive episodes
of either major depressive disorder or bipolar disorder.
Treatment
Agoraphobia may be treated either with cognitive–behavioral
therapy or a behavioral program of graded exposure,
in which the patient gradually and sequentially takes progressively
greater ‘steps’ toward and into the feared situation.
Critically, however, in those cases occurring secondary
to panic disorder, one must first treat the panic disorder
and render the patient free of panic attacks. The occurrence
of even one panic attack can, and often does, destroy any
gains made by cognitive–behavioral or exposure therapy.
20.12 SPECIFIC (SIMPLE) PHOBIA
The patient with a specific phobia, or, as it was formerly
known, a simple phobia, experiences extreme anxiety upon
approaching something that for others arouses little or no
20.12 Specific (simple) phobia 635
apprehension. Although adult patients acknowledge the
irrationality of their fear, they go out of their way to avoid
the feared object. First described by Hippocrates, this condition
is quite common, occurring in at least 10 percent of
the general population; it is about twice as frequent in
females as in males.
In the past it was fashionable to subdivide specific phobia
according to the feared object or situation, and thus
one reads of arachnophobia, acrophobia, claustrophobia,
etc. For the most part, however, this subdividing added little
to our understanding of the disorder, with one probable
exception, namely blood-injury phobia, which, as noted
below, may be a unique specific phobia.
Clinical features
The age of onset of specific phobia ranges from childhood
to early adult years: animal phobias and blood-injury phobia
tend to first appear in childhood, whereas the other
phobias may first appear at any point from childhood to
adult years (Marks and Gelder 1966).
A wide range of objects or situations may come to be
feared, including snakes, spiders, heights, being in closed
spaces, darkness, storms, and the sight of blood. Although
most patients with specific phobia have only one phobia, in
a minority two or more may be present.
On approaching the feared object or situation, or even
upon simply imagining doing so, patients experience the
acute onset of an anxiety attack, characterized by anxiety,
tremor, tachycardia, diaphoresis, and piloerection; in some
cases, these symptoms may be accompanied by depersonalization.
Some patients may be able to steel themselves
and stay nearby, but for the most part the fear and anxiety
is so great that they must escape, no matter how humiliating
or embarrassing such behavior might be for them.
Importantly, as soon as patients can get away, the anxiety
ceases and patients, although perhaps a little ‘shaken’ by
the experience, promptly return to normal.
Blood-injury phobia, as indicated earlier, may be unique.
A common example is found in patients who are phobic
about having a venipuncture (Chapman et al. 1993). If these
patients can force themselves to hold still for the phlebotomist,
they typically experience a biphasic symptomatology.
Initially, there is anxiety and tachycardia, similar to that
seen in the anxiety attack just described; soon after, however,
these sympathetic symptoms give way to a parasympathetic
response, with hypotension and either pre-syncope or actual
fainting (Curtis and Thyer 1983). It is this second phase that
gives blood-injury phobia its unique status.
Course
Phobias with an onset in childhood tend to remit within
months or a year or so. In cases of childhood-onset phobias
that persist, and in cases characterized by later onsets in adolescence
or early adult years, the course tends to be chronic.