World Health Organisation. (1996). Diagnostic and Management Guidelines for Mental Disorders in Primary Care: ICD-10 Chapter V Primary Care Version. Gottingen, Germany: WHO/Hogrefe & Huber Publishers.

Phobic Disorders (F40)

(Includes agoraphobia, social phobia)

Presenting complaints

Patients may avoid or restrict activities because of fear.

They may have difficulty travelling to the doctor's office, going shopping, visiting others.

Patients sometimes present with physical symptoms (palpitations, shortness of breath, "asthma"). Questioning will reveal specific fears.

Diagnostic features

• Unreasonably strong fear of specific places or events. Patients often avoid these situations altogether.

Commonly feared situations include:

leaving home	crowds or public places
open spaces	travelling in busses, cars, trains, or planes
speaking in public	social events

Patients may be unable to leave home or unable to stay alone because of fear.

Differential diagnosis

• If anxiety attacks are prominent see Panic disorder - F41.0
• If low or sad mood is prominent see Depression F32#
• Many of the management guidelines opposite may also be helpful for specific phobias (eg fear of water, fear of heights).

Phobic disorders F40 - management guidelines

Essential information for patient and family

• Phobias can be treated.
• Avoiding feared situations allows the fear to grow stronger
• Following a set of specific steps can help a person overcome fear.

Counselling of patient and family

• Encourage the patient to practice controlled breathing methods to reduce physical symptoms of fear.
• Ask the patient to make a list of all situations that he/she fears and avoid although other people do not.
• Discuss ways to challenge these exaggerated fears (eg Patient reminds him/herself "I am feeling a little anxious because there is a large crowd. The feeling will pass in a few minutes.")
• Plan a series of steps to enable the patient to confront and get used to feared situations:
  • Identify a small step towards the feared situation (eg take a short walk away from home with a family member)
  • This step should be practiced for one hour each day until the patient is no longer frightened.
  • If the feared situation still causes anxiety the patient should practice slow and relaxed breathing, telling him /herself that the panic will pass within 30 minutes. The patient should not leave the feared situation until the fear subsides.
  • Move on to a slightly more difficult step and repeat the procedure (eg spend a longer time away from home).
  • Take no alcohol or anti-anxiety medication for at least four hours before practicing these steps.
• Identify a friend or family member who will help in over coming the fear. Self-help groups can assist in confronting feared situations.
• The patient should avoid using alcohol or benzodiazepine drugs to cope with feared situations.

Medication

• With the use of these counselling methods, many patients will not need medication. However if depression is also present, antidepressant medication may be helpful (eg imipramine 50-150mg a day).
• For patients with infrequent and limited symptoms, occasional use of anti-anxiety medications (eg benzodiazepines) may help. Regular use may lead to dependence, however, and is likely to result in return of symptoms when discontinued.
• For management of performance anxiety (eg fear of public speaking) beta-blockers may reduce physical symptoms.

Specialist consultation

Consider consultation if disabling fears persist (eg patient is unable to leave home). Referral for behavioural psychotherapy, if available may be effective for patients who do not improve.