Chapter: Psychiatric Mental Health Nursing : Anxiety, Anxiety Disorders, and Stress-Related Illness


A phobia is an illogical, intense, and persistent fear of a specific object or a social situation that causes extreme dis-tress and interferes with normal functioning.



A phobia is an illogical, intense, and persistent fear of a specific object or a social situation that causes extreme dis-tress and interferes with normal functioning. Phobias usu-ally do not result from past negative experiences. In fact, the person may never have had contact with the object of the phobia. People with phobias understand that their fear is unusual and irrational and may even joke about how “silly” it is. Nevertheless, they feel powerless to stop it (Andreasen & Black, 2006).


People with phobias develop anticipatory anxiety even when thinking about possibly encountering the dreaded phobic object or situation. They engage in avoidance behavior that often severely limits their lives. Such avoid-ance behavior usually does not relieve the anticipatory anxiety for long.


There are three categories of phobias:


·    Agoraphobia (discussed earlier in text)


·    Specific phobia, which is an irrational fear of an object or a situation


·    Social phobia, which is anxiety provoked by certain so-cial or performance situations.


Many people express “phobias” about snakes, spiders, rats, or similar objects. These fears are very specific, easy to avoid, and cause no anxiety or worry. The diagnosis of a phobic disorder is made only when the phobic behavior significantly interferes with the person’s life by creating marked distress or difficulty in interpersonal or occupa-tional functioning.


Specific phobias are subdivided into the following categories:


·    Natural environmental phobias: fear of storms, water, heights, or other natural phenomena


·    Blood-injection phobias: fear of seeing one’s own or oth-ers’ blood, traumatic injury, or an invasive medical pro-cedure such as an injection


·    Situational phobias: fear of being in a specific situation such as on a bridge or in a tunnel, elevator, small room, hospital, or airplane


·    Animal phobia: fear of animals or insects (usually a spe-cific type; often this fear develops in childhood and can continue through adulthood in both men and women; cats and dogs are the most common phobic objects)


·    Other types of specific phobias: for example, fear of get-ting lost while driving if not able to make all right (and no left) turns to get to one’s destination.


In social phobia, also known as social anxiety disorder, the person becomes severely anxious to the point of panic or incapacitation when confronting situations involving people. Examples include making a speech, attending a social engagement alone, interacting with the opposite sex or with strangers, and making complaints. The fear is rooted in low self-esteem and concern about others’ judg-ments. The person fears looking socially inept, appearing anxious, or doing something embarrassing such as burp-ing or spilling food. Other social phobias include fear of eating in public, using public bathrooms, writing in pub-lic, or becoming the center of attention. A person may have one or several social phobias; the latter is known as generalized social phobia (Culpepper, 2006).

Onset and Clinical Course


Specific phobias usually occur in childhood or adolescence. In some cases, merely thinking about or handling a plastic model of the dreaded object can create fear. Specific phobias that persist into adulthood are lifelong 80% of the time.


The peak age of onset for social phobia is middle ado-lescence; it sometimes emerges in a person who was shy as a child. The course of social phobia is often continuous, although the disorder may become less severe during adulthood. Severity of impairment fluctuates with life stress and demands.




Behavioral therapy works well. Behavioral therapists ini-tially focus on teaching what anxiety is, helping the client to identify anxiety responses, teaching relaxation tech-niques, setting goals, discussing methods to achieve those goals, and helping the client to visualize phobic situations. Therapies that help the client to develop self-esteem and self-control are common and include positive reframing and assertiveness training (explained earlier in text).


One behavioral therapy often used to treat phobias is systematic (serial) desensitization, in which the therapist progressively exposes the client to the threatening object in a safe setting until the client’s anxiety decreases. During each exposure, the complexity and intensity of exposure gradually increase, but the client’s anxiety decreases. The reduced anxiety serves as a positive reinforcement until the anxiety is ultimately eliminated. For example, for the client who fears flying, the therapist would encourage the client to hold a small model airplane while talking about his or her experiences; later, the client would hold a larger model airplane and talk about flying. Even later exposures might include walking past an airport, sitting in a parked airplane, and, finally, taking a short ride in a plane. Each session’s challenge is based on the success achieved in pre-vious sessions (Andreasen & Black, 2006).


Flooding is a form of rapid desensitization in which a behavioral therapist confronts the client with the phobic object (either a picture or the actual object) until it no longer produces anxiety. Because the client’s worst fear has been realized and the client did not die, there is little reason to fear the situation anymore. The goal is to rid the client of the phobia in one or two sessions. This method is highly anxiety producing and should be conducted only by a trained psychotherapist under controlled circum-stances and with the client’s consent.


Drugs used to treat phobias are listed in Table 13.3.


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