Snapshot A 32-year-old man is brought to his primary care physician by his sister. The patient describes an intense fear of going outside by himself. While in college, he was uncomfortable in large crowds and whenever he was forced to use public transportation, and these feelings have worsened with time. He now rarely leaves his house and has food and groceries delivered to him. His sister convinced him to leave the house to accompany him to his doctor's appointment, noting that he is always anxious and nervous to go out in public. (Agoraphobia) Introduction Overview severe, marked, persistent (> 6 months) fear or anxiety as a result of the presence or anticipation of an object or situation person recognizes fear is excessive person avoids phobic trigger phobic disorders encompass 3 DSM-V diagnoses social anxiety disorder login to view 4 more bullets specific phobia login to view 1 more bullet agoraphobia login to view 2 more bullets Epidemiology prevalence in the US social anxiety disorder - 7% specific phobia - 7-9% agoraphobia - 1.7% demographics incidence in women vs. men is ~ 1.5-2 to 1 social anxiety disorder: majority of patients experience onset between ages 8-15 years specific phobias: most develop during childhood then eventually disappear agoraphobia: onset peaks in late adolescence and early adulthood Pathophysiology ↑ activation in the prefrontal and orbitofrontal cortex, anterior cingulate cortex, insula, and amygdala with phobia-related triggers sympathetic nervous system activation results in ↑ HR and BP Associated conditions anxiety depression substance abuse Prognosis most patients respond to treatment with adequate resolution of symptoms specific phobias often eventually disappear after childhood prognosis influenced by several factors diagnosis severity level of functioning prior to symptom onset motivation for treatment presence of a social support system compliance with medications and/or psychotherapy Presentation Symptoms anxiety/severe emotional distress avoidance of feared object/situations Physical exam manifestations of anxiety sweating palpitations ↑ BP and heart rate dyspnea dizziness tremor Treatment Lifestyle cognitive behavioral therapy (CBT) indications login to view 1 more bullet Medical selective serotonin reuptake inhibitors (SSRIs) (e.g.,paroxetine and sertraline) indication login to view 1 more bullet selective serotonin/norepinephrine reuptake inhibitors (SNRI) (e.g., venlafaxine) indication login to view 1 more bullet β-blockers (e.g., propanolol) indication login to view 1 more bullet Complications Suicide attempts and suicidal ideation Substance abuse