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  1. 1. Presented by Premnath R Ist MSc. (N) CNK
  2. 2.  The word phobia is derived from the Greek phobos meaning extreme fear and flight.  The ancient Greek god, Phobos, was believed to be able to reduce the enemies of the Greeks to a state of abject terror, making victory in battle more likely.
  3. 3. Fear cued by the presence or anticipation of a specific object or situation, exposure to which almost invariably provokes an immediate anxiety response or panic attack even though the subject recognizes that the fear is excessive or unreasonable. The phobic stimulus is avoided or endured with marked distress. (Shahrokh & Hales, 2003)
  4. 4. According to the American Psychiatric Association, a phobia is an irrational and excessive fear of an object or situation. Phobia is persistent avoidance behaviour secondary to irrational fear of a specific object, activity or situation. (Ashok Singhal)
  5. 5. Marks has defined phobia on the following four criteria: 1. The fear is out of proportion to the demands of the situation. 2. It cannot be explained or reasoned away. 3. It is beyond voluntary control. 4. The fear leads to an avoidance of the feared situation.
  6. 6. Epidemiology  Phobias are the most common of all anxiety disorders.  Social phobia is the most common of all phobias  Lifetime prevalence rates of agoraphobia have been reported from a number of studies.  Social phobia in males -11.1 and females -15.5 and a total of 13.3.
  7. 7.  Specific phobia occurs in 2.4 to 9.2 percent of children and adolescents, with usual onset between 5 and 13 years of age.  Women receive diagnoses of specific phobia more often than men.  Onset is often sudden and course usually chronic.
  8. 8. According to NIMH,  1%-12.5% of Americans have phobias.  Psychiatric disease commonest between the women of all the ages and are the second common disease between the men oldest of 25.  Typical age of onset of phobias is usually childhood and adolescence.  The age of onset is earliest in animal phobias, intermediate in social phobias and latest in agoraphobia.
  9. 9.  Patients with agoraphobia consistently have the highest rate of co-morbidity, and animal and situational.  Patients with social phobia have an increased rate of suicidal ideation, financial dependancy and having sought medical treatment.
  10. 10.  Pairing of a naturally frightening stimulus with a second inherently neutral stimulus.  As a result of the contiguity, especially when the two stimuli are paired on several occasions, the originally neutral stimulus takes on the capacity to arouse anxiety by itself.  The neutral stimulus, therefore, becomes a conditioned stimulus for anxiety production.
  11. 11.  Anxiety is a drive that motivates the organism to do what it can, to obviate the painful affect.  In the course of its random behaviour, the organism learns that certain actions enable it to avoid the anxiety-provoking stimulus.  Those avoidance patterns remain stable for long periods of time; as a result of the reinforcement they receive from their capacity to diminish activity.
  12. 12.  In social and specific phobia, the conflict is regarding sexual arousal, leading to castration anxiety.  When repression fails to be entirely successful, the ego must call on auxiliary defences like displacement, symbolization and avoidance.  In agoraphobia, it is the separation anxiety playing a central role.
  13. 13.  Interaction between genetic constitutional diathesis and environmental stressors.
  14. 14. Anxiety Ego Defense mechanism Fails Secondary defence mechanism Displacement Anxiety turned to a neutral, harmless object
  15. 15.  Phobias are generally caused by an event recorded by the amygdala and hippocampus and labelled as deadly or dangerous.  Thus whenever a specific situation is approached again the body reacts as if the event were happening repeatedly afterward.
  16. 16.  Treatment comes in some way or another as a replacing of the memory and reaction to the previous event perceived as deadly with something more realistic and based more rationally.  Subconscious association causes far more fear than is warranted based on the actual danger of the stimulus.
  17. 17. ICD- 10  F40.0 Agoraphobia .00 Without panic disorder .01 With panic disorder  F40.1 Social phobias  F40.2 Specific (isolated) phobias  F40.8 Other phobic anxiety disorders  F40.9 Phobic anxiety disorder, unspecified DSM IV TR  F40 Phobic anxiety disorders  300.01 Panic disorder without agoraphobia  300.21 Panic disorder with agoraphobia  300.22 Agoraphobia without history of panic disorder  300.29 Specific phobia  300.23 Social phobia
  18. 18. AGORAPHOBIA It is characterised by an irrational fear of being in places away from the familiar setting of home, in crowds, or in situations that the patient cannot leave easily.
  19. 19. Diagnostic guidelines All of the following criteria should be fulfilled for a definite diagnosis:  (a) the psychological or autonomic symptoms must be primarily manifestations of anxiety and not secondary to other symptoms, such as delusions or obsessional thoughts;  (b) the anxiety must be restricted to (or occur mainly in) at least two of the following situations: crowds, public places, travelling away from home, and travelling alone; and  (c) avoidance of the phobic situation must be, or have been, a prominent feature.
  20. 20. Signs &Symptoms  Overriding fear of open or public spaces (primary symptom)  Deep concern that help might not be available in such places.  Avoidance of public places and confinement to home.  When accompanied by panic disorder, fear that having panic attack in public will lead to embarrassment or inability to escape (for symptoms of a panic attack).
  21. 21. Social Phobia It is an irrational fear of performing activities in the presence of other people or interacting with others. The patient is afraid of his own actions being viewed by others critically, resulting in embarrassment or humiliation.
  22. 22. Diagnostic guidelines All of the following criteria should be fulfilled for a definite diagnosis: (a) The psychological, behavioural, or autonomic symptoms must be primarily manifestations of anxiety and not secondary to other symptoms such as delusions or obsessional thoughts; (b) The anxiety must be restricted to or predominate in particular social situations; and (c) The phobic situation is avoided whenever possible.
  23. 23. Signs &Symptoms  Hyperventilation  Sweating, cold, and clammy hands  Blushing  Palpitations  Confusion  Gastrointestinal symptoms  Trembling hands and voice  Urinary urgency  Muscle tension  Anticipatory anxiety  Fear or embarrassment or ridicule
  24. 24. Specific Phobia It is an irrational fear of a specific object or stimulus. Simple phobias are common in childhood .By early teenage most of these fears are lost, but a few persist till adult life. Sometimes they may reappear after a symptom-free period. Exposure to the phobic object often results in panic attack.
  25. 25. Diagnostic guidelines All of the following should be fulfilled for a definite diagnosis: (a)The psychological or autonomic symptoms must be primary manifestations of anxiety, and not secondary to other symptoms such as delusion or obsessional thought; (b) the anxiety must be restricted to the presence of the particular phobic object or situation (c) the phobic situation is avoided whenever possible.
  26. 26. Signs &Symptoms  Irrational and persistent fear of object or situation  Immediate anxiety on contact with feared object or situation  Loss of control, fainting, or panic response.  Avoidance of activities involving feared stimulus.  Anxiety when thinking about stimulus.  Worry with anticipatory anxiety.  Possible impaired social or work functioning.
  28. 28. INSIGHT-ORIENTED PSYCHOTHERAPY It is superior to psychoanalytic psychotherapy. Insight-oriented psychotherapy enables the patient to understand the origin of the phobia, phenomena of secondary gain and the role of resistance, and enables the patient to seek healthy ways of dealing with anxiety provoking stimuli.
  29. 29. BEHAVIOUR THERAPY  Desensitization  Flooding  Social skill training
  30. 30. Desensitization Desensitization (also known as exposure therapy), is a cognitive-behavioral therapy in which people are gradually exposed to the frightening object or event until they become used to it and their physical symptoms decrease.
  31. 31. Flooding Flooding is a more dramatic, cognitive- behavioral approach in which person is immediately exposed to the feared object or situation. The person remains in the situation until the anxiety lessens.
  32. 32. Social skill training Social skill training includes  Modeling  Role-playing
  33. 33. The key aspects of successful behavior therapy are, 1. The patient’s commitment to treatment. 2. Clearly identified problems and objectives. 3. Available alternative strategies for coping with the patient’s feelings.
  34. 34. Pharmacotherapy  Antidepressant - Phenelzine, tranylcypromine, imipramine, sertralin e.  Benzodiazepines- clonazepam, alprazolam, lorazepam, diazepam.  Beta-adrenergic antagonist –propranolol, atenolol.
  35. 35. Supportive therapy  Eye Movement Desensitization and Reprocessing (EMDR) used to treat Post-traumatic stress disorder, specific trauma.  Hypnotherapy coupled with Neuro-linguistic programming can also be used to help remove the associations that trigger a phobic reaction.
  36. 36. NURSING MANAGEMENT Assessment  Anticipatory anxiety (when thinking about the phobic object)  Panic anxiety (when confronted with the phobic object)  Avoidance behaviors that interfere with relationships or functioning  Recognition of the phobia as irrational  Embarrassment over the phobic fear  Sufficient discomfort to seek treatment
  37. 37. Nursing diagnosis 1  Fear related to a specific stimulus or causing embarrassment to self in front of others, evidenced by behaviour directed towards avoidance of the feared object/situation. Nursing Interventions  Encourage the client to express feelings, initially, without discussing the phobic situation specifically.
  38. 38.  Teach the client and family or significant others about phobic reactions.  Reassure the client that he or she can learn to decrease the anxiety and gain control over the anxiety attacks.  Reassure the client that he or she will not be forced to confront the phobic situation until prepared to do so.
  39. 39.  Assist the client to distinguish between the actual phobic trigger and problems related to avoidance behaviors.  Encourage the client to practice relaxation until he or she is successful.  Explain systematic desensitization thoroughly to the client.  Reassure the client that you will allow him or her as much time as needed at each step.
  40. 40.  Have the client develop a hierarchy of situations that relate to the phobia by ranking from the least anxiety-producing to the most anxiety-producing situation.  Beginning with the least anxiety-producing situation, have the client use progressive relaxation until he or she is able to decrease the anxiety. When the client is comfortable with that situation, go to the next item on the list, and repeat the procedure.
  41. 41.  It may be necessary to address specific avoidance behavior(s) if any persist after the client has completed the desensitizing process.  Give positive feedback for the client's efforts at each step. Convey the idea that he or she is succeeding at each step.
  42. 42.  If the client becomes excessively anxious or begins to feel out of control, return to the former step with which the client was successful; then proceed slowly to subsequent steps.  As the client progresses in systematic desensitization, ask the client if his or her avoidance behaviors are decreasing.
  43. 43. Nursing diagnosis 2  Social isolation related to fear of being in a place from which one is unable to escape, evidenced by staying alone, refusing to leave the room/home. Interventions  Convey an accepting attitude and unconditional positive regard.  Make brief, frequent contacts.  Be honest and keep all promises.  Attend group activities with the patient that may be frightening for him.
  44. 44.  Administer anti-anxiety medications as ordered by physician, monitor for effectiveness and adverse effects.  Discuss with the patient signs and symptoms of increasing anxiety and techniques to interrupt the response.  Give recognition and positive reinforcement for voluntary interactions with others.
  45. 45. Other nursing diagnoses are,  Ineffective coping related to the fear attacks associated with disease condition.  Ineffective communication pattern related to the fear associated with social gatherings.