This CE module provides information about an off-label use of a product for a purpose other than for which it was approved by the US Food and Drug Administration.

Millicent appears to be a typical home health patient. She's dependent on insulin for her diabetes and oxygen for end-stage chronic lung disease. She also requires 11 different medications for other chronic disorders, as well as a small pressure ulcer. But unlike many other typical patients, Millicent has not left her home for 11 years. Not once. Her last trip to the grocery store ended in an allergic reaction that resulted in a three-week CCU stay on a ventilator. Millicent vowed only death would cause her to leave home again. Fortunately, she located a nurse practitioner who makes house calls, and all of Millicent’s care has been provided in her home.

Tammy, an ED nurse, is downright terrified of elevators. She reveals, “I just can’t bring myself to get into one. They’re so small — I know if I go inside, something bad will happen.” Unfortunately, her claustrophobic behavior has resulted in angry coworkers’ having to transport her patients to diagnostic studies and their rooms on other floors.

What do Millicent and Tammy have in common? They both have a phobia that impairs daily living or work performance. Excessive irrational fear and a prevailing sense of dread are common to all phobias. Millicent’s phobia was reinforced by a truly negative experience. Tammy’s fear of confined spaces has yet to be substantiated. Regardless, both find their reasons for avoidance important enough to risk isolation or alienation from others.

What’s your “Fear Factor”?

Phobias present diagnostic and treatment challenges for caregivers. They are often found in people with multiple medical conditions, especially cardiorespiratory, gastrointestinal, and neurological disorders.¹ There is also an increased incidence of phobia development after traumatic brain injury.² A connection with drug and alcohol abuse has also been established.³ Many individuals who reported inhalant abuse have also experienced a phobic disorder, with females more significantly impacted (28%) than males (14%).⁴

For patients, the impact can vary from minimally annoying to downright disabling. Phobias can emerge from a panic attack. For example, a panic attack experienced on an elevator may lead to an avoidance of elevators as a means to prevent another attack. Conversely, panic attacks can emerge from a phobia; for instance, a woman who dreads speaking in public develops a panic attack when she’s required to deliver a report at a meeting for her job. (Attributes associated with panic attacks are listed in the sidebar “Features Seen with Panic Attacks.”)

Whether or not they’re associated with panic attacks, phobias warrant assessment and intervention when they interfere with a patient’s normal routine, occupational or academic functioning, social activities, or relationships. Treatment is also necessary when the patient experiences marked distress about having the phobia.

Appreciating the impact

Recent estimates reveal that phobias affect 19 million American adults.⁵ Research substantiates both sides of a “nature vs. nurture” argument about the etiology of the development of phobias.^6,7,8 On the nature side, neurotransmitters, including serotonin, dopamine, and norepinephrine, influence how we interpret and react to situations. For example, similar to the flight-or-fight response, balanced neurotransmitters help us develop a plan and use coping strategies, while imbalanced neurotransmitters can facilitate internalizing fears. For instance, a reduction in levels of brain gamma-aminobutyric acid (GABA), an amino acid that acts to inhibit responses, has also been found to contribute to the development of panic among phobic patients.⁹ Specific areas of the brain have shown increased reactivity in individuals with phobias when evaluated with magnetic resonance imaging.⁶

The question of nature versus nurture or a combination of both factors contributing to the development of phobias continues to be explored with evidence supporting the impact of both. Researchers continue to examine the biological and chemical changes that occur with people of all ages who experience phobia. Evidence is emerging that the development of phobias may be associated with prematurity and low birth weight. One study revealed a significantly increased risk of phobia development among infants with a birth weight of less than 3.5 kg.¹⁰

A genetic predisposition to phobic disorders has also been proposed with strong supporting evidence. One of the most compelling associations is seen among children who have Fragile X syndrome – the most common known cause of inherited mental impairment. Individuals with FraX are more likely to have cognitive, behavioral, and emotional dysfunction and be diagnosed with autism and social phobia.¹¹

One interesting study evaluated the impact of the lack of maternal encouragement to engage in social interactions among 173 mother/infant pairs. Eighty-nine of the mother/infant pairs had mothers without phobias, and 84 pairs had a mother with social phobia or generalized anxiety disorder. The infants were monitored for irritability and the mothers for social responsiveness and signs of anxiety when required to interact with a stranger. Parenting difficulties were found among the mothers with phobias, and their infants demonstrated signs of reduced social responsiveness.⁷

Exposure to environmental factors, such as confined spaces or extremes of temperature, and circumstances, such as experiencing a near-drowning as a child or being bitten by an animal, may lead to phobic avoidance.¹² However, studies involving groups of 7,500, 3,000, and 1,198 twins suggest that vulnerability to phobias is largely an innate process that does not arise directly from environmental experience.^13,14,15 Given the two theories of phobia development, a genetically predisposed person, when exposed to a distressing environmental experience, might be more likely to develop a phobia.¹⁶

Agoraphobia — when there’s no place like home

Dorothy in The Wizard of Oz concluded, “Everything I need I have right here at home.”¹⁷ The agoraphobic person may appear to agree, but a closer look often reveals entrapment rather than enchantment. Agoraphobia involves anxiety about being in places or situations from which escape might be difficult or embarrassing or in which help might not be available if a panic attack occurs. Those suffering from the disorder avoid distressing situations or endure them with marked distress, sometimes requiring the presence of a companion. People with agoraphobia typically fear such situations as being in a crowd or line or being outside the home, on a bridge, or in other places of exposure. They may also fear traveling by car, bus, train, or plane.¹⁸

People with agoraphobia are more likely to be women. If they’re married, there is often marital discord because their husbands are critical of their behavior.¹⁹ A high rate of perfectionism and personality disorders occurs among agoraphobics, who are often less likely to use positive problem-solving strategies. They often relate that during childhood, their parents were overprotective.²⁰ When faced with the stressor that provokes the phobic response, men tend to exhibit more anger, hostility, and depression, whereas women tend to internalize their distress and report more physical concerns.²¹

Agoraphobia can occur with or without panic attacks. Diagnosis with panic attacks requires recurrent, unexpected attacks with at least one being followed by a month-long history of significant behavioral change related to the occurrence; persistent fear of recurrent attacks; or fear of consequences of an attack, such as losing control, having difficulty breathing, or having a heart attack.¹⁸

Diagnosis of agoraphobia without a panic attack is related to the fear of developing panic-like symptoms. When people with agoraphobia have a general medical condition, their fears of the potential symptoms usually exceed typical concerns associated with the condition.¹⁸ The occurrence of agoraphobia among those with chronic conditions may be far from uncommon. For example, one study found that 41% of patients in an outpatient asthma clinic experienced some degree of agoraphobia either with or without panic disorder, like Millicent in our opening scenario.²² Similarly, people with balance disorders, including vestibular dysfunction, have also shown a tendency to have agoraphobic symptoms.²³ However, in the case of asthmatic patients, their fears may be grounded: A hyperreactive response to carbon dioxide (CO2) has been demonstrated as a respiratory-associated factor for agoraphobia and other panic disorders.²⁴ In fact, a CO2 challenge test can be performed to evaluate the efficacy of medications and interventions in controlling panic symptoms in individuals with phobias.²⁴ People with phobias, especially agoraphobia, tend to panic during the CO2 challenge. To evaluate prescription therapy effectiveness, the test can be administered. Diminished or absence of panic represents a therapeutic response. This test, however, isn’t routinely performed.

A clinical guideline for the diagnosis and management of anxiety disorders, including panic disorder, both with and without agoraphobia, can be viewed at http://www.guideline.gov/summary/summary.aspx?doc_id=6248&nbr=004008&string=phobia.

Social phobia — social anxiety disorder

Few people feel entirely comfortable when placed in public-speaking situations. Now imagine that feeling magnified a hundredfold when you just have to speak to a clerk to order food at a restaurant or pay for it in the checkout line at the grocery store. Such is the life of someone with social phobia, which can range from mild to debilitating. The hallmark of social phobia is anxiety produced by social performance that often leads to avoidant behavior.¹⁸

People with social phobia recognize that their fear is irrational but are powerless to overcome it. They have an inability to suppress negative thoughts related to social situations and evaluate themselves in the third person, critiquing themselves as observers would, not as individuals evaluating their own behavior.⁹ A vicious cycle ensues with escalating depersonalization as a key factor in the development and maintenance of social phobic behaviors.

People with social phobia go out of their way to avoid dreaded situations. They often do not involve themselves in social situations for fear of meeting new people. When severe, people with social phobia may miss time at work because they fear meeting situations in which they may be required to speak. They focus on potential negative outcomes and see positive outcomes from social interaction as unlikely. People with social phobia fear embarrassment or the harsh judgment of others. When others look at them, they often break into a sweat or tremble. The ability to process incoming information is also affected — a type of protective mechanism that social phobics have. They avoid elaborate processing of threatening material that’s evident when they are subsequently questioned. Because of this tuning-out process, they tend to miss the social cues, both positive and negative, that might enable them to properly interact with others.

The underlying roots of social phobia, much like agoraphobia, can be traced back to childhood and have been associated with parents who are overprotective or anxious.²⁰ Children who lack social support are also more likely to develop social phobia.²⁵ Fortunately, the majority of shy children eventually learn to interact with their peers and do not develop social phobia.²⁵

Environmental factors, including exposure to traumatic injury and rigidly prescribed gender roles, apparently more heavily influence the development of social phobia in women than in men.¹⁵ Women and people from lower socioeconomic status are more likely to develop social phobia. Although men may develop social phobia less frequently than women, men appear to be more likely to develop the most severe form. People with social phobia are also more likely to be diagnosed with avoidant personality disorder.²⁶

An important measure to reduce the development of social phobia is the timely intervention and treatment of panic attacks.²⁷ Cueing in on shyness and anxious or withdrawn behavior is also important because these may be risk factors for developing social phobia as well as an early manifestation of the disorder.¹⁶ Research has also shown that individuals with social phobia also have low levels of self-discipline.²⁸

Specific phobia

“Don’t climb high, or you’ll fall and break your neck.”

“Come inside when it’s dark — it’s not safe.”

“Don’t talk to strangers — they could snatch you up and take you away forever.”

Parenthood is difficult enough without having to stop and consider if the safety-related guidance children receive is conditioning them for subsequent phobic behavior. But indeed, depending on parenting style and the presence of parental anxiety disorders, children may be exposed to phobic role models or phobic-inducing beliefs at a young age. And yet parents also have the ability to dispel irrational fears and beliefs by providing accurate information and support that discourages fear or avoidant behaviors.¹⁶

Exposure to phobic stimuli seems to stimulate an anxiety response that may escalate into a full panic attack. People recognize that their fears are excessive or irrational, yet they are unable to control it. The stimulant is typically avoided or endured with intense anxiety and distress. This avoidance can interfere with their normal routine, occupational functioning, and social relationships.

Spiders and snakes, dentist visits, airplane trips, having blood drawn, hypoglycemic reaction — whatever. If it’s an object, place, or circumstance that cues marked and persistent fear that’s excessive or unreasonable when present, the person suffers from a specific phobia. These phobias can present problems for nurses involved in caregiving.

Phobia to blood draws and injections is likely to become apparent during routine patient encounters.¹⁴ If a patient appears excessively anxious before having blood drawn, getting an injection, or having an IV started, the nurse should spend a few minutes reassuring the person while assessing previous individual and family history. This phobia has a strong familial tendency.¹⁴ If feasible, perform the procedure with the patient lying down, rather than sitting or standing, because of the possibility of a strong vasovagal response.¹⁵ Be sure to keep ammonia smelling salts close by, just in case. This phobia can be a tremendous barrier to care planning for patients with diabetes requiring insulin therapy.

Patients with diabetes have a higher incidence of phobias, especially fears related to episodes of hypoglycemia, than the general population. These patients may fear low blood sugars so much that they overcompensate even when their glucose levels drop slightly and cause marked hyperglycemia. Phobia can often complicate glycemic control when needle phobia complicates using a lancet device to monitor blood glucose levels and administering insulin or other injectable diabetic medications, such as exenatide (Byetta) and pramlintide (Symlin).²⁹

Claustrophobia is the fear of closed-in spaces. While this is often associated with a fear of elevators, patients who try to avoid other closed-in spaces, such as a CT or MRI scanner, can complicate or delay obtaining adequate diagnosis and treatment recommendations.³⁰

Although some phobias have negative consequences, other phobias can promote practice of healthy behaviors. For instance, fear of contracting a sexually transmitted disease can help promote consistent condom use. On the other hand, phobias taken to extremes can precipitate behaviors common to obsessive-compulsive disorder, for example, people with a phobia of germs might be driven to constantly wash their hands.

Conquering Mount Phobia

For the untrained person, overcoming a phobia may seem like a simple case of promoting stronger willpower to overcome defective thinking by applying punishment, shame, or negative consequences. An example would be the boss who insists that an employee deliver a speech or be fired. While such a punitive approach may result in the employee delivering the speech out of fear of unemployment, the underlying phobic fear often remains unchanged or is reinforced by the internal conflict that an ultimatum produces.

Methods for combating phobias can involve the use of therapeutic techniques, medications, or a combination of both. Areas of the brain that coordinate the bodily defenses to threat include the amygdala, hippocampus, and cortical areas of the brain — areas that have been found to respond well to both therapeutic techniques and pharmacotherapy.³¹

Cognitive behavioral therapy (CBT) techniques are intended to decondition and reduce anxiety by helping patients identify and change negative or dysfunctional thoughts, beliefs, and automatic behaviors. Therapy can be provided on an individual or group basis, although younger adults with higher levels of anxiety tend to respond better to an individual approach.³² To view an evidenced-based clinical guideline for the delivery of CBT via computer, go to www.guideline.gov/summary/summary.aspx?doc_id=%209087&nbr=004901&string=phobia.

CBT, which also involves exposure to the source of the phobia to eliminate avoidance, can itself cause anxiety. Nevertheless, it has been proved effective.^33,24 Individuals with asthma who are treated with CBT have shown improvement in their pulmonary function.³⁴ Sustained remission likelihood decreases with patient age or when a dual diagnosis of depression or a personality disorder is also present.³³

Conditioning by virtual reality has been made possible through technological advances. Exposure to a cueing event in a controlled setting can produce behavioral changes in the natural environment with a varied duration of improvement for phobias, including agoraphobia and fear of flying, spiders, and cockroaches.^35,36,37

Videotaping with review and feedback and role playing are two therapeutic strategies that can help a person with social phobia. Patients also learn how to evaluate situations based on the reality of “here and now” and not preconceived ideas of failure.

Clinical trials have also shown promise with using yoga and hypnotherapy as complementary treatment options for phobias.^38,39

Pharmacological interventions with both classic and newer antidepressants play important roles in the treatment of phobias. MAOIs, including phenelzine (Nardil) and tranylcypromine (Parnate), may be prescribed, but are less often used because of the dietary restriction of tyramine-free foods and the potential for adverse drug interactions.

Selective serotonin reuptake inhibitors (SSRIs), including sertraline (Zoloft), citalopram (Celexa), and paroxetine (Paxil), have been found to be an effective long-term treatment for social phobia.⁴⁰ SSRI drugs, along with the non-cyclic serotonin-norepinephrine reuptake inhibitor venlafaxine (Effexor) in general tend to provide a treatment response ranging from 66% to 69%. However, in some patients, an effective response may take up to 12 weeks, and patients should be encouraged to continue therapy.⁴¹ In addition, the adverse effects of jitteriness or weight gain with some antidepressants may be a barrier to adherence. Loss of libido can also reduce adherence. Patients need to know about potential adverse effects and measures to minimize them in advance.

While not approved by the U.S. Food and Drug Administration for the treatment of phobias, some evidence suggests that atypical antipsychotics, such as quetaipine (Seroquel) and olanzapine (Zyprexa), may be beneficial for some people. These powerful drugs are often only considered by prescribing professionals to use “off-label” as last-resort interventions with patientss who have phobias unresponsive to other conventional treatment interventions or medications. The concern to limit atypical is related to the potential for numerous associated adverse events, including alterations in lipid profiles, weight gain, disturbances in blood glucose homeostasis, and an increase type 2 diabetes diagnosis.^42,43

The anticonvulsant gabapentin (Neurontin) and the beta-blocker propranolol (Inderal) have also been found helpful because of their anxiety-reducing properties. Pregabalin (Lyrica) has also shown promise in clinical trials for treatment of social phobia. Advantages to these medications over SSRIs include fewer adverse effects. A drawback to gabapentin is the need for monitoring of therapeutic dosing blood levels.⁴⁴

The exclusive use of benzodiazepines has shifted to the use of combination therapy of benzodiazepines and antidepressants. One exception would be the short-term need for overcoming a phobia that impedes immediate care delivery, like giving intranasal midazolam (Versed) spray to facilitate CT or MRI scanning.⁴⁵

Combination therapy of benzodiazepines, including alprazolam (Xanax) or lorazepam (Ativan), has often been used in conjunction with CBT for agoraphobia, but research indicates that CBT alone often provides the best overall outcome. The opposite is true for the combination therapy of CBT and antidepressants, which is better than CBT alone for agoraphobia.⁴⁶

While many of the antidepressant drugs can be highly effective in management of phobias, the FDA has issued an alert and required many of them to contain updated black box warnings regarding increased risks of suicidal thinking and behavior, especially among young adults ages 18 to 24 during initial treatment (generally the first one to two months of drug use). To access the FDA news releases, question and answer sheets, and a complete list of all medications included in the warnings, visit www.fda.gov/cder/drug/antidepressants/default.htm

How nurses can help

Caring for patients with phobias can involve monitoring medications for effectiveness and adverse reactions, reinforcing concepts presented in therapy, and educating patients and their families on the significance of the phobia as a debilitating problem and not just a “character flaw” to be overcome.

Nurses can also teach patients to recognize the signs of increasing anxiety and to select anxiety-reduction measures appropriate for them. One of the most important things for nurses to remember when caring for patients experiencing phobia is to refrain from confronting or humiliating them. These patients truly need the benefit of a trusting relationship.

Be sure to carefully screen for suicidal ideation among people with phobias because environmental factors that predispose to phobias also contribute to the risk factors for suicide.⁴⁷ When social phobia is identified, especially among young adults, screening for substance abuse and depression is also important.⁴⁸

Culture may be an important and overlooked factor that impacts the experience and expression of phobias.¹ A problem with the interpretive process and cultural influences can hinder the detection or evaluation of a phobic disorder. Culture may also influence treatment seeking and adherence with medication and therapeutic management.

Phobias can intrude on many aspects of a person’s quality of life, causing emotional pain and physiological discomfort. An erosion of health-promoting behaviors can also take place. While overcoming phobias is difficult, there is hope. With the right treatment, many people with phobias can lead productive, fulfilling lives.