14th February 2025

Phobias and stress disorders

Phobias

Overview of phobias

Phobias are recurrent, excessive (disproportionate) and irrational fears with anxiety symptoms regarding specific objects or situations. They often lead to avoidance behaviours.

For a phobia diagnosis, symptoms must last for at least several months and be severe enough to cause significant distress and impairment in interpersonal, social and/or occupational functioning.

In general, first-line treatment is with CBT and may include exposure therapy (graded desensitisation) and relaxation training. Pharmacological measures may also be needed, including SSRIs or SNRIs. Beta blockers can be used as required for somatic anxiety symptoms (particularly in social phobia). Benzodiazepines are used for short-term treatment only, such as to help engage with exposure therapy.

Specific phobias

In specific phobias, a simple object or situation, or anticipation of its exposure, is the subject of the phobia. This is in contrast to “complex” phobias such as agoraphobia or social phobia. 

The most common subjects are spiders (arachnophobia), snakes (ophidiophobia) and heights (acrophobia).

Agoraphobia

Agoraphobia is an anxiety disorder characterised by anxiety symptoms in places which are difficult to leave, such as crowded or public spaces, with active avoidance of these situations. There are fears regarding specific negative outcomes such as incapacitation, panic attacks, or embarrassing events.

There is an overlap of aetiological factors, clinical features, and effective treatments with panic disorder.

Social phobia

Social phobia is also known as social anxiety disorder.

The patient has severe anxiety symptoms in specific social situations, such as meeting strangers, public speaking or eating in front of others. There are preoccupations that the individual will be negatively perceived by others due to how they come across. These social situations are either avoided or endured with intense anxiety symptoms.

There is a high rate of concomitant anxiety disorders, depressive disorders and substance misuse.

Stress disorders

Acute stress reaction

This is a temporary experience with a quick onset and resolution. It occurs as a result of severe stress, which typically threatens the security or safety of the individual or someone close to them, such as natural disasters, war, sexual or physical violence, and witnessing death or injuries of others.

It is a syndrome of transient emotional, physical, cognitive and/or behavioural symptoms, including autonomic anxiety symptoms (e.g. tachycardia), confusion, low mood, anxiety, social withdrawal, dissociation, and stupor. The response to the stressor occurs within an hour and subsides within a few days of removal from exposure. If removal is not possible, symptoms reduce in intensity within a month.

Due to the short natural history of acute stress reaction, management is typically supportive until resolution.

Acute stress disorder

Acute stress disorder is a continuation of the acute stress reaction, with a larger role of dissociative symptoms. It is more common with particular stressors, such as witnessing mass shootings, assault, and involvement in a road traffic accident, and in those with concomitant psychiatric disorders, substance misuse and a history of trauma.

Onset of symptoms is within 4 weeks of the stressor and persists for up to another 4 weeks. After this, the diagnosis changes to post-traumatic stress disorder.

Brief psychological interventions such as CBT may reduce the risk of developing post-traumatic stress disorder or other chronic problems. 

Post-traumatic stress disorder (PTSD)

PTSD is a significant psychological disturbance following a traumatic incident or incidents which may have occurred recently or many years before (although usually within 6 months). The incident must be severe in its intensity, such as exposure to actual or threatened death, serious injury or sexual violence. The individual may have experienced, witnessed, or learned about the incident.

Archetypal symptoms of post-traumatic stress disorder are:

• Involuntary reliving the traumatic event(s) via intrusive thoughts, flashbacks, or nightmares
• Avoidance of thoughts, activities or situations which are associated with the event(s)
• Persistent “hypervigilance” with increased perception of threat and exaggerated startle reaction

In addition to these core symptoms, low self-esteem, hopelessness, emotional dysregulation, and emotional numbness are commonly seen. Medically unexplained symptoms may be present.

Symptoms must last for at least a few weeks and impede social, occupational and/or interpersonal functioning.

NICE recommends trauma-focused psychological treatments, including trauma-focused CBT and eye movement desensitisation and reprocessing (EMDR). Antidepressants (SSRI, SNRI) may be considered along with patient preference or if psychological treatments are awaited or ineffective. Sleep is often disrupted, so short courses of hypnotic medications such as zopiclone may be required.

Adjustment disorder

Adjustment disorder is a variant of PTSD where the reaction is similar but milder in intensity, with functional impairment. The precipitating stressor is usually less severe in nature, such as divorce, loss of a job, or diagnosis of an illness. Another distinction is that the symptoms resolve within 6 months. Adjustment disorder carries a significant risk of suicide and deliberate self-harm, especially in younger patients.

References

• Semple D, Smyth R. Oxford handbook of psychiatry. Oxford; New York: Oxford University Press; 2019
• World Health Organization. ICD-11 for Mortality and Morbidity Statistics [Internet]. WHO; 2019 [cited 2022 Mar 17]. Available from: https://icd.who.int/browse11/l-m/en#/http://id.who.int/icd/entity/1707067746
• Huberman A. Phobias [Internet]. BMJ Best Practice; 2022 [cited 2022 Mar 21]. Available from: https://bestpractice.bmj.com/topics/en-gb/693
• NHS. Phobias [Internet]. NHS UK. NHS; 2021. Available from: https://www.nhs.uk/mental-health/conditions/phobias/
• Hoskins M, Lewis C. Post-traumatic stress disorder [Internet]. BMJ Best Practice; 2022 [cited 2022 Mar 28]. Available from: https://bestpractice.bmj.com/topics/en-gb/430
• National Institute for Health and Care Excellence. Post-traumatic Stress Disorder [Internet]. NICE; 2020 [cited 2022 Mar 28]. Available from: https://cks.nice.org.uk/topics/post-traumatic-stress-disorder/