THE CASE
Joe S* is a 25-year-old white man who lives with his mother and has a 5-year history of worsening hypertension. He recently presented to the clinic with heart palpitations, shortness of breath, abdominal distress, and dizziness. He said that it was difficult for him to leave his home due to the intense fear he experiences. He said that these symptoms did not occur at home, nor when he visited specific “safe” locations, such as his girlfriend’s apartment. He reported that his fear had increased over the previous 2 years, and that he had progressively limited the distance he traveled from home. He also reported difficulty being in crowds and said, “The idea of going to the movies is torture.”
● HOW WOULD YOU PROCEED WITH THIS PATIENT?
*The patient’s name has been changed to protect his identity.
The most prevalent psychiatric maladies in primary care are anxiety and mood disorders.1,2 Anxiety disorders are patterns of maladaptive behaviors in conjunction with or response to excessive fear or anxiety.3 The most prevalent anxiety disorder in the United States is specific phobia, the fear of a particular object or situation, with a 12-month prevalence rate of 12.1%.2
Other phobias diagnosed separately in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), include social phobia and agoraphobia, which are, respectively, the fear of being negatively evaluated in social situations and the fear of being trapped in public/open spaces. Social phobia and agoraphobia have diagnostic criteria nearly identical to those of simple phobias regarding the fear response, with the primary differences being the specific phobic situations or stimuli.
Unfortunately, these phobias are likely to be undiagnosed and untreated in primary care partly because patients may not seek treatment.4-6 The ease of avoiding some phobic situations contributes to a lack of treatment seeking.5 Furthermore, commonly used brief measures for psychiatric conditions generally identify depression and anxiety but not phobias. However, family physicians do have resources not only to diagnose these disorders, but also to work with patients to ameliorate them. Collaboration with behavioral health providers is key, as patients with phobias generally benefit from cognitive behavioral therapy (CBT), while those with comorbid psychiatric conditions may benefit from a combination of CBT and medication.
Phobic response vs adaptive fear and anxiety
The terms anxiety and fear often overlap when used to describe a negative emotional state of arousal. However, fear is a response to an actual (or perceived) imminent threat, whereas anxiety is the response to a perceived future threat.3 Fear, although unpleasant, serves an adaptive function in responding to immediate danger.7 Anxiety, in turn, may represent an adaptive function for future activities associated with fear. For example, a cave dweller having seen a bear enter a cave in the past (fear-evoking stimulus) may experience anxiety when exploring a different cave (anxiety that a bear may be present). In this situation, the cave dweller’s fear and anxiety responses are important for survival.
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