Unlike an anxiety attack, a phobia focuses on a specific object or situation. The patient is chronically fearful of a particular animal or situation and becomes extremely anxious or panic stricken and incapacitated when placed in a situation that evokes the phobia. These situations are avoided at all costs. As a result, it may be impossible for the patient to leave the house or neighborhood unaccompanied or at all, mingle in a crowd, walk across a bridge, or travel by air. This fear of being in places or situations from which escape might be difficult or extremely embarrassing is spoken of as agoraphobia. (Agoraphobia, however, is a secondary feature of other psychiatric disorders, the most frequent being anxiety with panic attacks as already mentioned.) The most common phobia—and one that is not disabling for the most part—is claustrophobia, the fear of being confined in a close space such as an elevator or a magnetic resonance scanner. Other phobias are those of open (agoraphobia), closed, or high places, dogs, cats, insects, dirt, sprays and other contaminants, air travel, HIV, cancer, insanity, and death. Feelings of helplessness, pessimism, and despondency, the hallmarks of a depressive illness, result after years of phobic suffering. Often there are obsessive-compulsive tendencies as well, and some patients are hypochondriacal. Phobias are essentially obsessive fears and are somehow allied with this latter category of neurosis. The present authors have observed a number of patients whose phobic (or obsessive- compulsive) states became greatly exaggerated as an endogenous depression developed. Recovery from the depression returned them to their earlier and milder phobic state.
Like the pure phobic states, a state dominated by obsessions and compulsions is relatively rare, occurring in less than 5 percent of patients seeking help in a psychiatric outpatient clinic, but it can be extremely disabling. Minor compulsions (e.g., not stepping on cracks in the sidewalk), like minor phobias, are common in children, cause little or no distress, and disappear in later life. A few, such as rechecking a locked door or a gas stove, may persist throughout life. Also, certain habits and rigid, obsessional ways of thinking, stubbornness, extreme punctuality, and excessive attention to detail may be persistent but excite little attention medically unless they interfere with a diagnostic procedure or the treatment of a medical disease.
Obsessive-compulsive disorder begins in adolescence or early adult years, although treatment may not be sought until middle age. The 2 sexes are equally affected. The onset is usually gradual and often cannot be accurately dated, but in some cases it is precipitated by a particular event in the patient’s life, such as the death of a relative. The family history often discloses a high incidence of obsessional or phobic personality in other members. There is usually a prevailing undercurrent of insecurity and anxiety.