A 34-year-old woman comes to the office accompanied by her husband for an employment physical examination. The patient says, "I'd rather not be here, but my job requires labs every 2 years." While getting blood drawn, she starts to feel anxious, nauseated, and short of breath, and says, "I feel like the room is spinning." The patient's husband explains that she has had similar episodes since childhood, which began following a bike accident during which she cut her knee and bled profusely. Medical history is significant for asthma and type 2 diabetes mellitus. Temperature is 36.7 C (98.1 F), blood pressure is 140/90 mm Hg, pulse is 104/min, and respirations are 20/min. BMI is 36 kg/m². Physical examination is significant for anxious demeanor but is otherwise unremarkable. Which of the following is the most likely diagnosis?

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11ec160b_3649_f300_9249_d92a5ad9b11c_MD0001_00 This patient's marked anxiety response and fear regarding blood drawing (a specific phobic stimulus) with a history of avoidance behavior is consistent with specific phobia, one of the most common anxiety disorders. The blood-injection-injury type (ie, fear of blood, injections, and injury) is often accompanied by a vasovagal fainting response, and severe cases may be associated with avoidance of necessary medical procedures. Other subtypes of specific phobia, based on the type of phobic stimulus, include animals (eg, insects, snakes, dogs), natural environment (eg, heights, storms, water), and situations (eg, elevators, enclosed places, airplanes). The treatment of choice of specific phobia is cognitive-behavioral therapy with repetitive, graded exposure to the fear-inducing stimulus. (Choice A) Although medical conditions such as asthma or hypoglycemia can result in anxiety, it is more likely that this patient's longstanding and specific fear of blood is triggering her current symptoms. (Choice B) Illness anxiety disorder involves persistent preoccupation with having or developing a serious medical condition. (Choice C) Patients with specific phobia may experience anxiety that reaches the level of a panic attack when exposed to the phobic stimulus. However, panic attacks in specific phobia are always triggered by the phobic stimulus; diagnosis of panic disorder requires that patients experience recurrent, unexpected panic attacks with no trigger. (Choice D) Both specific phobia and posttraumatic stress disorder (PTSD) may be associated with anxiety and avoidance of situations related to a traumatic event. However, PTSD also involves intrusive symptoms of reexperiencing (eg, flashbacks, nightmares) that are not present in this patient. Educational objective: Specific phobia is a common anxiety disorder characterized by high levels of anxiety and panic attacks triggered by exposure, or anticipation of exposure, to a feared stimulus. As a result, these patients try to avoid the phobic stimulus whenever possible. __________ References: Specific phobia. (http://www.ncbi.nlm.nih.gov/pubmed/29763098)

A 34-Year-Old Woman Comes to the Office Accompanied by Her