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Stem
A 24-year-old female nursing student is referred to the liaison psychiatry team. For as long as she can remember she has been terrified of needles and blood. Over the past year she has fainted on three occasions during venepuncture: her heart rate dropped to 36/min and her blood pressure to 78/50 mmHg immediately before loss of consciousness. She is due to start clinical rotations and is avoiding the ward; she also missed a scheduled iron-deficiency work-up. She is otherwise well, takes no medication, and has no other psychiatric history. Her mother and maternal aunt have the same problem.
In a separate case, a 45-year-old woman has not left her home unaccompanied for six months. She avoids buses, trains, crowded markets, queues, and open public spaces because she fears she could not escape or get help if she felt unwell. She has never had an unexpected panic attack. Low-intensity guided self-help has produced no improvement, and she now has depressive symptoms.
Questions
a) Give the most likely diagnosis for the first case and justify it with two key features. (2 marks)
Blood-injection-injury (BII) specific phobia. Justification: (i) marked, persistent, cue-specific fear and avoidance of needles/blood with anticipation of exposure; (ii) the UNIQUE vasovagal response — bradycardia (HR 36/min) and hypotension (BP 78/50 mmHg) culminating in syncope, which is pathognomonic for BII phobia as opposed to the tachycardia seen in other phobias. The strong family history (mother, aunt) is consistent with the high (~64 percent) heritability of BII phobia.
b) List the DSM-5 diagnostic criteria for a specific phobia. (3 marks)
- Marked fear or anxiety about a specific object or situation.
- The phobic object/situation almost always provokes immediate fear/anxiety.
- The fear is out of proportion to the actual danger and to the sociocultural context.
- The situation is avoided or endured with intense fear/anxiety.
- The fear/anxiety/avoidance is persistent, lasting 6 months or more.
- The disturbance causes clinically significant distress or impairment.
- The disturbance is not better explained by another mental disorder (e.g. panic disorder, OCD, PTSD, social anxiety, separation anxiety).
c) Outline the first-line management for this patient, including a named behavioural technique and its rationale. (3 marks)
First-line is cognitive behavioural therapy with exposure. For BII phobia specifically, the APPLIED TENSION technique (Ost) is the treatment of choice: the patient repeatedly tense large muscle groups (arms, legs, torso) for about 20 seconds, release briefly, and repeat for five cycles, which raises blood pressure and prevents the vasovagal faint. This is combined with graded in-vivo exposure to needles, blood draw imagery, and actual venepuncture. Rationale: BII phobia's faint is driven by vagal overdominance (Bezold-Jarisch reflex), so raising BP mechanically aborts the syncope; standard relaxation is counter-productive because it lowers BP further. About 90 percent of patients are clinically improved after five sessions. Avoid benzodiazepines (impair extinction learning and risk dependence).
d) For the second case, give the diagnosis, the NICE stepped-care level now indicated, and the recommended treatment package. (2 marks)
Diagnosis: agoraphobia without panic disorder (fear of 2 of 5 agoraphobic situations; no unexpected panic attacks; housebound and impaired). NICE stepped care: she has failed step 2 (low-intensity self-help) and has comorbid depression, so step 3 is indicated — high-intensity CBT with in-vivo exposure across the avoided situations (delivered home-based or via a home treatment team given housebound status), plus an SSRI such as sertraline for the agoraphobia and depressive symptoms.