Specific Phobia

Primer

Specific Phobia is an anxiety disorder characterized by intense fear or anxiety in the presence of a particular situation or object (phobic stimulus). The four major types of fear are animals, environments, medical procedures, and situations (e.g. - elevators, planes, enclosed spaces).

Epidemiology
  • The 12-month prevalence rates for specific phobia are estimated to be between 7 to 9%.[1]
    • Rates are higher in adolescents (16%) than children (5%).[2]
    • Rates are generally lower in Asian, Latin American, and African countries.[3]
  • Specific phobias are more common in women than men (approximately 2:1).[4]
    • However, for blood-injection-injury phobia, men and women are equally affected.
  • The average individual with specific phobia fears 3 objects or situations, and close to 75% of individuals with specific phobia fear more than one object or situation.[5]
  • Specific phobias (in particular a fear of falling) is the most common anxiety disorder in older adults (4 to 8%).[6][7][8]
Prognosis
  • Specific phobia can often develop following a traumatic event (e.g. - being bitten than an animal), observing others going through a traumatic event (e.g. - watching someone drown)
    • Most individuals however, are unable to recall a specific trigger for their phobia.
  • The majority of cases of specific phobia prior to age 10.[9]
  • Phobias that develop in childhood and adolescence tend to wax and wane, but if they persist into adulthood, it is rare for them to remit.[10]
  • Depending on the phobic stimulus, it can have a varied impact on the individual:
    • e.g. - fear of falling leading to individual staying at home
    • e.g. - fear of choking leading to individual reducing food and dietary intake
  • The impact of specific phobias worsen with an increasing number of phobias present.
Comorbidity
  • Specific phobia is associated with depression in older adults.
  • It is also associated temporally with other mental disorders due to it commonly developing in early childhood, but there is not necessarily a causal relationship.
Risk Factors
  • Overprotective parenting, early childhood trauma/abuse, parental loss and separation, are risk factors.
  • Having experienced a traumatic event with the feared object event can also (but does not always) precedes the development of a specific phobia.
  • Having a first-degree relative with a specific phobia also increases the risk for the individual to develop the same specific phobia.[11]
Cultural
  • The individual's sociocultural context should always be taken into account. For example, fears of the dark may be reasonable in a context of ongoing violence, and fear of insects may be more disproportionate in settings where insects are consumed in the diet.

DSM-5 Diagnostic Criteria

Criterion A

Marked fear or anxiety about a specific object or situation (e.g. - flying, heights, animals, receiving an injection, seeing blood – the specific object or situation is called a phobic stimulus).

In children, the fear or anxiety may be expressed by crying, tantrums, freezing, or clinging.
Criterion B

The phobic object or situation almost always provokes immediate fear or anxiety.

Criterion C

The phobic object or situation is actively avoided or endured with intense fear or anxiety.

Criterion D

The fear or anxiety is out of proportion to the actual danger posed by the specific object, or situation and to the sociocultural context.

Criterion E

The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.

Criterion F

The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Criterion G

The disturbance is not better explained by the symptoms of another mental disorder, including:

Specifiers

Specifiers

Specify based on the phobia:

  • Animal (e.g. - spiders, insects, dogs).
  • Natural environment (e.g. - heights, storms, water).
  • Blood-injection-injury (e.g. - needles, invasive medical procedures).
  • Situational (e.g. - airplanes, elevators, enclosed places).
  • Other (e.g. - situations that may lead to choking or vomiting: in children, e.g. - loud sounds or costumed characters).

Panic Attack Specifier

Specify if:

  • Recurrent unexpected panic attacks. An abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time at least 4 of the following symptoms occur (Note: The abrupt surge can occur from a calm state or an anxious state):
  1. Sweating
  2. Trembling or shaking
  3. Unsteady, dizziness, light-headed, or faint
  4. Derealization (feelings of unreality) or depersonalization (being detached from one self)
  5. Excessive/accelerated heart rate, palpitations, or pounding heart
  6. Nausea or abdominal distress
  7. Tingling, numbness, parathesesias
  8. Shortness of breath
  9. Fear of losing control or “going crazy”
  10. Fear of dying
  11. Choking feelings
  12. Chest pain or discomfort
  13. Chills or heat sensations
Note: The symptoms presented in this specifier are for the purpose of identifying a panic attack. However, panic attacks are not a mental disorder. Panic attacks can occur in the context of any anxiety disorder as well as other mental disorders (e.g. - depressive disorders, posttraumatic stress disorder, substance use disorders) and some medical conditions (e.g. - cardiac, respiratory, vestibular, gastrointestinal). When the presence of a panic attack is identified, it should be noted as a specifier (e.g. - “social anxiety disorder with panic attacks”). For panic disorder, the presence of panic attack is contained within the criteria for the disorder and panic attack is not used as a specifier.
Note: Culture-specific symptoms (e.g. - tinnitus, neck soreness, headache, uncontrollable screaming or crying) may be seen. Such symptoms should not count as one of the four required symptoms.

Signs and Symptoms

  • Individuals with certain specific phobia (situational, natural environment, and animal specific phobias) usually experience an increase in sympathetic nervous system arousal in anticipation of or during exposure to a phobic object or situation.[12]
  • However, individuals with blood-injection-injury specific phobias often demonstrate a vasovagal fainting or near-fainting response.
    • There may be an initial brief acceleration of heart rate and elevation of blood pressure followed by a quick deceleration of heart rate and a drop in blood pressure.[13]

Screening and Rating Scales

Scales for Specific Phobia

Name Rater Description Download
Phobia Questionnaire (PHQ) Patient The Phobia Questionnaire (PHQ) is a 15-item questionnaire used to measure a person's avoidance to a particular object or situation as a factor of fear.[14] Link
Specific Phobia Questionnaire (SPQ) Patient The SPQ is a 45-item questionnaire designed to assess the extent of fear and interference for a broad range of objects and situations. Link
Fear Questionnaire (FQ) Patient The FQ isa 24-item scale used to assess the degree of avoidance for phobias. Link

Pathophysiology

  • Like in other anxiety disorders, current neural models for specific phobia suggest that the amygdala and related structures play a role in the fear response in specific phobia.[15]

Differential Diagnosis

  • Agoraphobia
    • Situational specific phobia can look very similar to agoraphobia. These two diagnoses overlap in that they are both about feared situations (e.g. - flying, enclosed places, elevators).
      • If an individual fears only 1 of the agoraphobia situations, then specific phobia, situational, may be diagnosed.
        • For example, an individual who fears airplanes and elevators (which overlap with the '“public transportation” agoraphobic situation) but does not fear other agoraphobic situations would be diagnosed with specific phobia, situational.
      • If 2 or more agoraphobic situations are feared, then a diagnosis of agoraphobia is likely warranted.
        • For example, an individual who fears airplanes, elevators, and crowds (which overlap with 2 agoraphobic situations, (1) “using public transportation” and (2) “standing in line and or being in a crowd”) would be diagnosed with agoraphobia.
    • Remember that in agoraphobia, a core feature is that the individual has “thoughts that escape might be difficult or help might not be available in the event of developing panic-like symptoms or other incapacitating or embarrassing symptoms.” This can be useful in differentiating agoraphobia from specific phobia. If the fear is over being harmed directly by the phobic stimulus (e.g. - fear of a car crashing, fear of a spider biting) then a diagnosis of specific phobia diagnosis is more appropriate.
  • Social anxiety disorder
    • If the situations are feared because of concerns about negative evaluation, social anxiety disorder should be diagnosed.
  • Separation anxiety disorder
    • If the situation feared is about the separation from a primary caregiver or attachment figure, separation anxiety disorder should be diagnosed.
  • Panic disorder
    • Individuals with specific phobia may experience panic attacks when engaged with the feared situation or object. A diagnosis of specific phobia would be given if the panic attacks only occurred in response to the specific object or situation. On the other hand, a diagnosis of panic disorder would only be given if the individual also experienced panic attacks that were unexpected (i.e. - not in response to the phobic stimulus).
  • Obsessive-compulsive disorder (OCD).
    • If an individual's primary fear or anxiety is about an object or situation as a result of obsessions (e.g. - fear of blood due to obsessive thoughts about contamination from blood-borne pathogens; fear of driving due to obsessive images of harming others), and criteria for OCD are met, then OCD should be diagnosed instead.
  • Posttraumatic stress disorder (PTSD)
    • If the phobia develops following a traumatic event, PTSD should be considered on the differential diagnosis. However, traumatic events can precede the onset both of PTSD and specific phobia.
  • Eating disorders
    • If the avoidance behavior is limited to avoidance of food and related cues, a diagnosis of anorexia nervosa or bulimia nervosa should be considered.
  • Schizophrenia spectrum and other psychotic disorders
    • When the fear and avoidance are due to delusional symptoms, a diagnosis of specific phobia should not be given.

Investigations

  • Depending on the initial presenting symptoms (e.g. - dizziness, tachycardia), potential investigations can include: CBC, fasting glucose, fasting lipid profiles, electrolytes, liver enzymes, serum bilirubin, serum creatinine, urinalysis, urine toxicology for substance use, thyroid stimulating hormone (TSH).[16]

Physical Exam

  • As clinically indicated.

Treatment

Psychotherapy

Cognitive behavioural therapy with exposure is the first line treatment for specific phobias.[17]

  • Both in vivo (in real life) and virtual reality exposure (VRE) are superior than imaginal therapy.
  • Exposure therapy is more effective when sessions are grouped closely together and the exposure is real, and there is some degree of therapist involvement.
  • There is no difference between “flooding” and gradual (graded) exposure in specific phobias
  • Treatment with CBT and exposure therapies provides sustained long-term benefits.

Psychological Treatments in Specific Phobias

Katzman, M. A. et al. (2014). Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders. BMC psychiatry, 14(1), 1-83.
Psychological treatment Phobia
Exposure-based treatments All specific phobias
Virtual reality exposure Heights, flying, spiders, claustrophobia
Computer-based self-help programs Spiders, flying, small animals
Applied muscle tension (exposure combined with muscle tension exercises) Blood-injection-injury type
Cognitive therapy and exposure Dental, flying
Recommended Reading

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Pharmacotherapy

  • There is a limited role for the use of pharmacotherapy in the treatment of specific phobias, and there is little research on its role. This is because exposure based therapies are very successful. Benzodiazepines may sometimes be used in clinical practice for acute symptom relief, or in cases where there is a very specific feared situation that would warrant one-time medication use (e.g. - claustrophobia in MRI machine, or fear of flying for an unexpected urgent flight).[18]

Guidelines

Specific Phobia Guidelines

Guideline Location Year PDF Website
Canadian Clinical Practice Guidelines for the Management of Anxiety, Posttraumatic Stress and Obsessive-Compulsive Disorders Canada 2014 - Link

Resources

For Patients
For Providers
Articles
Research

References

1) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
2) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
3) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
4) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
5) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
6) Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan & Sadock's synopsis of psychiatry: Behavioral sciences/clinical psychiatry (Eleventh edition.). Philadelphia: Wolters Kluwer.
7) Deshpande, N., Metter, E. J., Lauretani, F., Bandinelli, S., & Ferrucci, L. (2009). Interpreting fear of falling in the elderly: what do we need to consider?. Journal of geriatric physical therapy (2001), 32(3), 91.
8) Cohen, C. I., Magai, C., Yaffee, R., Huangthaisong, P., & Walcott-Brown, L. (2006). The prevalence of phobia and its associated factors in a multiracial aging urban population. The American journal of geriatric psychiatry, 14(6), 507-514.
9) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
10) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
11) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
12) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
13) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
14) Marks, I. M., & Mathews, A. M. (1979). Brief standard self-rating for phobic patients. Behaviour research and therapy, 17(3), 263-267.
15) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
16) Katzman, M. A., Bleau, P., Blier, P., Chokka, P., Kjernisted, K., & Van Ameringen, M. (2014). Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders. BMC psychiatry, 14(1), 1-83.
17) Katzman, M. A., Bleau, P., Blier, P., Chokka, P., Kjernisted, K., & Van Ameringen, M. (2014). Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders. BMC psychiatry, 14(1), 1-83.
18) Katzman, M. A., Bleau, P., Blier, P., Chokka, P., Kjernisted, K., & Van Ameringen, M. (2014). Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders. BMC psychiatry, 14(1), 1-83.