Specific Phobia (formerly Simple Phobia)

Diagnostic Features
The essential feature of Specific Phobia is marked and persistent fear of clearly discernible, circumscribed objects or situations (Criterion A). Exposure to the phobic stimulus almost invariably provokes an immediate anxiety response (Criterion B). This response may take the form of a situationally bound or situationally predisposed Panic Attack. Although adolescents and adults with this disorder recognize that their fear is excessive or unreasonable (Criterion C), this may not be the case with children. Most often, the phobic stimulus is avoided, although it is sometimes endured with dread (Criterion D). The diagnosis is appropriate only if the avoidance, fear, or anxious anticipation of encountering the phobic stimulus interferes significantly with the person’s daily routine, occupational functioning, or social life, or if the person is markedly distressed about having the phobia (Criterion E). In individuals under age 18 years, symptoms must have persisted for at least 6 months before Specific Phobia is diagnosed (Criterion F). The anxiety, Panic Attacks, or phobic avoidance are not better accounted for by another mental disorder (e.g., Obsessive-Compulsive Disorder, Posttraumatic Stress Disorder, Separation Anxiety Disorder, Social Phobia, Panic Disorder With Agoraphobia, or Agoraphobia Without History of Panic Disorder) (Criterion G).

The individual experiences a marked, persistent, and excessive or unreasonable fear when in the presence of, or when anticipating an encounter with, a specific object or situation.

The focus of the fear may be anticipated harm from some aspect of the object or situation (e.g., an individual may fear air travel because of a concern about crashing, may fear dogs because of concerns about being bitten, or may fear driving because of concerns about being hit by other vehicles on the road). Specific Phobias may also involve concerns about losing control, panicking, somatic manifestations of anxiety and fear (such as increased heart rate or shortness of breath), and fainting that might occur on exposure to the feared object. For example, individuals afraid of blood and injury may also worry about the possibility of fainting; people afraid of heights may also worry about dizziness; and people afraid of closed-in situations may also worry about losing control and screaming. These concerns may be particularly strong in the Situational Type of Specific Phobia.

Anxiety is almost invariably felt immediately on confronting the phobic stimulus (e.g., a person with a Specific Phobia of cats will almost invariably have an immediate anxiety response when forced to confront a cat). The level of anxiety or fear usually varies as a function of both the degree of proximity to the phobic stimulus (e.g., fear intensifies as the cat approaches and decreases as the cat withdraws) and the degree to which escape from the phobic stimulus is limited (e.g., fear intensifies as the elevator approaches the midway point between floors and decreases as the doors open at the next floor). However, the intensity of the fear may not always relate predictably to the phobic stimulus (e.g., a person afraid of heights may experience variable amounts of fear when crossing the same bridge on different occasions). Sometimes full-blown Panic Attacks are experienced in response to the phobic stimulus, especially when the person must remain in the situation or believes that escape will be impossible. Occasionally, the Panic Attacks are delayed and do not occur immediately upon confronting the phobic stimulus. This delay is more likely in the Situational Type. Because marked anticipatory anxiety occurs if the person is confronted with the necessity of entering into the phobic situation, such situations are usually avoided. Less commonly, the person forces himself or herself to endure the phobic situation, but it is experienced with intense anxiety.

Adults with this disorder recognize that the phobia is excessive or unreasonable. The diagnosis would be Delusional Disorder instead of Specific Phobia for an individual who avoids an elevator because of a conviction that it has been sabotaged and who does not recognize that this fear is excessive and unreasonable. Moreover, the diagnosis should not be given if the fear is reasonable given the context of the stimuli (e.g., fear of being shot in a hunting area or a dangerous neighborhood). Insight into the excessive or unreasonable nature of the fear tends to increase with age and is not required to make the diagnosis in children.

Fears of circumscribed objects or situations are very common, especially in children, but in many cases the degree of impairment is insufficient to warrant a diagnosis. If the phobia does not significantly interfere with the individual’s functioning or cause marked distress, the diagnosis is not made. For example, a person who is afraid of snakes to the point of expressing intense fear in the presence of snakes would not receive a diagnosis of Specific Phobia if he or she lives in an area devoid of snakes, is not restricted in activities by the fear of snakes, and is not distressed about having a fear of snakes.

Subtypes
The following subtypes may be specified to indicate the focus of fear or avoidance in Specific Phobia (e.g., Specific Phobia, Animal Type).

Animal Type. This subtype should be specified if the fear is cued by animals or insects. This subtype generally has a childhood onset.

Natural Environment Type. This subtype should be specified if the fear is cued by objects in the natural environment, such as storms, heights, or water. This subtype generally has a childhood onset.

Blood-Injection-Injury Type. This subtype should be specified if the fear is cued by seeing blood or an injury or by receiving an injection or other invasive medical procedure. This subtype is highly familial and is often characterized by a strong vasovagal response.

Situational Type. This subtype should be specified if the fear is cued by a specific situation such as public transportation, tunnels, bridges, elevators, flying, driving, or enclosed places. This subtype has a bimodal age-at-onset distribution, with one peak in childhood and another peak in the mid-20s. This subtype appears to be similar to Panic Disorder With Agoraphobia in its characteristic sex ratios, familial aggregation pattern, and age at onset.

Other Type. This subtype should be specified if the fear is cued by other stimuli. These stimuli might include the fear of choking, vomiting, or contracting an illness; “space” phobia (i.e., the individual is afraid of falling down if away from walls or other means of physical support); and children’s fears of loud sounds or costumed characters.

The frequency of the subtypes in adult clinical settings, from most to least frequent, is Situational; Natural Environment; Blood-Injection-Injury; and Animal. Studies of community samples show a slightly different pattern, with phobias of heights and of spiders, mice, and insects most common, and phobias of other animals and other elements of the natural environment, such as storms, thunder, and lightning, least common. Phobias of closed-in situations (a Situational Type of phobia) may be more common in the elderly. In many cases, more than one subtype of Specific Phobia is present. Having one phobia of a specific subtype tends to increase the likelihood of having another phobia from within the same subtype (e.g., fear of cats and snakes). When more than one subtype applies, they should all be noted (e.g., Specific Phobia, Animal and Natural Environment Types).

Associated Features and Disorders

Associated descriptive features and mental disorders. Specific Phobia may result in a restricted lifestyle or interference with certain occupations, depending on the type of phobia. For example, job promotion may be threatened by avoidance of air travel, and social activities may be restricted by fears of crowded or closed-in places. Specific Phobias frequently co-occur with other Anxiety Disorders, Mood Disorders, and Substance-Related Disorders. For example, in community samples, rates of co-occurrence with other disorders range from 50% to 80%, and these rates may be higher among individuals with early-onset Specific Phobias. In clinical settings, Specific Phobias are very common comorbid diagnoses with other disorders. However, Specific Phobias are rarely the focus of clinical attention in these situations. The Specific Phobia is usually associated with less distress or less interference with functioning than the comorbid main diagnosis. Overall, only 12%-30% are estimated to seek professional help for their Specific Phobias. In the absence of other diagnoses, help seeking for Specific Phobias is more likely with more functionally impairing phobias (e.g., phobias of objects or situations that are commonly encountered), multiple phobias, and Panic Attacks in the phobic context. In contrast, individuals with irrational fears of blood injury, medical procedures, and medical settings may be less likely to seek help for phobias.

Associated physical examination findings and general medical conditions. A vasovagal fainting response is characteristic of Blood-Injection-Injury Type Specific Phobias; approximately 75% of such individuals report a history of fainting in these situations. The physiological response is characterized by an initial brief acceleration of heart rate and elevation in blood pressure followed by a deceleration of heart rate and a drop in blood pressure, which contrasts with the usual acceleration of heart rate and elevation in blood pressure in other Specific Phobias. Certain general medical conditions may be exacerbated as a consequence of phobic avoidance. For example, Specific Phobias, Blood-Injection-Injury Type, may have detrimental effects on dental or physical health, because the individual may avoid obtaining necessary medical care. Similarly, fears of choking may have a detrimental effect on health when food is limited to substances that are easy to swallow or when oral medication is avoided.

Specific Culture, Age, and Gender Features

The content of phobias varies with culture and ethnicity. For example, fears of magic or spirits are present in many cultures and should be considered a Specific Phobia only if the fear is excessive in the context of that culture and causes significant impairment or distress. Specific Phobias may be more common in the lower socioeconomic strata, although the data are mixed.

In children, the anxiety may be expressed by crying, tantrums, freezing, or clinging. Children often do not recognize that the fears are excessive or unreasonable and rarely report distress about having the phobias. Fears of animals and other objects in the natural environment are particularly common and are usually transitory in childhood. A diagnosis of Specific Phobia is not warranted unless the fears lead to clinically significant impairment (e.g., unwillingness to go to school for fear of encountering a dog on the street).

Overall, the ratio of women to men with Specific Phobias is approximately 2:1, even among the elderly. However, the sex ratio varies across different types of Specific Phobias. Approximately 75%-90% of individuals with the Animal and Natural Environment Type are female (except for fear of heights, where the percentage of females is 55%-70%). Similarly, approximately 75%-90% of individuals with the Situational Type are female. Approximately 55%-70% of individuals with the Blood-Injection-Injury Type are female.

Prevalence
Although phobias are common in the general population, they rarely result in sufficient impairment or distress to warrant a diagnosis of Specific Phobia. The reported prevalence may vary depending on the threshold used to determine impairment or distress and the number of types of phobias surveyed. In community samples, current prevalence rates range from 4% to 8.8%, and lifetime prevalence rates range from 7.2% to 11.3%. Prevalence rates decline in the elderly. Also, prevalence estimates vary for different types of Specific Phobias.

Course
The first symptoms of a Specific Phobia usually occur in childhood or early adolescence and may occur at a younger age for women than for men. Also, the mean age at onset varies according to the type of Specific Phobia. Age at onset for Specific Phobia, Situational Type, tends to be bimodally distributed, with a peak in childhood and a second peak in the mid-20s. Specific Phobias, Natural Environment Type (e.g., height phobia), tend to begin primarily in childhood, although many new cases of height phobia develop in early adulthood. The ages at onset for Specific Phobias, Animal Type, and for Specific Phobias, Blood-Injection-Injury Type, are also usually in childhood. Fear of a stimulus is usually present for some time before becoming sufficiently distressing or impairing to be considered a Specific Phobia.

Predisposing factors to the onset of Specific Phobias include traumatic events (such as being attacked by an animal or trapped in a closet), unexpected Panic Attacks in the to-be-feared situation, observation of others undergoing trauma or demonstrating fearfulness (such as observing others fall from heights or become afraid in the presence of certain animals), and informational transmission (e.g., repeated parental warnings about the dangers of certain animals or media coverage of airplane crashes). Feared objects or situations tend to involve things that may actually represent a threat or have represented a threat at some point in the course of human evolution. Phobias that result from traumatic events or unexpected Panic Attacks tend to be particularly acute in their development. Phobias of traumatic origin do not have a characteristic age at onset (e.g., fear of choking, which usually follows a choking or near-choking incident, may develop at almost any age). Specific Phobias in adolescence increase the chances of either persistence of the Specific Phobia or development of additional Specific Phobias in early adulthood but do not predict the development of other disorders. Phobias that persist into adulthood remit only infrequently (around 20% of cases).

Familial Pattern
There is an increased risk for Specific Phobias in family members of those with Specific Phobias. Also, there is some evidence to suggest that there may be an aggregation within families by type of phobia (e.g., first-degree biological relatives of persons with Specific Phobias, Animal Type, are likely to have animal phobias, although not necessarily of the same animal, and first-degree biological relatives of persons with Specific Phobias, Situational Type, are likely to have phobias of situations). Fears of blood and injury have particularly strong familial patterns.

Differential Diagnosis
Specific Phobias differ from most other Anxiety Disorders in levels of intercurrent anxiety. Typically, individuals with Specific Phobia, unlike those with Panic Disorder With Agoraphobia, do not present with pervasive anxiety, because their fear is limited to specific, circumscribed objects or situations. However, generalized anxious anticipation may emerge under conditions in which encounters with the phobic stimulus become more likely (e.g., when a person who is fearful of snakes moves to a desert area) or when life events force immediate confrontation with the phobic stimulus (e.g., when a person who is fearful of flying is forced by circumstances to fly).

Differentiation of Specific Phobia, Situational Type, from Panic Disorder With Agoraphobia may be particularly difficult because both disorders may include Panic Attacks and avoidance of similar types of situations (e.g., driving, flying, public transportation, and enclosed places). Prototypically, Panic Disorder With Agoraphobia is characterized by the initial onset of unexpected Panic Attacks and the subsequent avoidance of multiple situations thought to be likely triggers of the Panic Attacks. Prototypically, Specific Phobia, Situational Type, is characterized by situational avoidance in the absence of recurrent unexpected Panic Attacks. Some presentations fall between these prototypes and require clinical judgment in the selection of the most appropriate diagnosis. Four factors can be helpful in making this judgment: the focus of fear, the type and number of Panic Attacks, the number of situations avoided, and the level of intercurrent anxiety. For example, an individual who had not previously feared or avoided elevators has a Panic Attack in an elevator and begins to dread going to work because of the need to take the elevator to his office on the 24th floor. If this individual subsequently has Panic Attacks only in elevators (even if the focus of fear is on the Panic Attack), then a diagnosis of Specific Phobia may be appropriate. If, however, the individual experiences unexpected Panic Attacks in other situations and begins to avoid or endure with dread other situations because of fear of a Panic Attack, then a diagnosis of Panic Disorder With Agoraphobia would be warranted. Furthermore, the presence of pervasive apprehension about having a Panic Attack even when not anticipating exposure to a phobic situation also supports a diagnosis of Panic Disorder With Agoraphobia. If the individual has additional unexpected Panic Attacks in other situations but no additional avoidance or endurance with dread develops, then the appropriate diagnosis would be Panic Disorder Without Agoraphobia.

Concurrent diagnoses of Specific Phobia and Panic Disorder With Agoraphobia are sometimes warranted. In these cases, consideration of the focus of the individual’s concern about the phobic situation may be helpful. For example, avoidance of being alone because of concern about having unexpected Panic Attacks warrants a diagnosis of Panic Disorder With Agoraphobia (if other criteria are met), whereas the additional phobic avoidance of air travel, if due to worries about bad weather conditions and crashing, may warrant an additional diagnosis of Specific Phobia.

Specific Phobia and Social Phobia can be differentiated on the basis of the focus of the fears. For example, avoidance of eating in a restaurant may be based on concerns about negative evaluation from others (i.e., Social Phobia) or concerns about choking (i.e., Specific Phobia). In contrast to the avoidance in Specific Phobia, the avoidance in Posttraumatic Stress Disorder follows a life-threatening stressor and is accompanied by additional features (e.g., reexperiencing the trauma and restricted affect). In Obsessive-Compulsive Disorder, the avoidance is associated with the content of the obsession (e.g., dirt, contamination). In individuals with Separation Anxiety Disorder, a diagnosis of Specific Phobia is not given if the avoidance behavior is exclusively limited to fears of separation from persons to whom the individual is attached. Moreover, children with Separation Anxiety Disorder often have associated exaggerated fears of people or events (e.g., of muggers, burglars, kidnappers, car accidents, airplane travel) that might threaten the integrity of the family. A separate diagnosis of Specific Phobia would rarely be warranted.

The differentiation between Hypochondriasis and a Specific Phobia, Other Type (i.e., avoidance of situations that may lead to contracting an illness), depends on the presence or absence of disease conviction. Individuals with Hypochondriasis are preoccupied with fears of having a disease, whereas individuals with a Specific Phobia fear contracting a disease (but do not believe it is already present). In individuals with Anorexia Nervosa and Bulimia Nervosa, a diagnosis of Specific Phobia is not given if the avoidance behavior is exclusively limited to avoidance of food and food-related cues. An individual with Schizophrenia or another Psychotic Disorder may avoid certain activities in response to delusions, but does not recognize that the fear is excessive or unreasonable.

Fears are very common, particularly in childhood, but they do not warrant a diagnosis of Specific Phobia unless there is significant interference with social, educational, or occupational functioning or marked distress about having the phobia.

Diagnostic criteria for Specific Phobia

A. Marked and persistent fear that is excessive or unreasonable, cued by the presence or anticipation of a specific object or situation (e.g., flying, heights, animals, receiving an injection, seeing blood).
B. Exposure to the phobic stimulus almost invariably provokes an immediate anxiety response, which may take the form of a situationally bound or situationally predisposed Panic Attack. Note: In children, the anxiety may be expressed by crying, tantrums, freezing, or clinging.
C. The person recognizes that the fear is excessive or unreasonable. Note: In children, this feature may be absent.
D. The phobic situation(s) is avoided or else is endured with intense anxiety or distress.
E. The avoidance, anxious anticipation, or distress in the feared situation(s) interferes significantly with the person’s normal routine, occupational (or academic) functioning, or social activities or relationships, or there is marked distress about having the phobia.
F. In individuals under age 18 years, the duration is at least 6 months.
G. The anxiety, Panic Attacks, or phobic avoidance associated with the specific object or situation are not better accounted for by another mental disorder, such as Obsessive-Compulsive Disorder (e.g., fear of dirt in someone with an obsession about contamination), Posttraumatic Stress Disorder (e.g., avoidance of stimuli associated with a severe stressor), Separation Anxiety Disorder (e.g., avoidance of school), Social Phobia (e.g., avoidance of social situations because of fear of embarrassment), Panic Disorder With Agoraphobia, or Agoraphobia Without History of Panic Disorder.

Specify type:

Animal Type

Natural Environment Type (e.g., heights, storms, water)

Blood-Injection-Injury Type

Situational Type (e.g., airplanes, elevators, enclosed places)

Other Type (e.g., fear of choking, vomiting, or contracting an illness; in children, fear of loud sounds or costumed characters)

Provided by ArmMed Media
Revision date: July 6, 2011
Last revised: by Andrew G. Epstein, M.D.