Specific phobia

Essential (Required) Features:

• Marked and excessive fear or anxiety that consistently occurs upon exposure or anticipation of exposure to one or more specific objects or situations (e.g., proximity to certain kinds of animals, heights, enclosed spaces, sight of blood or injury) that is out of proportion to the actual danger posed by the specific object or situation.
• The phobic object or situation is actively avoided or else endured with intense fear or anxiety.
• A pattern of fear, anxiety, or avoidance related to specific objects or situations is not transient, that is, it persists for an extended period of time (e.g., at least several months).
• The symptoms are not better accounted for by another mental disorder (e.g., Social Anxiety Disorder, a primary psychotic disorder).
• The symptoms result in significant distress about experiencing persistent anxiety symptoms or significant impairment in personal, family, social, educational, occupational, or other important areas of functioning. If functioning is maintained, it is only through significant additional effort.

Additional Clinical Features:

• Specific Phobia encompasses fears of a broad and heterogeneous group of phobic stimuli. The most common are for particular animals (animal phobia), heights (acrophobia), enclosed spaces (claustrophobia), sight of blood or injury (blood-injury phobia), flying, driving, storms, darkness, and medical/dental procedures. Individuals’ reactions to phobic stimuli can range from feelings of disgust and revulsion (often occurring in animal phobias or blood-injury phobias), anticipation of danger or harm (common across most types of Specific phobia), and physical symptoms such as fainting (most common in response to blood or injury).
• The majority of individuals diagnosed with Specific Phobia report fear of multiple objects or situations. A single diagnosis of Specific Phobia is assigned regardless of the number of feared objects or situations. Unlike most phobic stimuli, which upon presentation or anticipation typically result in significant physiological arousal, individuals who fear the sight of blood, invasive medical procedures, or injury, may experience a vasovagal response that can result in a fainting spell.
• Some individuals with Specific Phobia may report a history of having observed another person (e.g., caregiver) react with fear or anxiety when confronted by an object or situation, resulting in vicarious learning of a fear response to the object or situation. Others may have had direct negative experience with an object or situation (e.g., having been bitten by a dog). However, previous negative experiences (direct or vicarious) are not necessary for the development of the disorder.
• Some individuals report that their fear or anxiety for an object or situation is not excessive. As such, clinicians must consider whether the reported fear, anxiety, or avoidance behaviour is disproportionate to the reasonable risk of harm, taking into consideration both accepted cultural norms as well as the specific environmental conditions that the individual is normally subjected to (e.g., fear of darkness may be justified in a neighbourhood where assaults are common at night).

Boundary with Normality (Threshold):

• In children and adolescents, some fears may be part of normal development (e.g., a young child who is afraid of dogs). Specific Phobia should only be diagnosed if the fear or anxiety is excessive in comparison to that of other individuals at a similar developmental level.

Course Features:

• Onset of Specific Phobia can occur at any age; however, initial onset is most common during early childhood (between 7 and 10 years of age) typically as a result of witnessing or experiencing a fear-provoking situation or event (e.g., choking, being attacked by an animal, witnessing someone drown).
• Younger age of onset has been associated with phobias related to animal and natural phenomena (fear of still water/weather, closed spaces); whereas, fear of flying- and height-related phobias generally have an older age of onset.
• Younger age of onset is also associated with an increased number of feared situations or stimuli.
• Individuals with Specific Phobia report high lifetime rates of co-occurring disorders, particularly, Depressive Disorders and other Anxiety or Fear-Related Disorders. In the majority of cases, Specific Phobia precedes the onset of other mental disorders.
• Specific phobias that persist from childhood into adolescence and adulthood rarely remit spontaneously.

Developmental Presentations:

• Anxiety or Fear-Related Disorders are the most prevalent mental disorders of childhood and adolescence. Among these conditions, Specific Phobia is one of the most common in young children, and may present in children as young as 3 years of age.
• In children, the diagnosis of Specific Phobia should not be assigned when the fears are developmentally normative (e.g., fear of the dark in young children).
• In preschool age children, phobic responses may include freezing, tantrums, or crying. Duration, frequency, and intensity of these reactions may be used to distinguish between age-typical fears and anxiety responses in Specific Phobia.
• Specific Phobias related to tangible objects (e.g., animals) are more common in younger children whereas those relating to possible harm to oneself or others (e.g., environmental, blood/injection) are more common in adolescents and adults.
• Similar to adults, excessive avoidance is seen in both children and adolescents, and may be driven by both the actual presence of the phobic stimuli, or anticipatory anxiety (e.g., refusing to go outside because of the possible presence of bees).

Culture-Related Features:

• Culture may play a role in shaping the fear response to specific stimuli. A diagnosis of Specific Phobia should not be assigned if a stimulus is feared by most people in a cultural group, unless the fear exceeds cultural norms. For example, people from some cultural groups may avoid walking at night in certain areas where they fear ghosts or spirits may be present.
• The salience of specific feared stimuli may differ by cultural group and environmental context. Common threats in the environment (e.g., poisonous snakes) may account for some of the cultural variation in feared stimuli.

Sex- and/or Gender-Related Features:

• Lifetime prevalence of Specific Phobia is approximately twice as high in females.
• Whereas males and females are equally likely to experience phobias related to blood, injection, and injury, situationally specific phobias and those related to animals and natural environments are more common among females.

Boundaries with Other Disorders and Conditions (Differential Diagnosis):

• Boundary with Panic Disorder: If an individual with Specific Phobia experiences panic attacks exclusively in the context of actual or anticipated encounters with the specific object or situation that represents the focus of apprehension, an additional diagnosis of Panic Disorder is not warranted and the presence of panic attacks may be indicated using the ‘with panic attacks’ specifier. However, if unexpected panic attacks also occur, an additional diagnosis of Panic Disorder may be assigned.
• Boundary with Agoraphobia: Specific Phobia is differentiated from Agoraphobia because it involves fear of circumscribed situations or stimuli (e.g., heights, animals, blood-injury) rather than because of fear or anxiety of imminent perceived dangerous outcomes (e.g., panic attacks, symptoms of panic, incapacitation, or embarrassing physical symptoms) that are anticipated to occur in multiple situations where obtaining help or escaping might be difficult.
• Boundary with Social Anxiety Disorder: In Social Anxiety Disorder, the fear and avoidance is triggered by social situations (e.g., speaking in public, initiating a conversation) and the primary focus of apprehension is about being negatively evaluated by others, whereas in Specific Phobia, the fear and avoidance is in response to other specific objects or situations.
• Boundary with Obsessive-Compulsive Disorder: In Obsessive-Compulsive Disorder, individuals may avoid specific stimuli or situations related to obsessions or compulsions (e.g., avoiding ‘contaminated’ situations in someone with a hand-washing compulsion) whereas in Specific Phobia, objects or situations are avoided because of fear associated with them and not because of obsessions or compulsions.
• Boundary with Hypochondriasis (Health Anxiety Disorder): In Hypochondriasis, individuals may avoid medical consultations or hospitals because of a fear that it will exacerbate their preoccupation with having a serious disease. In contrast, in Specific Phobia the fear and avoidance are related to the specific object or situation itself.
• Boundary with Post-Traumatic Stress Disorder and Complex Post-Traumatic Stress Disorder: Both Specific Phobia and Post-Traumatic Stress Disorder involve avoidance of stimuli that cause anxiety, and both may arise following exposure to a traumatic event. Post-Traumatic Stress Disorder can be differentiated from Specific Phobia by the presence of the other core symptoms of Post-Traumatic Stress Disorder (i.e., re-experiencing the trauma and persistent perceptions of heightened current threat). They are further differentiated by the fact that, unlike Specific Phobia in which the memories of the related traumatic event are experienced as belonging to the past, in Post-Traumatic Stress Disorder and Complex Post-Traumatic Stress Disorder, the traumatic event is experienced as if it were occurring again in the here and now (i.e., re-experiencing).
• Boundary with Feeding or Eating Disorders: Individuals with Feeding or Eating Disorders exhibit abnormal eating behaviour and/or preoccupation with food as well as prominent body weight and shape concerns and may avoid food because they fear it will lead to weight gain or because of its specific sensory qualities. In some Specific Phobias, individuals may avoid eating or food stimuli, but the avoidance is related to the anticipated direct effect of the phobic stimulus (e.g., eating may lead to choking or vomiting) rather than because of the caloric content or sensory qualities of the food itself.
• Boundary with Oppositional Defiant Disorder: Irritability, anger, and noncompliance are sometimes associated with anxiety in children and adolescents. For example, children may exhibit angry outbursts when asked to interact with a stimulus or enter situations that make them feel anxious (e.g., asking a child who fears dogs to go to the park where there might be dogs present). If the defiant behaviours only occur when triggered by a situation or stimulus that elicits anxiety, fear, or panic, a diagnosis of Oppositional Defiant Disorder is generally not appropriate.