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Anxiety Disorder: Specific Phobia
Article Last Updated: Aug 7, 2006
AUTHOR AND EDITOR INFORMATION
Section 1 of 9  
Author: Sandra L Friedman, MD, MPH, Assistant Professor of Pediatrics, Harvard University Medical School; Director of Pediatrics, LEND/UCEDD, Department of Medicine, Division of General Pediatrics, Children's Hospital of Boston
Sandra L Friedman is a member of the following medical societies: American Academy of Pediatrics and American Medical Directors Association
Coauthor(s):
Kerim M Munir, MD, MPH, DSc, Director of Psychiatry, LEND/UCEDD, Division of General Pediatrics, Dir of Mental Health and Developmental Disabilities (MHDD) Training Prog, Children's Hospital Boston;
Marilyn T Erickson, PhD, Professor Emeritus, Department of Psychology, Virginia Commonwealth University
Editors: Chet Johnson, MD, Medical Director, Child Development Unit, Department of Pediatrics, Professor, University of Kansas Medical Center; Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine.com, Inc; Daniel Rauch, MD, FAAP, Director, Pediatric Hospitalist Program, Associate Professor, Department of Pediatrics, New York University School of Medicine; Caroly Pataki, MD, Professor of Clinical Psychiatry, Department of Psychiatry and Biobehavioral Sciences, Division Chair of Child and Adolescent Psychiatry, Director of Training, Child and Adolescent Psychiatry Residency Program, University of Southern California Keck School of Medicine
Author and Editor Disclosure
Synonyms and related keywords:
anxiety disorder, specific phobia, SP, simple phobia, fears, fear, morbid dread, panic, animal phobia, zoophobia, blood-injection-injury phobia, environmental phobia, situational phobia, environmental-situational phobia, phobic avoidance, persistent fear, irrational fear, tremor, fainting, shaking, tantrums, behavioral inhibition, unreasonable fear, excessive fear
Background
Phobias are the most common anxiety disorder. Specific phobia (SP) is characterized by extreme and persistent fear of specific objects or situations that present little or no real threat. SP has behavioral, cognitive, and physiologic manifestations. A summary of the diagnostic criteria for SP, based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, includes the following:
- Criterion A: The patient has persistent or irrational fear that is unreasonable or excessive and is triggered by the presence or anticipation of a specific object or situation.
- Criterion B: Exposure to the above noted event or object almost always results in an immediate anxiety response.
- Criterion C: The person acknowledges this response to be unreasonable or excessive.
- Criterion D: The person either avoids such situations or objects or else experiences exposure with intensive anxiety or distress.
- Criterion E: The avoidance or distressful response significantly interferes with a person's daily functioning.
- Criterion F: Duration is at least 6 months for individuals younger than 18 years.
- Criterion G: The anxiety, distressful response, or avoidance is not accounted for by other mental disorders (see Differentials).
The patient must have 1 of the following 5 subtypes that best describe phobias:
- Animal
- Natural environment
- Blood-injection injury
- Situational
- Other (must be distinguished from normal feat and anxiety)
Individuals may have more than one SP, as clustering often occurs. Animal, natural environment, and situational SPs tend to cluster. Seventy percent of those with blood SP also have injection SP. SP may be associated with problems with peers, family, and school. These problems may negatively affect self-esteem. Unlike adults, children may not acknowledge their fear is excessive or unreasonable. Fears and phobias are common in young children; thus, preschool children are rarely referred and diagnosed as phobic. Common fears of childhood need to be distinguished from SP, as the latter is irrational, interferes more with daily routines, and leads to maladaptive behaviors. In some instances, natural environmental contingencies may extinguish a fear, whereas, in other instances, a fear may remain for the person's entire life. SPs in children generally attenuate over time, although they may persist into adulthood. In contrast, SPs that appear in adolescents and adults tend to persist, with only approximately 20% resolving without intervention. Assessments generally consist of structured or semistructured interviews by the practitioner with the child and his or her parents. Various rating scales are also available to assess anxiety disorders.
Frequency
United States
The National Institute of Mental Health (NIMH) estimates that 5-12% of Americans have phobias; SP affects approximately 6 million Americans. Approximately 7-9% of children have been estimated to have SP. No significant differences have been noted between whites and persons of Hispanic or African descent. No conclusive evidence links socioeconomic status with SP.
International
The prevalence rates and types of phobias vary among various cultural and ethnic groups. The overall reported prevalence rates in children in New Zealand, Puerto Rico, Switzerland, and Germany are low.
Sex
Females may be at higher risk for developing SP than males. The sex difference is less notable for certain SPs, such as heights.
Age
The mean age of onset depends on the type of phobia. Animal, blood, and storms and water - SPs typically develop in early childhood. Heights SP - develops in teenagers. Situational SPs (eg, claustrophobia) typically develop during the late teens and early third decade of life.
Fears and phobias are common in young children. Referral rates tend to increase in mid-to-late childhood and early adolescence. The peak age for referral of children diagnosed with SP is 10-13 years, with the average age of onset of symptoms at approximately 8 years.
History
- Behaviorally, phobias manifest as the need to escape or avoid the feared object or situation. The fear may be expressed somatically by tremor, feeling faint or actually fainting, nausea, diaphoresis, rapid heart rate, increased blood pressure, and feelings of panic. Children may present with crying, tantrums, clinging, or immobilization.
- Parents of children with anxiety disorders typically have a higher than average incidence of anxiety disorders in their histories. Similarly, children whose parents have SP display a higher rate of SP than control subjects.
Causes
Numerous theories about the etiology of specific phobias have been offered, with psychoanalytic theory offering early explanation, although it is no longer ascribed. Many other theories have been proposed and include the following:
- Learning theories
- Classic conditioning: A previous neutral stimulus has been paired with an aversive stimulus that elicits a strong fear or emotional response. Often, adults in the child's life may be unaware of the aversive episode. Some believe this learning may be direct or vicarious, which entails witnessing an event involving another person that elicits fear.
- Operant conditioning: Parents may inadvertently reinforce the phobic behavior by providing the child with increased amounts of social attention surrounding the avoidant behavior.
- Cognitive models: Because learning theories are not felt to adequately explain the development and persistence of phobias, attention has been focused on the role of cognition. Children with anxiety disorders are more likely to display distorted and maladaptive thoughts, although the extent to which these negative thoughts are causes or consequences of their fears is unclear.
- Genetic, familial, and constitutional theories
- A familial component of SP is often observed, although the SP is usually different.
- Genetic factors are felt to contribute to SP.
- Constitutional factors and individual experiences increase the risk for developing anxiety disorders.
- Children with anxiety disorders are more likely to display distorted and maladaptive thoughts, but whether these negative thoughts are causes or consequences of their fears is unclear.
- Manifestations of constitutional factors may be apparent in individual differences in responsiveness to environmental events. A sudden loud sound elicits a range of emotional responses in different children, some of which are the result of biological differences.
- Children who demonstrate a stable behavioral inhibition (becoming excessively distressed and withdrawn in novel situations) from infancy through childhood have higher rates of anxiety disorders than children who are not consistently inhibited. These findings suggest that childhood behavioral inhibition may be a risk factor for developing anxiety disorders.
- Personality is felt to be heritable.
- Functional magnetic resonance imaging (fMRI) findings have suggested a neural network for the processing of threatening stimuli, with increased activation in the prefrontal cortex, insula, and posterior cingulated cortex, when subjects were exposed to phobia-sensitive words (eg, spider phobia) compared with subjects without phobias.
Anxiety Disorder: Obsessive-Compulsive Disorder
Anxiety Disorder: Panic Disorder
Anxiety Disorder: Separation Anxiety and School Refusal
Eating Disorder: Anorexia
Eating Disorder: Bulimia
Eating Disorder: Pica
Eating Disorder: Rumination
Posttraumatic Stress Disorder in Children
Somatoform Disorder: Somatization
Other Problems to be Considered
Psychotic disorder
Medical Care
- Behavior therapy is the first-line treatment.
- Exposure therapy: The patient is repeatedly exposed to the feared stimulus until the anxiety response it elicits is habituated.
- Especially in children, a gradual exposure program is developed, in which the least-feared stimulus in a fear hierarchy is presented first, followed sequentially over time (in a graduated manner) by the more feared stimuli in the hierarchy. Fear hierarchies are created by the behavior therapist in collaboration with the child and parents.
- Exposure to the feared stimulus may be conducted in real-life or imaginary contexts, in which the child is requested to visualize the feared object or situation. The longer the child is exposed to the aversive stimulus, the greater the likelihood that habituation occurs and anxiety decreases.
- Cognitive behavior therapy: These procedures are used when the therapist determines that the maintenance of the phobia may have a significant cognitive component. Procedures may include those in which the child is taught skills for contingency management, modeling management, and self-control. Applied tension and relaxation may be introduced, as well as improvement of specific skill deficits.
- Psychotherapy: This type of therapy is not generally used to treat the SP. The presence of an increasingly complex or disabling profile, however, may require individual and family psychotherapy.
- Psychopharmacology: This type of treatment is generally felt to have limited utility in the treatment of SP, with behavioral therapy being the main route of intervention. In some instances, selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine, sertraline, fluvoxamine, citalopram, and paroxetine, have been reported to be used effectively. SSRIs have been used as adjunctive therapy, as patients may have coexisting anxiety disorders (See Medication).
- Computer technology: Virtual reality exposure therapy, using a computer to provide graded exposures, has been reported. However, use of this technology has not been well studied in children.
Although behavioral therapy is the main route of intervention for SPs that interferes with functioning, case reports have documented improvement of symptoms with the use of SSRIs; benzodiazepines have not been shown to be effective.
Drug Category: Selective serotonin reuptake inhibitors (SSRIs)
These antidepressant agents have been used as antianxiety medication to treat anxiety disorders such as panic disorders (with or without agoraphobia), generalized anxiety disorders, obsessive-compulsive disorders, and SPs.
SSRIs are now strongly preferred over other classes of antidepressants, both in terms of their clinical efficacy and tolerability. The adverse effect profile of SSRIs is less prominent, with improved compliance. These agents also do not carry the cardiac arrhythmia risk associated with tricyclic (tertiary and secondary amine) classical antidepressants. Arrhythmia risk is especially pertinent in accidental and intentional overdose. The suicide risk must always be considered when a child or adolescent with mood disorder is treated with any psychotropic medication, including SSRIs.
Physicians are advised to be aware of the following information and use appropriate caution when considering treatment with SSRIs in the pediatric population.
| Drug Name | Fluoxetine (Prozac) |
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| Description | Selectively inhibits presynaptic serotonin reuptake with minimal or no effect in the reuptake of norepinephrine or dopamine. |
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| Adult Dose | 20 mg/d PO in am and increase after several wk by 20 mg/d; not to exceed 80 mg/d
Note: If patient is taking 20 mg/d, may initiate once-weekly dosing with the 90-mg delayed-release product 7 d after the last daily dose of 20 mg |
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| Pediatric Dose | <8 years: Not established
>8 years: 10-20 mg PO qd |
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| Contraindications | Documented hypersensitivity; concurrent or recent (within 2 wk) MAOI administration; coadministration with thioridazine (both MAOIs and thioridazine are now rarely used) |
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| Interactions | Increases toxicity of diazepam and trazodone by decreasing clearance; also increases toxicity of MAOIs and highly protein-bound drugs; serotonin syndrome (ie, myoclonus, rigidity, confusion, nausea, hyperthermia, autonomic instability, coma, eventual death) occurs with simultaneous use of other serotonergic agents (eg, anorectic agents, tramadol, buspirone, trazodone, clomipramine, nefazodone, tryptophan), discontinue other serotonergic agents at least 2 wk prior to SSRIs |
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| Pregnancy | C - Safety for use during pregnancy has not been established.
|
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| Precautions | Caution in hepatic impairment and history of seizures; MAOIs should be discontinued at least 14 d before fluoxetine therapy is initiated |
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| Drug Name | Fluvoxamine (Luvox) |
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| Description | Potent selective inhibitor of neuronal serotonin reuptake. Does not significantly bind to alpha-adrenergic, histamine, or cholinergic receptors. |
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| Adult Dose | 50 mg PO qhs initially; may increase gradually; not to exceed 300 mg/d
Divided daily doses bid if >100 mg/d |
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| Pediatric Dose | >8 years: 25 mg PO qhs initially; may increase gradually; not to exceed 200 mg/d; may be administered either qd or divided bid |
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| Contraindications | Documented hypersensitivity; concurrent or recent (within 2 wk) MAOI administration |
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| Interactions | CYP3A4 inhibitor; risk of a hypertensive crisis increases in coadministration with MAOIs; fluvoxamine potentiates effect of triazolam and alprazolam and thus, when taking them concurrently, dose should be reduced by at least 50%; also, reduce the dose of theophylline by one third and monitor plasma levels if taking it concurrently with fluvoxamine; alcohol, cimetidine, sertraline, phenothiazines, and warfarin increase toxicity of fluvoxamine; serotonin syndrome (ie, myoclonus, rigidity, confusion, nausea, hyperthermia, autonomic instability, coma, eventual death) occurs with simultaneous use of other serotonergic agents (eg, anorectic agents, tramadol, buspirone, trazodone, clomipramine, nefazodone, tryptophan), discontinue other serotonergic agents at least 2 wk before SSRI use |
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| Pregnancy | C - Safety for use during pregnancy has not been established.
|
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| Precautions | Caution in liver dysfunction or cardiovascular disease and history of seizures or suicidal tendencies; may cause hyponatremia |
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| Drug Name | Paroxetine (Paxil) |
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| Description | Potent selective inhibitor of neuronal serotonin reuptake. Also has a weak effect on norepinephrine and dopamine neuronal reuptake. |
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| Adult Dose | 20 mg/d PO initially; may increase gradually prn; not to exceed 60 mg/d
Use lower starting dose (ie, 10 mg) for elderly persons or in patients with renal or hepatic dysfunction |
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| Pediatric Dose | >8 years: 5-10 mg PO qd initially; may increase by 5 mg/wk; not to exceed 30 mg/d |
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| Contraindications | Documented hypersensitivity; concurrent or recent (within 2 wk) MAOI administration |
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| Interactions | CYP2D6 inhibitor; phenobarbital and phenytoin decrease effects of paroxetine; alcohol, cimetidine, sertraline, phenothiazines, and warfarin increase toxicity of paroxetine; serotonin syndrome (ie, myoclonus, rigidity, confusion, nausea, hyperthermia, autonomic instability, coma, eventual death) occurs with simultaneous use of other serotonergic agents (eg, anorectic agents, tramadol, buspirone, trazodone, clomipramine, nefazodone, tryptophan), discontinue other serotonergic agents at least 2 wk before SSRI use |
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| Pregnancy | C - Safety for use during pregnancy has not been established.
|
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| Precautions | Caution with history of seizures, mania, or suicide attempt; caution in cardiac, hepatic, or renal disease; may cause hyponatremia |
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In/Out Patient Meds
- The condition alone does not require inpatient treatment. See Medication.
Deterrence/Prevention
- Intervention programs
- Gradual exposure programs
- Cognitive-behavioral interventions
Prognosis
- Prognosis is good with appropriate treatment; some SPs persist into adulthood.
- Poor response to therapy may be secondary to poor compliance, motivation, or understanding of treatment procedures. Interpersonal factors may also interfere with treatment results.
- Fears that persist into adulthood tend to be chronic unless treated.
- Patients may be at increased risk for future anxiety disorders.
Patient Education
Medical/Legal Pitfalls
- Failure to diagnose
- Failure to appropriately prescribe and monitor medication usage, if indicated
- Abene MV, Hamilton JD. Resolution of fear of flying with fluoxetine treatment. J Anxiety Disord. Nov-Dec 1998;12(6):599-603. [Medline].
- Albano AM, Chorpita BF. Treatment of anxiety disorders of childhood. Psychiatr Clin North Am. Dec 1995;18(4):767-84. [Medline].
- American Psychiatric Association. Anxiety disorders. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC. 1994;393-444.
- Antony MM, Barlow DH. Social and specific phobias. In: Tasman A, Kay J, Lieberman JA, eds. Psychiatry. Philadelphia, PA; WB Saunders. 1997: 1037-59.
- Balon R. Fluvoxamine for phobia of storms. Acta Psychiatr Scand. Sep 1999;100(3):244-5; discussion 245-6. [Medline].
- Benjamin J, Ben-Zion IZ, Karbofsky E, et al. Double-blind placebo-controlled pilot study of paroxetine for specific phobia. Psychopharmacology (Berl). Apr 2000;149(2):194-6. [Medline].
- Bernstein GA, Shaw K. Practice parameters for the assessment and treatment of children and adolescents with anxiety disorders. American Academy of Child and Adolescent Psychiatry. J Am Acad Child Adolesc Psychiatry. Oct 1997;36(10 Suppl):69S-84S. [Medline].
- Emmelkamp PM. Technological innovations in clinical assessment and psychotherapy. Psychother Psychosom. 2005;74(6):336-43. [Medline].
- Erickson MT. Behavior Disorders of Children and Adolescents: Assessment, Etiology, and Intervention. 3rd ed. Prentice-Hall;1998:251-259.
- Essau CA, Conradt J, Petermann F. Frequency, comorbidity, and psychosocial impairment of specific phobia in adolescents. J Clin Child Psychol. Jun 2000;29(2):221-31. [Medline].
- Fairbanks JM, Pine DS, Tancer NK, et al. Open fluoxetine treatment of mixed anxiety disorders in children and adolescents. J Child Adolesc Psychopharmacol. Spring 1997;7(1):17-29. [Medline].
- Goodwin RD, Gotlib IH. Panic attacks and psychopathology among youth. Acta Psychiatr Scand. Mar 2004;109(3):216-21. [Medline].
- Kendall PC, Howard BL, Epps J. The anxious child. Cognitive-behavioral treatment strategies. Behav Modif. Apr 1988;12(2):281-310. [Medline].
- Muris P, Schmidt H, Merckelbach H. The structure of specific phobia symptoms among children and adolescents. Behav Res Ther. Sep 1999;37(9):863-8. [Medline].
- NIMH. Anxiety disorders. Available at: http://www.nimh.nih.gov/publicat/anxiety.cfm. Last accessed January 13, 2006. [Full Text].
- Ollendick TH, Hersen M, Cllendick TH, eds. Handbook of Child Psychopathology. 3rd ed. Plenum;1998:243-260.
- Reinblatt SP, Walkup JT. Psychopharmacologic treatment of pediatric anxiety disorders. Child Adolesc Psychiatr Clin N Am. Oct 2005;14(4):877-908, x. [Medline].
- Silverman WK, Kearney CA. Listening to our clinical partners: informing researchers about children''s fears and phobias. J Behav Ther Exp Psychiatry. Jun 1992;23(2):71-6. [Medline].
- Silverman WK, Ginsburg GS. Specific phobia and generalized anxiety disorder. In: March JS, ed. Anxiety Disorders in Children and Adolescents. New York, NY: Guilford Press, 1995: 151-180.
- Silverman WK, Moreno J. Specific phobia. Child Adolesc Psychiatr Clin N Am. Oct 2005;14(4):819-43, ix-x. [Medline].
- Simon GE, Savarino J, Operskalski B, Wang PS. Suicide risk during antidepressant treatment. Am J Psychiatry. Jan 2006;163(1):41-7. [Medline].
- Straube T, Mentzel HJ, Glauer M, Miltner WH. Brain activation to phobia-related words in phobic subjects. Neurosci Lett. Dec 6 2004;372(3):204-8. [Medline].
- Strauss CC, Last CG. Social and simple phobias in children. Journal of Anxiety Disorders. 1993;2:141-52.
- Wilhelm K, Boyce P, Brownhill S. The relationship between interpersonal sensitivity, anxiety disorders and major depression. J Affect Disord. Apr 2004;79(1-3):33-41. [Medline].
Anxiety Disorder: Specific Phobia excerpt Article Last Updated: Aug 7, 2006
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