eMedicine Specialties > Pediatrics: Developmental and Behavioral > Medical Topics
Anxiety Disorder, Specific Phobia
Updated: Dec 5, 2008
Introduction
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. Specific phobia has behavioral, cognitive, and physiologic manifestations.
A summary of the diagnostic criteria for specific phobia, based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, includes the following:1
- 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 one of the following 5 subtypes that best describe phobias:
- Animal
- Natural environment
- Blood-injection injury
- Situational
- Other (must be distinguished from normal fear and anxiety)
Individuals may have more than one specific phobia, as clustering often occurs. Animal, natural environment, and situational specific phobias tend to cluster; 70% of those with blood specific phobia also have injection specific phobia.
Specific phobia 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 specific phobia, 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. Specific phobias in children generally attenuate over time, although they may persist into adulthood. In contrast, specific phobias 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.
Pathophysiology
The specific nature of anxiety associated with specific phobia is felt to be associated increase in tonic cardiac vagal tone, manifested by an increase in heart rate, which is considered to be greater compared with other anxiety disorders. These responses are mediated by the autonomic nerve system, more specifically by its parasympathetic branch. The vagus nerve attenuates the sympathetic nervous system output and is key to responsiveness to environmental cues.
Children with specific phobias are felt to display a greater degree of response to perceived threats, although they do not demonstrate an increase in anticipatory responsiveness. However, this physiologic change is not the same with all specific phobias because different specific phobias have been associated with differences in cardiac vagal tone. Functional MRI (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.
Frequency
United States
The National Institute of Mental Health (NIMH) estimates that 5-12% of Americans have phobias; specific phobias affect approximately 6 million Americans.2 Approximately 7-9% of children have been estimated to have specific phobia. No significant differences have been noted between whites and persons of Hispanic or African descent. No conclusive evidence links socioeconomic status with specific phobia.
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 specific phobia than males. The sex difference is less notable for certain specific phobias, such as heights.
Age
The mean age of onset depends on the type of phobia. Animal, blood, and storms and water specific phobias typically develop in early childhood. Height specific phobia develops in teenagers. Situational specific phobias (eg, claustrophobia) typically develop during the late teenage years 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 specific phobia is 10-13 years, with the average age of onset of symptoms at approximately 8 years.
Clinical
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 a specific phobia (SP) display a higher rate of specific phobia 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, citing learning theories, environmental influences, and genetic factors, as well as a combination of these factors. However, genetic and environmental factors are generally acknowledged to influence behavior, including anxiety disorders in general and specific phobias in particular.
- 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. In young children, familial influences have been reported to affect comorbidity between specific phobia and separation anxiety and between specific phobia and social phobia. These influences are felt to reflect shared environmental influences more than genetic factors. Learning and modeling, as well as parent-child interactions, have been proposed as possible explanations.
- 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 specific phobia is often observed, although the type of specific phobia is usually different.
- Genetic factors are felt to contribute to specific phobia. Genetic effects on early onset disorders have been reported to be more substantial than environmental factors.
- 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.
- Increased fears and phobias have been identified in children of parents with major depressive disorder and anxiety, although not found to be associated with parents with major depressive disorder without anxiety.3
- Avoidance of new foods has been found to be highly heritable in children aged 8-11 years, although less than one fourth of children with this presentation are also believed to be influenced by nonshared environmental factors.4
Differential Diagnoses
| Anxiety Disorder: Obsessive-Compulsive
Disorder | Eating Disorder: Pica |
| Anxiety Disorder: Panic Disorder | Eating Disorder: Rumination |
| Anxiety Disorder: Separation Anxiety and School
Refusal | Posttraumatic Stress Disorder in
Children |
| Eating Disorder: Anorexia | Somatoform Disorder: Somatization |
| Eating Disorder: Bulimia |
Other Problems to Be Considered
Psychotic disorder
Treatment
Medical Care
- Behavior therapy: This is the first-line treatment.
- Exposure therapy
- The patient is repeatedly exposed to the feared stimulus until the anxiety response it elicits is habituated. One-session treatment, as long as 3 hours, combining exposure therapy in a fear hierarchy with participant modeling, cognitive components, and reinforcement is a promising form of treatment in patients with specific phobias (SPs).5
- 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 behavioral 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. No significant differences in outcome have been reported comparing individual cognitive behavioral therapy with group cognitive behavioral therapy, with improvements noted in both types of therapeutic settings.6
- Exposure therapy
- Psychotherapy: This type of therapy is not generally used to treat the specific phobia. However, the presence of an increasingly complex or disabling profile may require individual and family psychotherapy.
- Psychopharmacology: This type of treatment is generally felt to have limited use in the treatment of specific phobia, 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 effective. SSRIs have been used as adjunctive therapy because 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.
Medication
Although behavioral therapy is the main route of intervention for specific phobias (SPs) that interferes with functioning, case reports have documented improvement of symptoms with the use of selective serotonin reuptake inhibitors (SSRIs); benzodiazepines have not been shown to be effective.
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 specific phobias.
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 have the cardiac arrhythmia risk associated with tricyclic antidepressants (tertiary and secondary amine). 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.
- In December 2003, the UK Medicines and Healthcare Products Regulatory Agency (MHRA) issued an advisory that most SSRIs are not suitable for use by persons younger than 18 years for treatment of "depressive illness." After review, this agency decided that the risks to pediatric patients outweigh the benefits of treatment with SSRIs, except fluoxetine (Prozac), which appears to have a positive risk-benefit ratio in the treatment of depressive illness in patients younger than 18 years.
- In October 2003, the US Food and Drug Administration (FDA) issued a public health advisory regarding reports of suicidality in pediatric patients being treated with antidepressant medications for major depressive disorder. This advisory reported suicidality (both ideation and attempts) in clinical trials of various antidepressant drugs in pediatric patients. The FDA has asked that additional studies be performed because suicidality occurred in both treated and untreated patients with major depression and thus could not be definitively linked to drug treatment.
- A more recent study, published in 2006, evaluated records of more than 65,000 children and adults treated for depression over a 10-year period. Results of this study did not support an increase in suicide risk or attempts after antidepressant medication was started or a higher risk with the newer types of antidepressant medication.7 However, close frequent monitoring of any patient treated with psychotropic medications remains imperative.
Fluoxetine (Prozac)
Selectively inhibits presynaptic serotonin reuptake with minimal or no effect in the reuptake of norepinephrine or dopamine.
Dosing
Adult
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
Pediatric
<8 years: Not established
>8 years: 10-20 mg PO qd
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
Contraindications
Documented hypersensitivity; concurrent or recent (within 2 wk) MAOI administration; coadministration with thioridazine (both MAOIs and thioridazine are now rarely used)
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in hepatic impairment and history of seizures; MAOIs should be discontinued at least 14 d before fluoxetine therapy is initiated
Fluvoxamine (Luvox)
Potent selective inhibitor of neuronal serotonin reuptake. Does not significantly bind to alpha-adrenergic, histamine, or cholinergic receptors.
Dosing
Adult
50 mg PO qhs initially; may increase gradually; not to exceed 300 mg/d
Divided daily doses bid if >100 mg/d
Pediatric
>8 years: 25 mg PO qhs initially; may increase gradually; not to exceed 200 mg/d; may be administered either qd or divided bid
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
Contraindications
Documented hypersensitivity; concurrent or recent (within 2 wk) MAOI administration
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in liver dysfunction or cardiovascular disease and history of seizures or suicidal tendencies; may cause hyponatremia
Paroxetine (Paxil)
Potent selective inhibitor of neuronal serotonin reuptake. Also has a weak effect on norepinephrine and dopamine neuronal reuptake.
Dosing
Adult
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
Pediatric
>8 years: 5-10 mg PO qd initially; may increase by 5 mg/wk; not to exceed 30 mg/d
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
Contraindications
Documented hypersensitivity; concurrent or recent (within 2 wk) MAOI administration
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution with history of seizures, mania, or suicide attempt; caution in cardiac, hepatic, or renal disease; may cause hyponatremia
Follow-up
Inpatient & Outpatient Medications
- Specific phobia (SP) 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 specific phobias 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.
- Self-medication with alcohol and drugs in adults that has been reported with some anxiety disorders is not commonly reported in patients with specific phobia.8
Patient Education
- Parents may be expected to assist in the therapeutic process.
- For excellent patient education resources, visit eMedicine's Anxiety Center. Also, see eMedicine's patient education articles Anxiety, Panic Attacks, and Hyperventilation.
Miscellaneous
Medicolegal Pitfalls
- Failure to diagnose
- Failure to appropriately prescribe and monitor medication usage, if indicated
References
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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, height phobia, fear of heights, claustrophobia, social phobia, major depressive disorder
Contributor Information and Disclosures
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, MD, MPH is a member of the following medical societies: American Academy of Pediatrics and American Medical Directors Association
Disclosure: Nothing to disclose.
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
Kerim M Munir, MD, MPH, DSc is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry and American Psychiatric Association
Disclosure: Nothing to disclose.
Marilyn T Erickson, PhD, Professor Emeritus, Department of Psychology, Virginia Commonwealth University
Disclosure: Nothing to disclose.
Medical Editor
Chet Johnson, MD, Medical Director, Child Development Unit, Department of Pediatrics, Professor, University of Kansas Medical Center
Chet Johnson, MD is a member of the following medical societies: American Academy of Pediatrics
Disclosure: Nothing to disclose.
Pharmacy Editor
Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner
CME Editor
Daniel Rauch, MD, FAAP, Director, Pediatric Hospitalist Program, Associate Professor, Department of Pediatrics, New York University School of Medicine
Daniel Rauch, MD, FAAP is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, and Society of Hospital Medicine
Disclosure: Baxter Honoraria Consulting
Chief Editor
Caroly Pataki, MD, Professor of Clinical Psychiatry and Behavioral Sciences, Department of Psychiatry, Division Chair, Child and Adolescent Psychiatry, Director of Training, Child and Adolescent Psychiatry Residency Program, University of Southern California Keck School of Medicine
Caroly Pataki, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, New York Academy of Sciences, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.