The video below is the section for Specific Phobia from Part 8 of TSM’s lecture series on DSM-5 and the EPPP, followed by a transcript. This lecture series aims to equip those preparing for the EPPP with everything you need to know about the impact DSM-5 will be having on the EPPP. To watch all of Part 8, click HERE. To watch earlier lectures in this series, or register for our webinar series on DSM-5 and the EPPP, click HERE.
Transcript of DSM-5 EPPP Lecture Video: Specific Phobia
In Specific Phobias, individuals experience excessive and persistent fear circumscribed to the presence of a particular situation or objects, which can be referred to as phobic stimulus. The level of fear is unreasonable, meaning it is not in proportion to the actual danger presented by the stimulus. Although adults with Specific Phobias recognize the irrational nature of their fears, children often fail to realize that the intensity of their fears goes beyond what is reasonable.
When anticipating or confronted with the feared stimulus, individuals with a Specific Phobia almost always react with an immediate anxiety response, with increase in physiological arousal, which may (in extreme instances) take the form of a situationally bound or situationally predisposed panic attack (with symptoms such as nausea, increased heart rate, shortness of breath, dizziness, trembling, or sweating, fear of losing control). Children may express their anxiety through crying, freezing, tantrums, or clinging to parents.
It is important to note that irrational fears, particularly fears of animals and other objects in the natural environment, are very common in children. These fears are typically transitory and do not warrant a diagnosis of Specific Phobia unless they cause clinically significant impairment (e.g., refusing to leave the house for fear of encountering a dog outside). Also, young children do not understand the concept of avoidance, and the clinician needs to assemble additional information from parents, teachers or others who know the child well. Thus, diagnosis of a Specific Phobia in children must take into account the developmental level of the child and the level of impairment experienced.
Individuals with a Specific Phobia attempt to avoid exposure to the phobic stimulus; when the stimulus cannot be escaped, it is endured with profound anxiety and distress. Unlike people with most other forms of anxiety disorders, individuals with a Specific Phobia tend not to experience pervasive, unrelenting anxiety. Instead, their symptoms are generally limited to discrete, circumscribed phobic situations. A Specific Phobia cannot be diagnosed if symptoms are better accounted for by Social Phobia.
An individual’s reaction to the phobic stimulus (e.g., avoidance, anxious anticipation, or distress in the presence of the feared stimulus) must lead to significant impairment in an important area of function (e.g., social or academic), interference with that individual’s normal routine, or considerable distress about having the phobia. The disabling symptoms must last at least six months.
The DSM-5 recognizes five forms of Specific Phobia: Animal Type (cued by animals or insects), Natural Environment Type (cued by objects or situations present in the nature, such as heights, water, storms), Blood-Injection-Injury Type (cued by the sight of blood, injury, receiving an injection, or undergoing an invasive procedure), and Situational Type (cued by being in a specific situation or environment such as being inside an elevator or airplane, driving, and crossing over a bridge). The specifier Other Type is used to denote Specific Phobias that are cued by stimuli not covered in the first four subtypes. Phobic stimuli in Other Type may include fear of choking, of loud noises, or of costumed characters.
Specific phobias usually develop in early childhood, with median age of onset between 7 and 11 years, although the Situational Type tends to have a later age of onset. It is estimated that between 7 to 9 percent of people will experience a Specific Phobia during their lifetime; incidence declines with age. Overall, women are twice as likely as men to be diagnosed with Specific Phobias. Gender differences do, however, vary among different Specific Phobia subtypes. Animal Type, Natural Environment Type, and Situational Type are more frequently experienced by women, while Blood-Injection-Injury Type is experienced nearly equally by men and women. In the United States, Asians and Latinos report significantly lower rates of specific phobia than non-Latin Whites, African Americans and Native Americans.
Individuals with specific phobias have an increased risk of developing other disorders, including other anxiety disorders, depressive and bipolar disorders, substance-related disorders, somatic symptom and related disorders, and personality disorders. Important differential diagnoses to consider are Agoraphobia (due to overlap in feared situations; but when two or more agoraphobic situations are feared, a diagnosis of agoraphobia may be warranted), Social Anxiety Disorder (generally related to social situations, with fear of being negatively evaluated), Panic Disorder (if panic attacks only occur in response to the phobic stimulus a diagnosis of panic disorder may be warranted), and trauma or stress-related disorder (if a traumatic event preceded the onset of panic, and the criteria for PTSD are not met).
The preferred treatment for Specific Phobia is in vivo exposure to the feared stimulus.In most cases of Specific Phobias, individuals receive instruction in relaxation techniques to help them cope with real-life contact with the phobic cue. The use of relaxation techniques, however, is contraindicated in cases of Blood-Injection-Injury Type. Individuals with this subtype experience a strong vasovagal reaction in response to the phobic cue, which results in a sudden drop in blood pressure and a tendency to faint; such individuals may also experience sweating, nausea, pallor, and tinnitus. As a result, relaxation techniques that are useful with other Specific Phobias may increase the risk of fainting if used by individuals with Blood-Injection-Injury Type. Instead, these individuals are taught to tense certain muscle groups, thus keeping blood pressure sufficiently high, when confronted with blood, injury, or the possibility of injection.
1. Involve excessive/persistent fears in response to specific stimuli or anticipation of these stimuli
2. Individuals with Specific Phobias attempt to avoid exposure to the phobic stimulus; when the stimulus cannot be escaped, it is endured with profound anxiety and distress. Anxiety may approach panic levels in extreme instances
3. Diagnosis made if phobia engenders considerable distress and yields true impairment
4. As a departure from most anxiety disorders, individuals with Specific Phobias do not experience pervasive anxiety. Anxiety generally limited to discrete, circumscribed phobic situations
5. Specific Phobia cannot be diagnosed if symptoms are better accounted for by Social Phobia
6. Five types of specific phobias: Animal, Natural Environment, Blood-Injection-Injury, Situational, and Other
7. Blood-Injection-Injury Type experience strong vasovagal reaction, blood pressure drop, may faint
8. Up to 10 percent of population with lifetime risk of Specific Phobia; women more likely to develop Specific Phobias
9. Most effective treatments are behavioral, often involving in vivo exposure to the feared stimulus, paired with relaxation training
10. In Blood-Injection-Injury Type, relaxation needs to be replaced with other strategies because of risk for fainting. Muscle tensing plus in vivo exposure used
Which of the following phobic stimuli is most likely to produce a strong vasovagal reaction in individuals with a Specific Phobia?
A. Being chased by a dog
B. Looking down from the observation deck at the Empire State Building
C. Having blood drawn by a nurse
D. Speaking in front of a large audience
C is correct, as Blood-Injection-Injury Type Specific Phobias can induce a vasovagal response to the feared stimulus. This means blood pressure may drop and there may be fainting. The other feared stimuli are not likely to produce such a response. Hence, responses A, B, and D are incorrect.