1. Specific Phobia: Anxiety Disorder

2. DSM-V Diagnostic Criteria
A. Marked fear or anxiety about a specific object or situation (in children the fear or anxiety may be expressed by crying, tantrums, freezing, or clinging)
B. The phobic object or situation almost always provokes immediate fear or anxiety
C. The phobic object or situation is actively avoided or endured with intense fear or anxiety
D. The fear or anxiety is out of proportion to the actual danger posed by the specific object or situation and to the sociocultural context
Here is the DSM-V diagnostic criteria, note that children my express their marked fear with crying, tantrums, freezing or clinging.
In specific phobia, the fear or anxiety is almost always provoked immediately.
Phobic stimulus is actively avoided or endured with intense fear or anxiety and this reaction is out of proportion within the sociocultural context

3. DSM-V Diagnostic Criteria
E. The fear, anxiety or avoidance is persistent, typically lasting for 6 months or more
F. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning
G. The disturbance is not better explained by the symptoms of another mental disorder, including fear, anxiety, and avoidance of situations associated with panic-like symptoms or other incapacitating symptoms (as in agoraphobia); objects or situations related to obsessions (as in OCD); reminders of traumatic events (as in PTSD); separation from home or attachment figures (as in SAD); or social situations (as in social anxiety disorder)
With specific phobia the fear/anxiety/avoidance typically lasting more than 6 months
There needs to be impairment and the disturbance cannot be better explained by the symptoms of another mental disorder (read off the options of G)

4. Specify if… The code assigned is based on the phobic stimulus:
Animal (spiders, insects, dogs)
Natural environment (heights, storms, water)
Blood-injection-injury (needles, invasive medical procedures)
Situational (airplanes, elevators, enclosed places)
Other (situations that may lead to choking or vomiting; in children, loud sounds or costumed characters)
Also make note for blood-injection-injury: for coding purposes this category is further broken down by: fear of blood, fear of injections and transfusions, fear of other medical care or fear of injury)
The DSM-V explains that it is common for individuals to have multiple specific phobias. For example, the average individual with a SP fears 3 objects or situations, and approximately 75% of individuals with SP fear more than one situation or object.
If an individuals fears objects or situations from more than one specifying category, multiple diagnoses would be given.

5. Diagnostic Features Phobic stimulus
For diagnosis, response must be different from “normal, transient fears that commonly occur in the population”
Amount of fear/anxiety experienced may vary with proximity to the phobic stimulus
Fear/anxiety may happen in anticipation of or in presence of actual stimulus
Highlight the diagnostic features noting the proximity to the stimulus will effect the amount of fear and anxiety experience.
Fears must be different from normal commonly occurring fears
Even in anticipation of the stimulus the fear response can be evoked

6. Diagnostic Features
Reaction may take form as a full or limited symptom panic attacks
Fear/anxiety evoked nearly every time contact is made with phobic stimulus
Fear/anxiety often expressed different in children and adults
Immediate rather than delayed reaction when in contact with phobic stimulus
Continue to go through DSM-V diagnostic features noting the response happening almost every time, immediately and the difference in responses in children versus adults

7. Diagnostic Features
Individual actively avoids phobic stimulus (intentionally behaves in ways that are designed to prevent/decrease contact with phobic stimulus)
Avoidance behaviors are obvious or less obvious
Physiological Arousal
Amygdala and related structures
Individuals with specific phobias actively avoid their phobic stimulus, sometimes even making obvious changes such as refusing to go to the doctor because of the fear of blood or taking a tunnel instead of bridges because of a fear of heights)
The avoidance behaviors can also be less obvious such as not looking at pictures that resemble form or shape of snakes because of the fear of snakes.
In terms of physiological arousal individuals with SP typically experience an increase in physiological arousal in anticipation od or during exposure to phobic stimulus
Physiological responses to the feared object or situation varies, for examples sympathetic arousal is associated with animal, situational, and natural environment and blood0inject injury SP often results in vasovagal fainting or near-fainting response that is marked by initial brief acceleration of heart rate/ elevation of blood pressure followed by deceleration of heart rate and a drop in blood pressure

8. SP Prevalence 12 month community prevalence estimate for US ~7-9%
European countries 6%
Asia, Africa, Latin American countries 2-4%
Children ~ 5% year olds 16%
Older individuals 3-5%
Females > males, 2:1 (varies across phobic stimulus)
Animal, natural environment , and situational SP are predominantly presented in females, blood-injection injury SP is presented equally in both genders

9. Comorbidity Unlikely to only present SP without other psychopathology
Frequently associated with range of disorders
Increased risk for developing other anxiety disorders, depression, bipolar, substance related disorders, somatic symptom and related disorders, and personality disorders (dependent personality disorder)
Comorbidity is common in SP, remind class of earlier onset symptoms having increased risks for other mental disorders

10. Course of SP
SP can occur: after experiencing or observing a traumatic event, informational transmission, unexpected panic reaction in presence of soon to be phobic stimulus
Many individuals are unable to recall the reason for onset of SP
Onset usually in early childhood, majority of cases develop before age 10, (type of SP varies onset)
Early onset is usually associated with a wax and wane pattern
There are different ways that SP can occur in an individual such as experiencing or observing a traumatic event. Also, individuals who experience an unexpected reaction to the soon to be phobic stimulus present with SP. Important to note that not everyone remembers the reason for the onset of their phobia.
Situational specific phobias tend to have later age onset than natural environment animal or blood-injection-injury
SP usually onsets in early childhood with most cases presenting before age 10. Interestingly phobias that do persist into adulthood are unlikely to remit for majority of individuals.

11. Risk and Prognostic Factors
Temperamental: Negative affectivity (neuroticism), behavioral inhibition
Environmental: Parental over protectiveness, parental loss & separation, physical/sexual abuse, negative or traumatic event
Genetic/Physiological: First degree relative with SP, significantly more likely to have SAME SP, individuals with blood-injection-injury show unique propensity to fainting in presence of phobic stimulus
Culture: Asians and Latinos report significantly lower rates of SP/ countries outside of US show differences in disorder
Suicide: 60% more likely to make suicide attempt w/ SP diagnosis
Temperamental, Environmental and Genetic/Physiological factors are proposed by the DSM-V
Cultural differences outside of the US have differing phobia content, age at onset and gender ratios (Why might that be?)
Suicide elevated rates may be due to comorbidity with personality disorders and other anxiety disorders

12. Differential Diagnosis
Agoraphobia: If individual fears only ONE of the agoraphobia situations- Specific Phobia-Situational
Social Anxiety Disorder: If situations are feared because of negative evaluation – SAD not SP
Separation Anxiety Disorder: If situations are feared because of separation from a primary caregiver or attachment figure- Separation Anxiety Disorder
Panic Disorder: If the panic attacks only occur in response to the specific phobia stimulus- Specific Phobia
Agoraphobia is only warranted if individual fears two or more of the agoraphobia situations, make it clear that although anxiety disorders may look similar and blur into one another that diagnositc criteria for SP is different from another anxiety disorders by these marked characteristics

13. Differential Diagnosis
OCD: If fear or anxiety is result of obsessions and other diagnostic criteria are met- OCD
Trauma- and stressor-related disorder: If phobia develops after traumatic event, consider PTSD, only assign SP if ALL PTSD criteria are not met
Eating disorders: If avoidance behavior is exclusively limited to avoidance of food and food-related cues, anorexia nervosa or bulimia considered
Schizophrenia spectrum and other psychotic disorders: When fear/avoidance are due to delusional thinking- SP NOT WARRANTED
Continue to highlight differential characteristics in the diagnostic process. Make note that for trauma related disorders you only can assign SP if all criteria for PTSD are NOT met

14. DSM-V Model
Experience or observation of traumatic event/information transmission/ situation
Suicide
Parental environment: protectiveness, separation, loss, physical or sexual abuse/ neglect
Phobia Stimulus: Specific object or situation
Comorbidity
Genetic predisposition: First degree relative risk/ amygdala and related structures
Emphasize that this is a basic model with many options for characteristics that may influence the development of SP, let’s take a look at the research to see if any offered models can assist us in adding in more understanding of SP
Specific phobia
Temperamental: Negative affectivity
Behavioral Inhibition

15. Fears are Normal
Mild fears are fairly common among children (Craske, 1997)
Infancy: children become fearful of stimuli in their immediate environment (Muris, Merckelbach, de Jong & Ollendick, 2002)
As child develops, fears start to incorporate anticipatory events and stimuli of an imaginary or abstract nature (Muris et al., 2002)
This developmental pattern is assumed to reflect everyday experiences and mediated by cognitive capacities (Muris et al., 2002)
Here make emphasis that fears are a normal occurring feature of development, reflecting everyday experience but are hopefully mediated by the growing cognitive capacity, individuals should start to incorporate anticipatory events and stimuli of the abstract into more rationalized thinking with increase cognitive capacity.

16. Here is a video of the immediate fear/anxiety response when presented with the phobic stimulus, pay special attention to the other developmental characteristics of the individual with the phobia.

17. Descriptives on SP (Essau, Conradt, & Petermann, 2000)
Examined the frequency, comorbidity, & psychosocial impairment of SP and specific fears
First wave of the Bremen Adolescent Study (BJS) (northern Germany)
How frequent in yr olds
Distribution according to sex and age
Comorbidity of other disorders
Level of impairment
Introduce the study by Essau, Conradt & Petermann in 2000 on the descriptives (frequency, comorbidity and impairment) of SP and specific fears
12-17 year old, researchers examined the level of impairment, comorbidity and sex/age distribution

19. **Make sure to note that impairment was based off of open ended questions and ratings of behaviors through self-report, read below the questions from the paper:
• Impairment related to specific phobia:
“If you think back on the worst time, how much did the (fear/ avoidance) of insects, snakes, birds, or other animals affect your life and your everyday activities?
Would you say not at all, somewhat, a lot, very much?
And in the last 4 weeks, how much did the (fear/avoidance) of insects, snakes, birds, or other animals affect your work/homework/studies; your leisure activities; your social contacts with family, friends, and colleagues? Would you say not at all, somewhat, a lot, very much?”