The clinical presentation of patients is relatively straightforward, as the majority of patients report significant anxiety when being in contact with the stimuli that triggers the attack. However, specific diagnostic criteria are made to recognize specific phobia. According to DSM-IV, these criteria include [2] [12]:

• Persistent and excessive or unreasonable fear when being exposed or anticipating the responsible stimuli (such as receiving an injection, going to work through tunnels that the individual is afraid of, etc.).
• Provocation of an anxiety attack or some other form of reaction (children may cry, for example) every time the phobic stimulus is present.
• Recognition by the individual that the expressed fear and reaction to the phobic stimulus is excessive and irrational, but in children this finding is not always reported.
• Constant attempts are made to avoid the situation in which the individual is in contact with the fearful event or object, while intense anxiety and distress are reported once being in contact.
• Patients experience significant disability as a result of their phobia in social, personal or occupational activities, or a significant personal distress is reported regarding the phobia itself.
• Duration of at least 6 months for individuals under 18 years of age.
• Exclusion of other disorders in which phobia may appear, such as OCD, social phobia, panic disorders and other.

• Crying

  In children, the anxiety may be expressed by crying, tantrums, freezing, or clinging. The person recognizes that the fear is excessive or unreasonable. In children, this feature may be absent. [en.wikipedia.org]

  In children, the anxiety may be expressed by crying, tantrums, freezing, or clinging, and children may not recognize that the fear is excessive. Treatment of specific phobias is two-fold. [tamargordonpsychology.com]

  In contrast to adults, children can respond to objects/situations with crying, tantrums, clinging behaviour, or freezing, instead of symptoms of anxiety. Also, a child may not understand that their symptoms of anxiety are unwarranted. Stein, D. [anxietydisordersontario.ca]

  Note: In children, the anxiety may be expressed by crying, tantrums, freezing, or clinging. C. The person recognizes that the fear is excessive or unreasonable. Note: In children, this feature may be absent. D. [behavenet.com]

• Pain

  Abstract Rather than viewing anxiety among chronic pain patients as simply a component of negative affectivity, investigators have developed a model of "pain anxiety" in which patients develop fear and avoidance of activity linked to pain. [ncbi.nlm.nih.gov]

  A Holistic Approach to Back Pain Jan 30, 2019 Anyone who has had back pain—and that’s nearly all of us—knows how debilitating it can be. Even more frustrating is that for many, that pain comes back, again and again, no matter what they try. [healthcare.utah.edu]

  ―骨代謝と生活習慣病の連関― Pharma Medica PNH Frontier Practice of Pain Management Pulmonary Hypertension Update Schizophrenia Frontier Surgery Frontier THE BONE THE GI FOREFRONT The Lipid The Liver Cancer Journal THE LUNG perspectives Thyroid Cancer Explore Trends [med.m-review.co.jp]

• Chills

  […] include: Fast, shallow breathing / shortness of breath Pounding heart Sense of danger or impending doom Sweating Shaking or trembling Intense fear that one is dying, losing control, and / or “going crazy” Chest tightness or heaviness Hot flashes or chills [evolvetreatment.com]

• Unconsciousness

  CONCLUSIONS: These findings provide evidence for unconscious threat processing in specific phobia, with the magnitude of amygdala responses specifically potentiated by sustained hypervigilance for threat. [ncbi.nlm.nih.gov]

• Vomiting

  BACKGROUND: Vomiting is an almost universal phenomenon, but little is known about the aetiology of a specific phobia of vomiting (SPOV). [ncbi.nlm.nih.gov]

• Choking

  […] dogs, snakes, or insects Situations such as flying, small enclosed spaces, or driving Blood, needles, injections, or minor injuries Things in nature, such as storms, water, or heights Other things, including fears of vomiting, doctors, dentists, or choking [uh.edu]

  Specify type: Animal Type Natural Environment Type (e.g., heights, storms, water) Blood-Injection-Injury Type Situational Type (e.g., airplanes, elevators, enclosed places) Other Type (e.g., phobic avoidance of situations that may lead to choking, vomiting [behavenet.com]

  Fears of choking, fear of contracting an illness; Children's fear of loud sounds. [quizlet.com]

  […] fear of: animals (e.g. snakes, spides, dogs, insects) the natural environment (e.g. heights, storms, water) blood, injuries or injections (e.g. needles, wounds, medical procedures) situations (e.g. aeroplanes, elevators, enclosed spaces) other (e.g. choking [au.reachout.com]

  The specific flavors deal with the source of the fear, either animal, natural event, blood-injection-injury, situational (like airplanes or elevators), or other (like choking, loud noises, or clowns). [study.com]

• Nausea

  Physical symptoms of anxiety or a panic attack, such as a pounding heart, nausea or diarrhea, sweating, trembling or shaking, numbness or tingling, problems with breathing (shortness of breath), feeling dizzy or lightheaded, feeling like you are choking [web.archive.org]

  This includes anxiety in specific situations such as in airplanes, buses, elevators,… Specific phobia regarding stimuli which can lead to vomiting, feeling light-headed, nausea, or an illness. [15minutes4me.com]

  Intense fear that one is dying, losing control, and / or “going crazy” Chest tightness or heaviness Hot flashes or chills The sense that nothing is real Feeling as if you’re outside your body or in a dream Dizziness or feeling faint Numbness or tingling Nausea [evolvetreatment.com]

• Diarrhea

  Physical symptoms of anxiety or a panic attack, such as a pounding heart, nausea or diarrhea, sweating, trembling or shaking, numbness or tingling, problems with breathing (shortness of breath), feeling dizzy or lightheaded, feeling like you are choking [web.archive.org]

  This anxiety is often accompanied by one or more of the following symptoms: Heart palpitations (heart beating abnormally fast) Trembling Excessive sweating Muscle pain Stomach ache Diarrhea Confusion When to Consult Do not wait to be unable to conduct [quebec.ca]

• Chest Pain

  You have sudden trouble breathing, chest pain, or a fast heartbeat. You want to harm yourself or others. Care Agreement You have the right to help plan your care. Learn about your health condition and how it may be treated. [drugs.com]

  Rapid heart rate High blood pressure Excessive sweating Shortness of breath Chest pain Involuntary trembling Feeling lightheaded or dizzy Churning stomach Tingling sensations ; hot or cold flashes Afraid of losing control or going crazy Knowing that you [healthcommunities.com]

• Palpitations

  This anxiety is often accompanied by one or more of the following symptoms: Heart palpitations (heart beating abnormally fast) Trembling Excessive sweating Muscle pain Stomach ache Diarrhea Confusion When to Consult Do not wait to be unable to conduct [quebec.ca]

• Sweating

  Common symptoms of specific phobia include avoidance behaviors or anxiety associated with the phobia as well as physical reactions and sensations when exposed to or thinking about the phobic object or situation, including sweating, rapid heartbeat, tight [biobehavioralinstitute.com]

  This reaction may resemble a panic attack, which has symptoms such as heightened heart rate, sweating, hyperventilation (rapid, shallow breathing) and feelings of terror and helplessness. [hope4ocd.com]

  My heart would pound and I would sweat bullets. When the airplane would start to ascend, it just reinforced the feeling that I couldn't get out. [fearclinic.ufl.edu]

  Physical symptoms of anxiety or a panic attack, such as a pounding heart, nausea or diarrhea, sweating, trembling or shaking, numbness or tingling, problems with breathing (shortness of breath), feeling dizzy or lightheaded, feeling like you are choking [web.archive.org]

• Fear

  The highest mean heritability (±SEM) among fear subtypes was found for animal fear (45%±0.004), and among specific phobias for the blood-injury-injection phobia (33%±0.06). [ncbi.nlm.nih.gov]

• Anxiety Disorder

  […] women with a specific phobia but not in women with a social anxiety disorder. [ncbi.nlm.nih.gov]

• Tantrums

  In children, the anxiety may be expressed by crying, tantrums, freezing, or clinging. The person recognizes that the fear is excessive or unreasonable. In children, this feature may be absent. [en.wikipedia.org]

  In children, the anxiety may be expressed by crying, tantrums, freezing, or clinging, and children may not recognize that the fear is excessive. Treatment of specific phobias is two-fold. [tamargordonpsychology.com]

  In contrast to adults, children can respond to objects/situations with crying, tantrums, clinging behaviour, or freezing, instead of symptoms of anxiety. Also, a child may not understand that their symptoms of anxiety are unwarranted. Stein, D. [anxietydisordersontario.ca]

  Note: In children, the anxiety may be expressed by crying, tantrums, freezing, or clinging. C. The person recognizes that the fear is excessive or unreasonable. Note: In children, this feature may be absent. D. [behavenet.com]

• Dizziness

  Physical symptoms of anxiety or a panic attack, such as a pounding heart, nausea or diarrhea, sweating, trembling or shaking, numbness or tingling, problems with breathing (shortness of breath), feeling dizzy or lightheaded, feeling like you are choking [web.archive.org]

  Symptoms include vertigo, dizziness, sweating, and feeling as if they’ll pass out or lose consciousness. Claustrophobia: This is a fear of enclosed or tight spaces. [healthline.com]

• Tingling

  Physical symptoms of anxiety or a panic attack, such as a pounding heart, nausea or diarrhea, sweating, trembling or shaking, numbness or tingling, problems with breathing (shortness of breath), feeling dizzy or lightheaded, feeling like you are choking [web.archive.org]

  Rapid heart rate High blood pressure Excessive sweating Shortness of breath Chest pain Involuntary trembling Feeling lightheaded or dizzy Churning stomach Tingling sensations ; hot or cold flashes Afraid of losing control or going crazy Knowing that you [healthcommunities.com]

  […] trembling Intense fear that one is dying, losing control, and / or “going crazy” Chest tightness or heaviness Hot flashes or chills The sense that nothing is real Feeling as if you’re outside your body or in a dream Dizziness or feeling faint Numbness or tingling [evolvetreatment.com]

• Vertigo

  Symptoms include vertigo, dizziness, sweating, and feeling as if they’ll pass out or lose consciousness. Claustrophobia: This is a fear of enclosed or tight spaces. [healthline.com]

The diagnosis can be firmly made by using DSM criteria for specific phobia and proper patient history is the single most important diagnostic tool in assessing these patients. Trying to identify phobic stimulus and circumstances that provoke anxiety reactions are vital, so that the specific phobia may be further classified into respective subtype [13]. Making the diagnosis is often not easy as patients may not reveal information that are vital for the diagnosis. For this reason, immense patience is required during history taking.

Exposure therapy is the main form of specific phobia management and aims to encourage the individual to confront the stimulus that causes anxiety, rather than using avoidance techniques [14] [12]. Through supervised and carefully determined activities, patients are slowly becoming more exposed to the phobic stimulus with the target to gradually reduce their fear [10], the process known as habituation [3]. This form of therapy, if conducted properly and if patient complies rigorously, is very effective and shows success rates of more than 90% [3]. Alternative treatments include cognitive-behavioral therapy, which attempts to rationalize the emotions expressed by individuals regarding their phobias and teach them that these reactions are irrational. Under very specific circumstances, pharmacological therapy with benzodiazepines may be indicated [3]. Other modalities include hypnotherapy, relaxation exercises and various forms of psychotherapy.

Specific phobia may be a particularly debilitating condition, especially if more than one phobia is concomitantly present. The estimated duration of the disorder is established to be around 20 years, which implies the significance of specific phobias in everyday life, having in mind that the majority of patients are children and young adolescents [9]. With appropriate treatment, however, the prognosis is good. Not recognizing specific phobia in patients may be an issue, as some studies determined that only 6.5% of patients with a definite diagnosis were treated specifically for this condition [8].

The exact causes of specific phobias remain to be discovered, but traumatic, physiological, genetic and environmental causes have all been implicated in their pathogenesis. Various studies have discovered higher prevalence rates of specific phobias among relatives, but further studies are necessary to determine the exact role of genetics [5] [6]. Factors figuring in psychodynamic and learning theories are thought to be important in the development of phobias and are postulated to involve impulses regarding traumatic events, unresolved oedipal conflicts and both cognitive and emotional stimuli. The etiology remains on speculations and theory, however, and science is yet to determine the exact mechanism of specific phobias.

Epidemiology studies establish that the prevalence rate of specific phobia is around 12.5% in the general population and is shown to be one of the most common anxiety disorders encountered in medical practice [7]. Some studies report data that suggest the presence of at least one fear in more than 75% of adolescents, with more than 35% reaching criteria for specific phobia [8]. When looking specific subtypes, prevalence rates for animal, natural environment, situational and B-I-I specific phobias are between 3.3-5.7%, 4.9-11.6%, 5.2-8.4% and 3.2-4.5%, respectively [2]. In terms of age, it was determined that the onset of phobias most commonly occurs during childhood, with the average age of onset being 9.7 years [9]. Several risk factors have been established in addition to young age, including female gender and low socioeconomic status. Studies have also shown that Asian or Hispanic ethnicity is related to lower risk of developing specific phobias [9]. It is important to note that patients often develop more than one specific phobia during their lifetime.

Although the cause and mechanism of specific phobia development remain unclear, several observations regarding its pathophysiology have been documented. Studies have shown that different neurophysiological events occur in the setting of different phobias. Namely, activation of the cingulate cortex and the anterior insula was observed in spider phobics, while activation of the thalamus and the occipito-temporo-parietal cortex was stimulated in patients that have B-I-I phobias [10]. Additionally, the pathophysiologic mechanism of B-I-I phobia is somewhat different from other subtypes, involving excessive vasovagal stimulation when in contact with fearful stimuli, which produces intense bradycardia and fainting. On the other hand the feeling of disgust is seen in other types [2]. Additional studies are imperative to determine the exact mechanism of occurrence of specific phobias. Actually, some studies tried to establish a correlation between various behavioral and emotional problems and B-I-I/natural phobias [11] but apart from speculations that involve evolutionary, personal, behavioral, social and environmental factors, not much has been solidified in terms of development of specific phobias.

As the exact cause of specific phobias remains unknown, an early diagnosis and proper therapy are key in reducing the disability this condition may cause. Prevention strategies, however, currently do not exist and the focus is on early identification.

Specific phobia is a term that describes the development of anxiety and panic attacks as a result of exposure to an object or certain situation. It is established to be the most common anxiety disorder worldwide [1]. The list of documented specific phobias is very long, but in general, they are classified into four main categories [2]:

• Animal phobia (zoophobia) develops in approximately 3-5.5% of individuals at some point and can include fear of various animals, such as snakes (ophidiophobia) or spiders (arachnophobia). It is seen in children between 6-9 years of age in most cases.
• Natural environment phobia is somewhat more common, with an estimated prevalence rate of 5-11%. Fear of thunderstorms (astraphobia), heights (acrophobia) and fear of water (hydrophobia) are some examples.
• Situational phobia is demarcated by fear of being in a particular situation, such as flying (aviophobia), being in an enclosed space (claustrophobia), driving, passing through tunnels and various other. This type of phobia is observed most commonly in teenagers and young adolescents.
• Blood/Injection/Injury (B-I-I) phobia encompasses fear of injections (trypanophobia), needles and other sharp objects (belonephobia) and blood (hemophobia).

Although a miscellaneous categories exist, in which fears of loud noises, costumed characters and some other are placed [2], these four categories are important to distinguish because of several reasons. Firstly, the appearance and onset of certain phobias is more commonly seen in specific patient populations. Secondly, different underlying mechanisms have been proposed to result in particular specific phobia and consequently, different symptoms may be reported. Namely, patients with a natural environment and situational phobia often claim they feel endangered or existentially threatened under such circumstances, while individuals suffering from B-I-I phobia experience an intense panic attack that stimulates vasovagal pathways and causes syncope. Usually, these attacks appear within seconds after individuals are exposed to the fearful stimuli [3]. Additionally, constant attempts to avoid these stimuli may be an obvious sign of a phobia, for example avoiding bridges, tunnels, elevators or airplanes. For these reasons, a detailed patient history is necessary to determine the exact psychological background behind anxiety attacks and to conduct properly designed therapy. Prior to making a definite diagnosis, various other conditions must be excluded, such as substance abuse, other anxiety disorders such as obsessive-compulsive disorder (OCD), depression, as well as other affective disorders. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM), the criteria for the diagnosis of specific phobia include excessive and unreasonable fear that persists for more than 6 months, awareness of the individual that the fear is unreasonable and irrational, avoidance of exposure to the "harmful" stimuli, significant disability caused by phobia and exclusion of all other diseases which may mimic such symptoms [2]. Once the diagnosis is made, the focus of therapy is to alleviate fears through various forms of psychotherapy. The most effective being exposure therapy [1], and cognitive-behavioral therapy [4]. Phobias are effectively managed if therapy is carried out as planned, but its success significantly depends on patient compliance.

Specific phobia is a condition that is characterized by fear and development of anxiety when being in contact with a particular object or when being exposed to a certain stimulus. The cause is thought to be a combination of various environmental, psychological, genetic and individual factors, but the exact reason why phobias develop remains to be found. There are hundreds of specific phobias and they are classified into four main categories :

• Animal (known as zoophobia, which denotes fear when being in close contact with certain animals, most commonly snakes, spiders, and mice)
• Natural-environmental (fear of thunderstorms, heights or elements such as water)
• Situational (anxiety provoked when being in a specific situation, for example in a tunnel, flying, or in a tight space)
• Blood-injection-injury category (known as B-I-I phobia, where fear of blood, needles, sharp objects and trauma are main forms)

Each form has some distinguishing characteristics, but in general, they most commonly appear in children around 9 years of age, with the exception of situational phobia, which is shown to appear most frequently in teenagers and young adolescents. The overall prevalence rates suggest that approximately 12% of the population have some form of phobia and more than one phobia may be simultaneously present. In addition to young age, risk factors include female gender (as specific phobias are more frequently encountered among females) and poor socioeconomic background. To make the diagnosis of a specific phobia, the physician must patiently and carefully obtain patient history in order to distinguish specific phobia from other disorders. Excessive and irrational fear or anxiety when being in contact with a phobic stimulus recognized by the individual, constant attempts to avoid being exposed to the fearful event (such as being in elevators, or flying), prolonged duration of such emotions (more than 6 months in patients who are younger than 18 years) and significant impairment of daily activities because of phobia are definite signs of specific phobia. Once the diagnosis is made, therapy consists of supporting the individual to expose him/herself to the stimulus that causes excessive fear and if therapy is conducted properly, eradication of fear occurs in more than 90% of cases. There are other forms of therapy, such as cognitive-behavioral therapy, which attempts to explain to the individuals that the experienced fear is based on irrational arguments. Drugs may sometimes be used but under very strict circumstances. Specific phobias can cause significant debilitation in everyday life, but it has a good prognosis if patients comply with treatment.

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