General Information (including ICD-9/-10 Codes)

Description :

  • anxiety disorder, irrational fear resulting in conscious avoidance of specific situation

Also called :

  • specific phobia, simple phobia

ICD-9 Codes :

  • 300.20 phobia, unspecified
  • 300.29 other isolated or simple phobias

ICD-10 Codes :

  • F40.2 specific (isolated) phobias
  • F40.8 other phobic anxiety disorder
  • F40.9 phobic anxiety disorder, unspecified
  • F93.1 phobic anxiety disorder of childhood

Types :

  • acarophobia (itching), acrophobia (heights), ailurophobia (cats), algophobia (pain), apiphobia (bees), cynophobia (dogs), erythrophobia (blushing), gynephobia (women), hedonophobia (pleasure), rhabdophobia (being beaten), taphophobia (being buried alive), thanatophobia (death), xenophobia (strangers)
  • in decreasing frequency - fear of animals, storms, heights, illness, injury, death

Who is most affected :

  • women 2x, late childhood onset

Incidence/Prevalence :

  • #1 anxiety disorder, 5-12% population in past 6 mos, 3-5% prevalence
  • 11.3% lifetime prevalence and 5.5% 30-day prevalence of simple phobia in United States, based on National Comorbidity Survey, median age of onset 15 years (Arch Gen Psychiatry 1996 Feb;53(2):159)

Causes and Risk Factors

Pathogenesis :

  • failure of repression, displacement, symbolization

Complications and Associated Conditions

Complications :

  • phobic situation avoided or endured with intense anxiety
  • simple phobia associated with increased risk for suicide attempts and possibly suicidal ideation
    • cross-sectional study of 7,076 persons in the Netherlands
      • 809 (11.4%) had suicidal ideation, 205 (2.9%) had suicide attempts and 734 (10.4%) had simple phobia
      • 205 (28%) with simple phobia had suicidal ideation (odds ratio 3.74, adjusted odds ratio 1.2 [not significant])
      • 74 (10.1%) with simple phobia had suicide attempts (odds ratio 5.55, adjusted odds ratio 1.79 [95% CI 1.2-2.68])
    • longitudinal study of 4,796 persons (4,246 in analysis of suicidal ideation, 4,670 in analysis of suicide attempts)
      • new-onset suicidal ideation occurred in 2% and new-onset suicide attempts occurred in 0.84%
      • 3.5% persons with simple phobia developed suicidal ideation (odds ratio 2.08, adjusted odds ratio 1.1 [not significant])
      • 2.5% persons with simple phobia developed suicide attempt (odds ratio 4.71, adjusted odds ratio 2.71 [95% CI 1.07-6.87])
    • Reference - Arch Gen Psychiatry 2005 Nov;62(11):1249

History

History of Present Illness (HPI) :

  • patient realizes fear is unfounded, ego-dystonic

Family History (FH) :

  • many run in families

Physical

General Physical :

  • possible findings of anxiety upon physical exam include
    • tremor
    • sighing
    • exaggerated startle response
    • difficulty concentrating
    • repetitive trivial motion
    • bitten nails
    • clammy hands
    • irritability

Diagnosis

Making the diagnosis :

  • DSM-IV-TR criteria
    • marked and persistent fear that is excessive or unreasonable, cued by presence or anticipation of specific object or situation
    • exposure to phobic stimulus provokes immediate anxiety response
    • patient recognizes fear as excessive or unreasonable
    • phobic situation avoided or endured with intense anxiety or distress
    • interferes with functioning or marked distress
    • duration > 6 months if < 18 years old
    • anxiety, avoidance or panic attacks not better accounted for by another mental disorder

Rule out :

Other diagnostic testing :

  • Rorschach testing - anatomy forms, bodily harm
  • Draw-A-Person (DAP) - body image distortions

Prognosis

Prognosis :

  • chronic course, good-to-excellent prognosis with treatment, may spread if untreated, agoraphobia most resistant

Treatment

Counseling :

  • hypnosis
  • supportive therapy
  • cognitive therapy
  • behavior therapy
    • systematic desensitization
    • flooding
    • study of computer-generated (virtual reality) graded exposure in the treatment of acrophobia, 10 of 12 subjects completed exposure program, group exposed to virtual environments displayed significant improvement in all measures of anxiety, distress and avoidance, 8 controls showed no improvement (Am J Psychiatry 1995 Apr;152(4):626)
  • computerized cognitive behavioral therapy (FearFighter) recommended for panic and phobia by NICE (BMJ 2006 Mar 4;332(7540):504)
  • psychoanalysis ineffective

Medications :

  • TCA, MAOI, BZD - very few studies

Other management :

  • family therapy

Prevention and Screening

  • not applicable

References including Reviews and Guidelines

Reviews :

Guidelines :

Patient Information

Patient information :