Which of the following is an example of a situational type of specific phobia?

DIAGNOSTIC CRITERIA

Mild fears (i.e., fears that do not interfere with a child's day-to-day functioning and are short-lived) are developmentally normal.168 When fears exceed what would be typical of a particular developmental period and cause severe distress on the part of a child, a diagnosis of specific phobia should be considered.178 Table 18B-4 provides the diagnostic criteria for Specific Phobia as it relates to children and adolescents.

The types of specific phobias include animal, natural environment (e.g., heights, storms), blood-injection-injury, or situational type (e.g., elevators, airplanes), or the phobia can be noted as “other.” For accurate diagnosis, a clinician must differentiate between a specific phobia and an anxiety reaction caused by another anxiety disorders, such as avoidance of a situation because of PTSD, avoidance of school because of SAD or social phobia, or the uncued attacks of panic disorder.

5.13.2 Prevalence, Phenomenology, and Comorbidity

Specific phobias

Specific phobias are characterized by a “marked and persistent fear that is excessive or unreasonable, cued by the presence or anticipation of a specific object or situation” (American Psychiatric Association, 2000). Examples of specific phobias include flying, heights, animals, receiving an injection, and seeing blood. Specific phobias are among the most prevalent psychiatric conditions and are associated with substantial impairment. In fact, specific phobias are thought to be the most common psychiatric illness in women, and lifetime prevalence in one European study among young women was 12.8% (Becker et al., 2007). Lifetime prevalence of specific phobia in the NESARC study was 9.4%, and 12-month prevalence was 7.1% (Stinson et al., 2007). In the NCS, approximately half of all respondents reported an “unreasonably strong fear of one or more of” eight phobia stimuli most commonly reported. However, only 22.7% of these respondents met criteria for specific phobia (Curtis et al., 1998). The common nature of these fears has raised questions in the field as to whether all specific phobias actually represent bona fide psychiatric disorders.

Animals and heights were the most commonly reported phobic objects in the NESARC and NCS surveys; their prevalence rates in the NESARC study were 4.7% and 4.5%, respectively. One-third of respondents with specific phobia reported fears and/or avoidance of flying or being in closed spaces. Between 20% and 26% of respondents reported fear and/or avoidance of storms, water, seeing blood, receiving injections, and going to the dentist, with associated prevalence rates between 2.0% and 2.4% (Stinson et al., 2007). Fear of animals is the most prevalent phobia among women, either with or without a diagnosis of specific phobia, while fear of heights is most common among men (Curtis et al., 1998). The mean number of fears among respondents with specific phobia was 3.1, with only approximately one-quarter of respondents with specific phobia reporting only one phobic object, 19.6% reporting four to five phobic objects, and 14.5% reporting six or more. The degree of social and occupational dysfunction increased with increasing numbers of phobic objects. The likelihood of substance abuse or dependence did not seem to vary as a function of increasing phobic objects. However, nicotine dependence was more likely among those respondents with higher numbers of feared objects, as was the odds ratio of having a comorbid anxiety disorder (Curtis et al., 1998; Stinson et al., 2007).

After adjusting for sociodemographic variables and other Axis I and II disorders, individuals with specific phobia had more significant disability compared with those without the disorder. When compared with other Axis I disorders, the disability of specific phobia was less severe than mood disorders but comparable to substance use disorders (Stinson et al., 2007). Although 60% of respondents in the NCS study with simple fears (but not specific phobia) recovered, this was true of only 30% of those with specific phobia having two to three fears and only 20% of those with five to eight fears (Curtis et al., 1998).

Mean age of onset of specific phobia in the NESARC study was 9.7 years, with a median age of onset of 11.2 years. Mean duration of specific phobia was 20.1 years, and median duration was 22.9 years. Only 8.0% of those with specific phobia in this study reported treatment specifically for this disorder. Mean age at first treatment was 31.3 years, indicating a significant delay in treatment for the disorder (Stinson et al., 2007). Median age of onset in the NCS study was similar, at 12 years, and the authors of this study reported that 90% of patients have developed the disorder by age 25 years (Curtis et al., 1998). Specific fears seem to vary in their age of onset; for example, animal phobias tend to begin early in life, with a mean age of onset of 6.2 years, whereas the mean age of onset of situational phobias, like elevators, flying, and driving, is 13.4 years (Becker et al., 2007).

Like other anxiety disorders, females have significantly greater odds of developing specific phobia. Asian and Hispanic adults had a lower risk for specific phobia in US-based studies. Lower-income groups had higher odds ratio for specific phobia compared with the highest-income group (Stinson et al., 2007).

Specific phobia is also highly comorbid with other psychiatric disorders, namely bipolar spectrum disorders, other anxiety disorders, particularly panic disorder with agoraphobia, and substance use disorders. Specific phobia was more strongly related to dependence than abuse for the substance use disorders (Stinson et al., 2007). Lifetime prevalence for comorbid anxiety disorders was highest at 28.3%, followed by affective disorders (13.7%), eating disorders (4%), somatoform disorders (3.2%), and substance-related disorders (2.2%) (Becker et al., 2007).

7.08.3.1 Age of Onset

It has been suggested from the younger adult literature that age of onset for anxiety disorders may be based at least to some degree on developmental stage (Beidel & Turner, 1991). For example, the onset of specific phobias seems to mirror the progression of developmentally appropriate normal fears through childhood; that is, animal phobias are often first noticed between the ages of four and seven, when animal fears are common (Marks & Gelder, 1996; Ost, 1987), and phobias of natural disasters and health-related situations frequently begin among older elementary school children at the ages when these fears are commonly reported (Barrios, Hartmann, & Shigetomi, 1981). Likewise, the age of onset for social phobia is typically in early to late adolescence when the establishment of social relationships is a critical developmental task (Beidel & Turner, 1991). These patterns suggest that some phobias reported by older adults may represent fears which originated in earlier developmental stages and continued through later adulthood, while others may have developed more recently from concerns that are developmentally appropriate for older adults, for example, fears of falling (Downton & Andrews, 1990). In fact, available data regarding age of onset for phobias in elderly people are mixed, suggesting the possibility of varying periods of onset for different fears. In a British survey of older adults, Lindesay (1991) reported that specific phobias generally had their onset during childhood, a finding that is consistent with data from the younger adult literature (Thyer, Parrish, Curtis, Nesse, & Cameron, 1985). Alternatively, data from the the US ECA study implied that many phobias reported by older adults were of recent onset (Eaton et al., 1989). Similarly, Lindesay reported that agoraphobic fears (e.g., of enclosed places crowds, public transportation, going away from home) among elderly people most often were of recent onset. However, many of these “agoraphobic”fears began after an episode of physical illness or trauma. As such, the fears may have represented realistic or excessive fears of physical limitations rather than anticipation of panic, suggesting that a diagnosis of specific phobia might have been more appropriate for consideration than agoraphobia (see McNally (1994) for a discussion of this diagnostic issue in younger adults). In addition, a high incidence of depression in Lindesay's sample suggested that “agoraphobic”fears may have been associated with a social withdrawal characteristic of a depressive clinical picture (Flint, 1994).

In light of these inconsistent findings and important differential diagnosis issues, as well as the influential role played by developmental stages in the origin of phobias, further investigation is needed to understand patterns of onset for different types of phobias reported by elderly people. In this area, the important differentiation of realistic versus excessive fear is central, particularly given developmentally appropriate fears that may be characteristic of normal aging.

The age of onset for GAD among elderly people appears to have a bimodal distribution. In Wave 2 of the US ECA study, 39% of participants reported duration of GAD for 21 years or more (Blazer et al., 1991). For these individuals, GAD may have been conceptualized best as a personality disturbance rather than an Axis I disorder, a perspective that has received some attention in the literature of the 1990s (Sanderson & Wetzler, 1991). For another 52% of participants, the onset of GAD was reported within five years of the interview. For this subset of older adults, GAD may have begun as a reaction to stressful life events, a pattern that has been documented in both younger and older adults (Blazer, Hughes, & George, 1987; Ganzini, McFarland, & Culter, 1990). In particular, younger adult men and women interviewed in Wave 2 of the ECA survey experienced a threefold increase in risk for GAD in the year following one or more unexpected, negative, and important life events (Blazer et al., 1987). In a separate sample of older adults, an increased incidence of GAD was reported during the 20 months following a catastrophic financial loss (Ganzini et al., 1990). In this sample, 27% of participants reported symptoms meeting criteria for GAD during the postloss period relative to 10% of elders in a control sample during this same time.

A bimodal pattern of onset for GAD was also reported in a sample of older adults recruited for participation in a treatment study (Beck, Stanley, & Zebb, 1996a). A comparison of clinical features (e.g., anxiety, depression, specific fears) in patients with onset of GAD in childhood (before age 15) and those reporting onset in middle adulthood (after age 39) revealed very few differences. The impact of age of onset on treatment response was not studied, however, given inadequate sample sizes.

Given that prevalence rates for PD and OCD in older adults are quite low, few data are available to address the onset of these syndromes. Although ECA data indicated that neither of these disorders typically began in older age (Eaton et al., 1989), a retrospective chart review of 51 elderly clinic patients with panic disorder revealed that over half reported onset at age 60 years or later (Raj, Covea, & Dagon, 1993). Related case reports have also suggested that panic disorder may begin in later life (Luchins & Rose, 1989; Sheikh, King, & Taylor, 1991). However, conclusions about time and mode of onset for PD and OCD will require greater study.

The potential role of stressful life events in the development of anxiety in later life has already been noted (Ganzini et al., 1990). It has also been demonstrated in studies of Holocaust survivors and World War Two prisoners of war that stress-related symptoms of PTSD can persist into old age (Kluznick, Speed, Van Valkenberg, & Magraw, 1986; Kuch & Cox, 1992). However, no data are available regarding onset of PTSD in elderly people. Given the number of traumatic life events that can occur for older adults (e.g., elder abuse, muggings, motor vehicle accidents), onset of PTSD symptoms in later life is of significant interest and importance. Relevant to this issue are published findings suggesting that prior experience with trauma can serve to “inoculate” older adults against the anxiety-related effects of natural disasters (Norris & Murrell, 1988). The more general role of prior stress as a buffer against the development of PTSD in late life will need to be considered.

Introduction

In DSM-IV (APA, 1994), a specific phobia is defined as a marked and persistent fear that is cued by the presence or anticipation of a specific object or situation. The fear must be recognized by the individual to be excessive or unreasonable, must be associated with functional impairment or subjective distress, and is typically accompanied by an immediate anxiety response and avoidance of the feared object or situation. In some individuals, phobic avoidance is minimal, although exposure to the situation reliably leads to intense levels of fear. Specific phobias may be differentiated from other phobic disorders based on the types of situations avoided as well as the associated features of the disorder. For example, individuals who avoid a range of specific situations typically associated with agoraphobia (e.g., crowds, driving, enclosed places) are likely to receive a diagnosis of panic disorder with agoraphobia, especially if the focus of apprehension in the feared situation is on the possibility of experiencing a panic attack. Similarly, a person who fears and avoids situations involving social evaluation (e.g., public speaking, meeting new people) is likely to receive a diagnosis of social phobia. In DSM-IV, a diagnosis of specific phobia is not assigned if the fear is better accounted for by another mental disorder.

DSM-IV includes five main specific phobia types: animal type, natural environment type, blood–injection–injury type, situational type, and other type. The introduction of these types was based on a series of reports to the DSM-IV Anxiety Disorders Work Group (e.g., Craske, 1989; Curtis, Himle, Lewis & Lee, 1989) showing that specific phobia types tend to differ on a variety of dimensions including age of onset, gender composition, patterns of covariation among phobias, focus of apprehension (i.e., anxiety over physical sensations), timing and predictability of the phobic response, and type of physical reaction during exposure to the feared object or situation.

Phobias from the animal type may include fears of any animal, although animals that are commonly feared include snakes, spiders, insects, dogs, cats, mice, and birds. Animal phobias typically begin in childhood and tend to have an earlier age of onset than other phobia types (Himle, McPhee, Cameron & Curtis, 1989; Marks & Gelder, 1966; Öst, 1987). In addition, they more common among women than men, with percentages of patients who are female ranging from about 75% in epidemiological studies (Agras, Sylvester & Oliveau, 1969; Bourdon, Boyd, Rae, Burns, Thompson & Locke, 1988) to 95% or more in studies of clinical patients (Himle et al., 1989; Marks & Gelder, 1966; Ost, 1987). Among women, animal phobias are the most common type of specific phobia (Bourdon et al., 1988).

Natural environment phobias include fears of storms, water, and heights. These fears are quite common; in fact, among men, height phobias are the most commonly reported specific phobia (Bourdon et al., 1988). Natural environment fears tend to begin in childhood, although there is some evidence that height phobias begin later than other phobias from this type (Curtis, Hill & Lewis, 1990). Large epidemiological studies have found that storm and water phobias are more common among women than men. For example, anywhere from 78% (Bourdon et al., 1988) to 100% (Agras, Sylvester & Oliveau, 1969) of individuals with storm phobias tend to be female. With respect to sex ratio, height phobias appear to be different than other natural environment phobias in that only 58% of individuals with height phobias tend to be female (Bourdon et al., 1988). These data, as well as other recent findings (e.g., Antony, Brown & Baldwin, 1997a,b) suggest that height phobias may not be typical of the natural environment type.

Blood–injection–injury phobias include fears of seeing blood, receiving injections, watching or undergoing surgical procedures, and other related medical situations. They tend to begin in childhood or early adolescence, and are more common in females, although sex differences are less pronounced than for animal phobias (Agras et al., 1969; Öst, 1987, 1992). Unlike other phobias, blood–injection–injury phobias are often associated with a diphasic physiological response during exposure to the feared situation. This response begins with an initial increase in arousal which is subsequently followed by a sharp drop in heart rate and blood pressure, often leading to fainting. Approximately 70% of individuals with blood phobia and 56% of those with injection phobias report a history of fainting in the feared situation (Öst, 1992). As discussed in a later section, the tendency for individuals with blood and injection phobias to faint has led to the development of specific treatment strategies for preventing fainting in this group.

Situational phobias include specific phobias of situations that are often feared by individuals with agoraphobia. Typical examples include enclosed places, driving, elevators, and airplanes. Situational phobias tend to have a mean age of onset in the twenties (Himle et al., 1989; Öst, 1987); and tend to be more common in women than men. Situational phobias are more likely to be associated with delayed and unpredictable panic attacks in some studies (Antony et al., 1997a; Ehlers, Hofmann, Herda & Roth, 1994), although other studies have found contradictory results (e.g., Craske & Sipsas, 1992).

Finally, an “other type” was included in DSM-IV to describe phobias not easily classified using the four main specific phobia types. Examples of phobias from the “other type” include fears of choking, vomiting, and balloons, although any phobia not easily classified as one of the other four types would be classified in this category.

Which of the following is an example of a specific phobia quizlet?

What are the 5 types of specific phobias?

What are specific phobias?

What are the 4 phobia categories?