The fear or anxiety is out of proportion to the actual danger that the object or situation poses, or more intense than is deemed necessary (Criterion D). Although individuals with specific phobia often recognize their reactions as disproportionate, they tend to overesti- mate the danger in their feared situations, and thus the judgment of being out of propor- tion is made by the clinician. The individual’s sociocultural context should also be taken into account. For example, fears of the dark may be reasonable in a context of ongoing violence, and fear of insects may be more disproportionate in settings where insects are consumed in the diet. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more (Criterion E), which helps distinguish the disorder from transient fears that are common in the population, particularly among children. However, the duration criterion should be used as a general guide, with allowance for some degree of ﬂexibility.
The specific phobia must cause clinically significant distress or impairment in social, oc- cupational, or other important areas of functioning in order for the disorder to be diag- nosed (Criterion F).
Individuals with specific phobia typically experience an increase in physiological arousal in anticipation of or during exposure to a phobic object or situation. However, the physi- ological response to the feared situation or object varies. Whereas individuals with situa- tional, natural environment, and animal specific phobias are likely to show sympathetic nervous system arousal, individuals with blood-injection-injury specific phobia often demonstrate a vasovagal fainting or near-fainting response that is marked by initial brief acceleration of heart rate and elevation of blood pressure followed by a deceleration of heart rate and a drop in blood pressure. Current neural systems models for specific phobia emphasize the amygdala and related structures, much as in other anxiety disorders.
In the United States, the 12-month community prevalence estimate for specific phobia is approximately 7%—9%. Prevalence rates in European countries are largely similar to those in the United States (e.g., about 6%), but rates are generally lower in Asian, African, and
Latin American countries (2%—4%). Prevalence rates are approximately 5% in children and are approximately 16% in 13— to 17-year-olds. Prevalence rates are lower in older individ- uals (about 3%—5%), possibly reﬂecting diminishing severity to subclinical levels. Females are more frequently affected than males, at a rate of approximately 2:1, although rates vary across different phobic stimuli. That is, animal, natural environment, and situational spe- cific phobias are predominantly experienced by females, whereas blood-injection-injury phobia is experienced nearly equally by both genders.
Specific phobia sometimes develops following a traumatic event (e.g., being attacked by an animal or stuck in an elevator), observation of others going through a traumatic event (e.g., watching someone drown), an unexpected panic attack in the to be feared situation (e.g., an unexpected panic attack while on the subway), or informational transmission (e.g., ex- tensive media coverage of a plane crash). However, many individuals with specific phobia are unable to recall the specific reason for the onset of their phobias. Specific phobia usu- ally develops in early childhood, with the majority of cases developing prior to age 10 years. The median age at onset is between 7 and 11 years, with the mean at about 10 years.
Situational specific phobias tend to have a later age at onset than natural environment, an- imal, or blood-injection-injury specific phobias. Specific phobias that develop in child- hood and adolescence are likely to wax and wane during that period. However, phobias that do persist into adulthood are unlikely to remit for the majority of individuals.
When specific phobia is being diagnosed in children, two issues should be considered.