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Samenvatting OWG 3 leerdoelen uitgewerkt (specifieke fobie)
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Leerdoelen Taak 31. Wat is een specifieke fobie (DSM 5 criteria)?
Bron: DSM 5:
A. Marked fear or anxiety about a specific object or situation (e.g., flying, heights, animals,
receiving an injection, seeing blood).
Note: 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.
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
obsessive-compulsive disorder); reminders of traumatic events (as in
posttraumatic stress disorder); separation from home or attachment figures (as in separation
anxiety disorder); or social situations (as in social anxiety disorder).
Specify if:
Code based on the phobic stimulus:
300.29 (F40.218) Animal (e.g., spiders, insects, dogs).
300.29 (F40.228) Natural environment (e.g., heights, storms, water).
300.29 (F40.23X) Blood-injection-injury (e.g., needles, invasive medical procedures).
Coding note: Select specific ICD-10-CM code as follows: F40.230 fear of blood;
F40.231 fear of injections and transfusions; F40.232 fear of other medical care; or
F40.233 fear of injury.
300.29 (F40.248) Situational (e.g., airplanes, elevators, enclosed places).
300.29 (F40.298) Other (e.g., situations that may lead to choking or vomiting: in children, e.g.,
loud sounds or costumed characters).
Coding note: When more than one phobic stimulus is present, code all ICD-10-CM codes that apply
(e.g., for fear of snakes and flying, F40.218 specific phobia, animal, and F40.248 specific phobia,
situational).
Specifiers
It is common for individuals to have multiple specific phobias. The average individual with specific
phobia fears three objects or situations, and approximately 75% of individuals with specific phobia
fear more than one situation or object. In such cases, multiple specific phobia diagnoses, each with
its own diagnostic code reflecting the phobic stimulus, would need to be given. For example, if an
individual fears thunderstorms and flying, then two diagnoses would be given: specific phobia,
natural environment, and specific phobia, situational.
Diagnostic Features
A key feature of this disorder is that the fear or anxiety is circumscribed to the presence of a
particular situation or object (Criterion A), which may be termed the phobic stimulus. The categories
of feared situations or objects are provided as specifiers. Many individuals fear objects or situations
,from more than one category, or phobic stimulus. For the diagnosis of specific phobia, the response
must differ from normal, transient fears that commonly occur in the population. To meet the criteria
for a diagnosis, the fear or anxiety must be intense or severe (i.e., "marked") (Criterion A). The
amount of fear experienced may vary with proximity to the feared object or situation and may occur
in anticipation of or in the actual presence of the object or situation. Also, the fear or anxiety may
take the form of a full or limited symptom panic attack (i.e., expected panic attack). Another
characteristic of specific phobias is that fear or anxiety is evoked nearly every time the individual
comes into contact with the phobic stimulus (Criterion B). Thus, an individual who becomes anxious
only occasionally upon being confronted with the situation or object (e.g., becomes anxious when
flying only on one out of every five airplane flights) would not be diagnosed with specific phobia.
However, the degree of fear or anxiety expressed may vary (from anticipatory anxiety to a full panic
attack) across different occasions of encountering the phobic object or situation because of various
contextual factors such as the presence of others, duration of exposure, and other threatening
elements such as turbulence on a flight for individuals who fear flying. Fear and anxiety are often
expressed differently between children and adults. Also, the fear or anxiety occurs as soon as the
phobic object or situation is encountered (i.e., immediately rather than being delayed). The individual
actively avoids the situation, or if he or she either is unable or decides not to avoid it, the situation or
object evokes intense fear or anxiety (Criterion C). Active avoidance means the individual
intentionally behaves in ways that are designed to prevent or minimize contact with phobic objects or
situations (e.g., takes tunnels instead of bridges on daily commute to work for fear of heights; avoids
entering a dark room for fear of spiders; avoids accepting a job in a locale where a phobic stimulus is
more common). Avoidance behaviors are often obvious (e.g., an individual who fears blood refusing
to go to the doctor) but are sometimes less obvious (e.g., an individual who fears snakes refusing to
look at pictures ihat resemble the form or shape of snakes). Many individuals with specific phobias
have suffered over many years and have changed their living circumstances in ways designed to avoid
the phobic object or situation as much as possible (e.g., an individual diagnosed with specific phobia,
animal, who moves to reside in an area devoid of the particular feared animal). Therefore, they no
longer experience fear or anxiety in their daily life. In such instances, avoidance behaviors or ongoing
refusal to engage in activities that would involve exposure to the phobic object or situation (e.g.,
repeated refusal to accept offers for work-related travel because of fear of flying) may be helpful in
confirming the diagnosis in the absence of overt anxiety or panic. 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 overestimate the danger in their feared situations, and thus the
judgment of being out of proportion 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, occupational, or other important areas of functioning in
order for the disorder to be diagnosed (Criterion F).
Associated Features Supporting Diagnosis
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 physiological
response to the feared situation or object varies. Whereas individuals with situational, 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.
2. Welke subtypes van specifieke fobie kunnen onderscheiden worden?
Bron: DSM 5:
Specify if: Code based on the phobic stimulus:
300.29 (F40.218) Animal (e.g., spiders, insects, dogs).
300.29 (F40.228) Natural environment (e.g., heights, storms, water).
300.29 (F40.23X) Blood-injection-injury (e.g., needles, invasive medical procedures).
Coding note: Select specific ICD-10-CM code as follows: F40.230 fear of blood;
F40.231 fear of injections and transfusions; F40.232 fear of other medical care; or
F40.233 fear of injury.
300.29 (F40.248) Situational (e.g., airplanes, elevators, enclosed places).
300.29 (F40.298) Other (e.g., situations that may lead to choking or vomiting: in children,
e.g., loud sounds or costumed characters such as a clown).
3. Wat is het verschil tussen BII en andere fobieën?
Bron: DSM 5:
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 physiological
response to the feared situation or object varies. Whereas individuals with situational, 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.
BII bloeddruk/harstlag/adrenaline gaat eerst omhoog en daarna omlaag (vasovalgale syncope,
/hypotensie), bij andere fobieën gaat die juist omhoog. Het gevolg is dat je kunt flauwvallen
(omlaag gaan van bloeddruk). hoofdstuk 18 van het handboek + artikel van Ayala
BII life-time prevalentie: mannen 3,5% vrouwen 4,9%
BII: reactie is vaak “disgusting” i.p.v. “fear”
4. Epidemiologie (prevalentie, age of onset, gender) en verloop specifieke fobieën?
Bron: DSM 5:
Prevalence
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 individuals (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 specific phobias are predominantly experienced by
females, whereas blood-injection-injury phobia is experienced nearly equally by both genders.
Development and Course
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., extensive 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 usually 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, animal, or blood-injection-injury specific phobias. Specific phobias that develop in
childhood 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. First,
young children may express their fear and anxiety by crying, tantrums, freezing, or clinging. Second,
young children typically are not able to understand the concept of avoidance. Therefore, the clinician
should assemble additional information from parents, teachers, or others who know the child well.
Excessive fears are quite common in young children but are usually transitory and only mildly
impairing and thus considered developmentally appropriate. In such cases a diagnosis of specific
phobia would not be made. When the diagnosis of specific phobia is being considered in a child, it is
important to assess the degree of impairment and the duration of the fear, anxiety, or avoidance, and
whether it is typical for the child's particular developmental stage.
Although the prevalence of specific phobia is lower in older populations, it remains one of the
more commonly experienced disorders in late life. Several issues should be considered when
diagnosing specific phobia in older populations. First, older individuals may be more likely to endorse
natural environment specific phobias, as well as phobias of falling. Second, specific phobia (like all
anxiety disorders) tends to co-occur with medical concerns in older individuals, including coronary
heart disease and chronic obstructive pulmonary disease. Third, older individuals may be more likely
to attribute the symptoms of anxiety to medical conditions. Fourth, older individuals may be more
likely to manifest anxiety in an atypical manner (e.g., involving symptoms of both anxiety and
depression) and thus be more likely to warrant a diagnosis of unspecified anxiety disorder.
Additionally, the presence of specific phobia in older adults is associated with decreased quality of life
and may serve as a risk factor for major neurocognitive disorder.
Although most specific phobias develop in childhood and adolescence, it is possible for a specific
phobia to develop at any age, often as the result of experiences that are traumatic. For example,
phobias of choking almost always follow a near-choking event at any age.
Suicide Risk
Individuals with specific phobia are up to 60% more likely to make a suicide attempt than are
individuals without the diagnosis. However, it is likely that these elevated rates are primarily due to
comorbidity with personality disorders and other anxiety disorders.
Functional Consequences of Specific Phobia
Individuals with specific phobia show similar patterns of impairment in psychosocial functioning and
decreased quality of life as individuals with other anxiety disorders and alcohol and substance use
disorders, including impairments in occupational and interpersonal functioning. In older adults,
impairment may be seen in caregiving duties and volunteer activities. Also, fear of falling in older
adults can lead to reduced mobility and reduced physical and social functioning, and may lead to
receiving formal or informal home support. The distress and impairment caused by specific phobias
tend to increase with the number of feared objects and situations. Thus, an individual who fears four
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