Specific phobia

Last updated
Specific Phobia
Specialty Psychiatry

Specific phobia is an anxiety disorder, characterized by an extreme, unreasonable, and irrational fear associated with a specific object, situation, or concept which poses little or no actual danger. [1] [2] Specific phobia can lead to avoidance of the object or situation, persistence of the fear, and significant distress or problems functioning associated with the fear. A phobia can be the fear of anything.

Contents

Although fears are common and normal, a phobia is an extreme type of fear where great lengths are taken to avoid being exposed to the particular danger. Phobias are considered the most common psychiatric disorder, affecting about 10% of the population in the US, [3] according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), (among children, 5%; among teens, 16%). About 75% of patients have more than one specific phobia.

It can be described as when patients are anxious about a particular situation. It causes a great load of difficulty in life. Patients have a lot of distress or interference when functioning in their daily life. Unreasonable or irrational fears get in the way of daily routines, work, and relationships due to the effort that a patient makes to avoid the terrifying feelings associated with the fear. [4]

Females are twice as likely to be diagnosed than males with a specific phobia (although this can depend on the stimulus).[ dubious – discuss ]

Children and adolescents who are diagnosed with a specific phobia are at an increased risk for additional psychopathology later in life. [1]

Signs and symptoms

Fear, discomfort or anxiety may be triggered both by the presence and the anticipation of the specific object or situation. The main behavioral sign of a specific phobia is avoidance. [5] The fear or anxiety associated with specific phobia can also manifest in physical symptoms such as an increased heart rate, shortness of breath, muscle tension, sweating, or a desire to escape the situation. [6]

Causes

The exact cause of specific phobias is not known. [5] The mechanisms for development of specific phobias can be distinguished between innate (genetic and neurobiological) factors, and learned factors.

In neurobiology, one explanation proposed for specific phobia is that the typical activation of the amygdala in response to stimuli may be exaggerated due to pathological changes. According to this theory, a deficiency in amygdala habituation may also contribute to the persistence of non-experiential phobia. [7] Certain phobias that are less lethal (e.g. dogs) seem to be more frequently observed and easily acquired in comparison to potentially lethal fears which are more relevant to developed human society (e.g. cars and guns). This was theorised to be due to biological adaptation being passed through evolution which makes recent threats less prone to easy acquisition. [8] However, a 2014 study found evidence against this evolutionary theory, which stated: "Our findings are inconsistent with the hypothesis that fears/phobias of individual stimuli result from genetic and environmental factors unique to that stimulus. Instead, we observed substantial sharing of risk factors across individual fears." [9] There is also evidence for the validity of a genetic component contributing to blood-injection-injury phobias and animal phobias, although this evidence did not support the idea that other specific phobias had genetic influence. [9] Blood-injection-injury phobias are also believed to be the most heritable among specific phobias. [10]

The classical conditioning model of learning has also been used to suggest that a phobia will be learned when an event that causes a fear or anxiety reaction is paired with a neutral event. [5] An example of this model is when being near a dog (neutral event) is paired with the emotional experience of being bitten by a dog, resulting in a chronic fear which is described as a specific phobia to dogs. [5] An alternative proposed mechanism of association is through observational learning. [5] According to this theory, a person may internalize another person's fears about a specific object or situation through observation of their reactions. [5]

Diagnosis

Diagnosis in the ICD or the DSM requires a marked fear, anxiety or avoidance that is long-lasting (greater than six months) and consistently occurs in the presence of the feared object or situation. The DSM-5 that the fears should be out of proportion to the danger posed, compared to the ICD-10 which specifies that the symptoms must be excessive or unreasonable. [11] Minor differences have persisted between the ICD-11 and DSM-5. [12]

In the DSM-5, there are several types which specific phobia can be classified under:

Although the avoidance resulting from specific phobia is comparable to other anxiety disorders, differential diagnosis is done through examining underlying causes for the behavior. [11] Agoraphobia is also considered distinct from specific phobia, along with substance use disorders, and avoidant personality disorder. [5] The occurrence of panic attacks is not itself a symptom of specific phobias and falls under the criteria of panic disorder. [5]

Treatment

There are a variety of treatment options available for specific phobias, most of which focus on psychosocial interventions. [13] Different psychological treatments have varying levels of effects depending on the specific phobia being addressed. [13]

Cognitive behavioral therapy (CBT)

Cognitive behavioral therapy is a short term, skills-focused therapy that aims to help people diffuse unhelpful emotional responses by helping people consider them differently or change their behavior. CBT represents the gold standard and first line of therapy in specific phobias. [14] [13] CBT is effective in treating specific phobias primarily through exposure and cognitive strategies to overcome a person's anxiety. [14] [13] Computer-assisted treatment programs, self-help manuals, and delivery by a trained practitioner are all methods of accessing CBT. A single session of CBT in one of these modalities can be effective for individuals who have a specific phobia. [15]

Exposure therapy

Exposure therapy is a particularly effective form of CBT for many specific phobias, however, treatment acceptance and high drop-out rates have been noted as concerns.[ medical citation needed ] In addition, a third of people who complete exposure therapy as a treatment for specific phobia may not respond, regardless of the type of exposure therapy. [16] Other interventions have been successful for particular types of specific phobia, such as virtual reality exposure therapy (VRET) for spider, dental, and height phobias, applied muscle tension (AMT) for needle phobia, and psychoeducation with relaxation exercises for fear of childbirth.[ medical citation needed ] With exposure therapy, a type of cognitive-behavioural therapy, clinically significant improvement was experienced by up to 90% of patients. [15] While very long-term outcomes remain unknown, many of the benefits of exposure therapy persisted after one year. [15] Treatment may be more successful at reducing symptoms in people with low trait anxiety, high motivation, and high self-efficacy entering exposure therapy. In addition, high cortisol levels, high heart rate variation, evoking disgust, avoiding relaxation, focusing on cognitive changes, context variation, sleep, and memory-enhancing drugs can also reduce symptoms following exposure therapy. [16]

Exposure can be "live"(in real life) or imaginal (in ones imagination) and can involve:

Exposures that are imaginal are less effective.[ medical citation needed ]

Specifically for acrophobia, in-vivo exposure (exposure to real-world height-scenarios while maintaining anxiety at controlled levels) has been shown to significantly improve measures of anxiety in the short-term, but this effect decreased over a longer term. Likewise, virtual reality exposure was statistically significant in some measures of anxiety reduction, but not others. [18]

Pharmacotherapeutics

As of late 2020, there is limited evidence for the use of pharmacotherapy in the treatment of specific phobia. Pharmacological treatments are typically used in combination with behaviorally-focused psychotherapy, as introducing pharmacological interventions independently may result in relapsing of symptoms. [19] Different treatments are better suited for certain types of specific phobia. For instance, beta blockers are useful in those with performance anxiety. [19] The selective serotonin re-uptake inhibitors (SSRIs), paroxetine and escitalopram, have shown preliminary efficacy in small randomized controlled clinical trials. [13] However, these trials were too small to show any definitive benefits of anxiolytic medication alone in treating phobia. [20] Benzodiazepines are occasionally used for acute symptom relief, but have not been shown to be effective for long-term treatment. [20] There are some findings suggesting that adjuvant use of the NMDA receptor partial agonist, d-cycloserine, with virtual reality exposure therapy may improve specific phobia symptoms more than virtual reality exposure therapy alone. As of 2020, studies on the use of adjunct d-cycloserine are inconclusive. [20]

Prognosis

The majority of those that develop a specific phobia first experience symptoms in childhood. Often individuals will experience symptoms periodically with periods of remission before complete remission occurs. However, specific phobias that continue into adulthood are likely to experience a more chronic course. Specific phobias in older adults has been linked with a decrease in quality of life. [3] Those with specific phobias are at an increased risk of suicide. Greater impairment is found in those that have multiple phobias. Response to treatment is relatively high but many do not seek treatment due to lack of access, ability to avoid phobia, or unwilling to face feared object for repeated CBT sessions. [21]

Epidemiology

Specific phobia is estimated to affect 6-12% of people at some point in their life. [11] There may be a large amount of underreporting of specific phobias as many people do not seek treatment, with some surveys conducted in the US finding that 70% of the population reports having one or more unreasonable fears. [1]

Specific phobias have a lifetime prevalence rate of 7.4% and a one-year prevalence of 5.5% according to data collected from 22 different countries. [22] The usual age of onset is childhood to adolescence. During childhood and adolescence, the incidence of new specific phobias is much higher in females than males. The peak incidence for specific phobias amongst females occurs during reproduction and childrearing, possibly reflecting an evolutionary advantage. There is an additional peak in incidence, reaching nearly 1% per year, during old age in both men and women, possibly reflective of newly occurring physical conditions or adverse life events. [1] The development of phobias varies with subtypes, with animal and blood injection phobias typically beginning in childhood (ages 5–12), whereas development of situational specific phobias (i.e., fear of flying) usually occurs in late adolescence and early adulthood. [23]

In the US, the lifetime prevalence rate is 12.5% and a one-year prevalence rate of 9.1%. [22] An estimated 12.5% of U.S. adults experience specific phobia at some time in their lives and the prevalence is approximately double in females compared to males. An estimated 19.3% of adolescents experience specific phobia, but the difference between males and females is not as pronounced. [24]

See also

Related Research Articles

<span class="mw-page-title-main">Phobia</span> Anxiety disorder classified by a persistent and excessive fear of an object or situation

A phobia is an anxiety disorder, defined by a persistent and excessive fear of an object or situation. Phobias typically result in a rapid onset of fear and are usually present for more than six months. Those affected go to great lengths to avoid the situation or object, to a degree greater than the actual danger posed. If the object or situation cannot be avoided, they experience significant distress. Other symptoms can include fainting, which may occur in blood or injury phobia, and panic attacks, often found in agoraphobia and emetophobia. Around 75% of those with phobias have multiple phobias.

<span class="mw-page-title-main">Anxiety disorder</span> Cognitive disorder with an excessive, irrational dread of everyday situations

Anxiety disorders are a cluster of mental disorders characterized by significant and uncontrollable feelings of anxiety and fear such that a person's social, occupational, and personal functions are significantly impaired. Anxiety may cause physical and cognitive symptoms, such as restlessness, irritability, easy fatigue, difficulty concentrating, increased heart rate, chest pain, abdominal pain, and a variety of other symptoms that may vary based on the individual.

<span class="mw-page-title-main">Agoraphobia</span> Anxiety disorder

Agoraphobia is a mental and behavioral disorder, specifically an anxiety disorder characterized by symptoms of anxiety in situations where the person perceives their environment to be unsafe with no easy way to escape. These situations can include public transit, shopping centers, crowds and queues, or simply being outside their home on their own. Being in these situations may result in a panic attack. Those affected will go to great lengths to avoid these situations. In severe cases, people may become completely unable to leave their homes.

Post-traumatic stress disorder (PTSD) is a mental and behavioral disorder that develops from experiencing a traumatic event, such as sexual assault, warfare, traffic collisions, child abuse, domestic violence, or other threats on a person's life or well-being. Symptoms may include disturbing thoughts, feelings, or dreams related to the events, mental or physical distress to trauma-related cues, attempts to avoid trauma-related cues, alterations in the way a person thinks and feels, and an increase in the fight-or-flight response. These symptoms last for more than a month after the event. Young children are less likely to show distress, but instead may express their memories through play. A person with PTSD is at a higher risk of suicide and intentional self-harm.

<span class="mw-page-title-main">Hypochondriasis</span> Medical condition

Hypochondriasis or hypochondria is a condition in which a person is excessively and unduly worried about having a serious illness. Hypochondria is an old concept whose meaning has repeatedly changed over its lifespan. It has been claimed that this debilitating condition results from an inaccurate perception of the condition of body or mind despite the absence of an actual medical diagnosis. An individual with hypochondriasis is known as a hypochondriac. Hypochondriacs become unduly alarmed about any physical or psychological symptoms they detect, no matter how minor the symptom may be, and are convinced that they have, or are about to be diagnosed with, a serious illness.

Abnormal psychology is the branch of psychology that studies unusual patterns of behavior, emotion, and thought, which could possibly be understood as a mental disorder. Although many behaviors could be considered as abnormal, this branch of psychology typically deals with behavior in a clinical context. There is a long history of attempts to understand and control behavior deemed to be aberrant or deviant, and there is often cultural variation in the approach taken. The field of abnormal psychology identifies multiple causes for different conditions, employing diverse theories from the general field of psychology and elsewhere, and much still hinges on what exactly is meant by "abnormal". There has traditionally been a divide between psychological and biological explanations, reflecting a philosophical dualism in regard to the mind-body problem. There have also been different approaches in trying to classify mental disorders. Abnormal includes three different categories; they are subnormal, supernormal and paranormal.

<span class="mw-page-title-main">Avoidant personality disorder</span> Personality disorder

Avoidant personality disorder (AvPD) or Anxious personality disorder is a Cluster C personality disorder characterized by excessive social anxiety and inhibition, fear of intimacy, severe feelings of inadequacy and inferiority, and an overreliance on avoidance of feared stimuli as a maladaptive coping method. Those affected typically display a pattern of extreme sensitivity to negative evaluation and rejection, a belief that one is socially inept or personally unappealing to others, and avoidance of social interaction despite a strong desire for it. It appears to affect an approximately equal number of men and women.

<span class="mw-page-title-main">Generalized anxiety disorder</span> Long-lasting anxiety not focused on any one object or situation

Generalized anxiety disorder (GAD) is a mental and behavioral disorder, specifically an anxiety disorder characterized by excessive, uncontrollable and often irrational worry about events or activities. Worry often interferes with daily functioning, and individuals with GAD are often overly concerned about everyday matters such as health, finances, death, family, relationship concerns, or work difficulties. Symptoms may include excessive worry, restlessness, trouble sleeping, exhaustion, irritability, sweating, and trembling.

Taijin kyofusho is a Japanese culture-specific syndrome. The term taijin kyofusho translates into the disorder (sho) of fear (kyofu) of interpersonal relations (taijin). Those who have taijin kyofusho are likely to be extremely embarrassed about themselves or fearful of displeasing others when it comes to the functions of their bodies or their appearances. These bodily functions and appearances include their faces, odor, actions, or even looks. They do not want to embarrass other people with their presence. This culture-bound syndrome is a social phobia based on fear and anxiety.

Mysophobia, also known as verminophobia, germophobia, germaphobia, bacillophobia and bacteriophobia, is a pathological fear of contamination and germs. It is classified as a type of specific phobia, meaning it is evaluated and diagnosed based on the experience of high levels of fear and anxiety beyond what is reasonable when exposed to or in anticipation of exposure to stimuli related to the particular concept. William A. Hammond first coined the term in 1879 when describing a case of obsessive–compulsive disorder (OCD) exhibited in repeatedly washing one's hands.

Cynophobia is the fear of dogs and canines in general. Cynophobia is classified as a specific phobia, under the subtype "animal phobias". According to Timothy O. Rentz of the Laboratory for the Study of Anxiety Disorders at the University of Texas, animal phobias are among the most common of the specific phobias and 36% of patients who seek treatment report being afraid of dogs or afraid of cats. Although ophidiophobia or arachnophobia are more common animal phobias, cynophobia is especially debilitating because of the high prevalence of dogs and the general ignorance of dog owners to the phobia. The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) reports that only 12% to 30% of those with a specific phobia will seek treatment.

Exposure therapy is a technique in behavior therapy to treat anxiety disorders.

Avoidant/restrictive food intake disorder (ARFID) is a feeding or eating disorder in which people avoid eating certain foods, or restrict their diets to the point it ultimately results in nutritional deficiencies. This can be due to the sensory characteristics of food, such as its appearance, smell, texture, or taste; due to fear of negative consequences such as choking or vomiting; having little interest in eating or food, or a combination of these factors. People with ARFID may also be afraid of trying new foods, a fear known as food neophobia.

Mental health professionals often distinguish between generalized social phobia and specific social phobia. People with generalized social phobia have great distress in a wide range of social situations. Those with specific social phobia may experience anxiety only in a few situations. The term "specific social phobia" may also refer to specific forms of non-clinical social anxiety.

<span class="mw-page-title-main">Thalassophobia</span> Fear of the sea or large open water

Thalassophobia is the persistent and intense fear of deep bodies of water such as the sea, oceans, or lakes. Though very closely related, thalassophobia should not be confused with aquaphobia which is classified as the fear of water itself. Thalassophobia can include fear of being in deep bodies of water, fear of the vast emptiness of the sea, of sea waves, aquatic creatures, and fear of distance from land.

<span class="mw-page-title-main">Social anxiety disorder</span> Anxiety disorder associated with social situations

Social anxiety disorder (SAD), also known as social phobia, is an anxiety disorder characterized by sentiments of fear and anxiety in social situations, causing considerable distress and impairing ability to function in at least some aspects of daily life. These fears can be triggered by perceived or actual scrutiny from others. Individuals with social anxiety disorder fear negative evaluations from other people.

<span class="mw-page-title-main">Panic disorder</span> Anxiety disorder characterized by reoccurring unexpected panic attacks

Panic disorder is a mental and behavioral disorder, specifically an anxiety disorder characterized by reoccurring unexpected panic attacks. Panic attacks are sudden periods of intense fear that may include palpitations, sweating, shaking, shortness of breath, numbness, or a feeling that something terrible is going to happen. The maximum degree of symptoms occurs within minutes. There may be ongoing worries about having further attacks and avoidance of places where attacks have occurred in the past.

<span class="mw-page-title-main">Fear of flying</span>

Fear of flying is a fear of being on an airplane, or other flying vehicle, such as a helicopter, while in flight. It is also referred to as flying anxiety, flying phobia, flight phobia, aviophobia, aerophobia, or pteromerhanophobia.

Autophobia, also called monophobia, isolophobia, or eremophobia, is the specific phobia or a morbid fear or dread of oneself or of being alone, isolated, abandoned, and ignored. This specific phobia is associated with the idea of being alone, often causing severe anxiety.

Separation anxiety disorder (SAD) is an anxiety disorder in which an individual experiences excessive anxiety regarding separation from home and/or from people to whom the individual has a strong emotional attachment. Separation anxiety is a natural part of the developmental process. It is most common in infants and little children, typically between the ages of six to seven months to three years, although it may pathologically manifest itself in older children, adolescents and adults. Unlike SAD, normal separation anxiety indicates healthy advancements in a child's cognitive maturation and should not be considered a developing behavioral problem.

References

  1. 1 2 3 4 Eaton WW, Bienvenu OJ, Miloyan B (August 2018). "Specific phobias". The Lancet. Psychiatry. 5 (8): 678–686. doi:10.1016/S2215-0366(18)30169-X. PMC   7233312 . PMID   30060873.
  2. ↑ "Specific Phobia". National Institute of Mental Health (NIMH). U.S. Department of Health and Human Services. Archived from the original on 22 February 2022. Retrieved 2021-06-14.
  3. 1 2 Diagnostic and Statistical Manual of Mental Disorders (DSM–5). American Psychiatric Association (APA). 22 May 2013. ISBN   978-0-89042-557-2 . Retrieved 2021-06-14.
  4. ↑ Smith M, Robinson L, Segal R, Segal J (September 2020). "Phobias and Irrational Fears". HelpGuide.org. Retrieved 2021-06-14.
  5. 1 2 3 4 5 6 7 8 Samra CK, Abdijadid S (2021). "Specific Phobia". StatPearls. Treasure Island (FL): StatPearls Publishing. PMID   29763098 . Retrieved 2021-11-29.
  6. ↑ "Phobias Symptoms & Causes | Boston Children's Hospital". www.childrenshospital.org. Archived from the original on 2019-02-04. Retrieved 2021-06-14.
  7. ↑ Garcia R (September 2017). "Neurobiology of fear and specific phobias". Learning & Memory. 24 (9): 462–471. doi:10.1101/lm.044115.116. PMC   5580526 . PMID   28814472.
  8. ↑ Davis TE, Ollendick TH, Öst LG (May 2019). "One-Session Treatment of Specific Phobias in Children: Recent Developments and a Systematic Review". Annual Review of Clinical Psychology. 15 (1): 233–256. doi:10.1146/annurev-clinpsy-050718-095608. PMID   30550722. S2CID   54632384.
  9. 1 2 Loken EK, Hettema JM, Aggen SH, Kendler KS (August 2014). "The structure of genetic and environmental risk factors for fears and phobias". Psychological Medicine. 44 (11): 2375–2384. doi:10.1017/S0033291713003012. PMC   4079768 . PMID   24384457.
  10. ↑ Van Houtem CM, Laine ML, Boomsma DI, Ligthart L, van Wijk AJ, De Jongh A (May 2013). "A review and meta-analysis of the heritability of specific phobia subtypes and corresponding fears" (PDF). Journal of Anxiety Disorders. 27 (4): 379–388. doi:10.1016/j.janxdis.2013.04.007. hdl:11245/1.398074. PMID   23774007. S2CID   34359477.
  11. 1 2 3 Craske MG, Stein MB (December 2016). "Anxiety". Lancet. 388 (10063): 3048–3059. doi:10.1016/S0140-6736(16)30381-6. PMID   27349358. S2CID   208789585.
  12. ↑ First MB, Gaebel W, Maj M, Stein DJ, Kogan CS, Saunders JB, et al. (February 2021). "An organization- and category-level comparison of diagnostic requirements for mental disorders in ICD-11 and DSM-5". World Psychiatry. 20 (1): 34–51. doi:10.1002/wps.20825. PMC   7801846 . PMID   33432742.
  13. 1 2 3 4 5 Katzman MA, Bleau P, Blier P, Chokka P, Kjernisted K, Van Ameringen M, et al. (2014). "Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders". BMC Psychiatry. 14 (Suppl 1): S1. doi: 10.1186/1471-244X-14-S1-S1 . PMC   4120194 . PMID   25081580.
  14. 1 2 David D, Cristea I, Hofmann SG (2018). "Why Cognitive Behavioral Therapy Is the Current Gold Standard of Psychotherapy". Frontiers in Psychiatry. 9: 4. doi: 10.3389/fpsyt.2018.00004 . PMC   5797481 . PMID   29434552.
  15. 1 2 3 "Phobias - Symptoms, diagnosis and treatment | BMJ Best Practice". bestpractice.bmj.com. 2021-10-28. Retrieved 2021-11-28.
  16. 1 2 Böhnlein J, Altegoer L, Muck NK, Roesmann K, Redlich R, Dannlowski U, Leehr EJ (January 2020). "Factors influencing the success of exposure therapy for specific phobia: A systematic review". Neuroscience and Biobehavioral Reviews. 108: 796–820. doi:10.1016/j.neubiorev.2019.12.009. PMID   31830494. S2CID   208988502.
  17. 1 2 Sadock BJ, Sadock SA, Ruiz P (2017). Kaplan & Sadock's comprehensive textbook of psychiatry (Tenth ed.). [Philadelphia]. ISBN   978-1-4963-8915-2. OCLC   988106757.{{cite book}}: CS1 maint: location missing publisher (link)
  18. ↑ Arroll B, Wallace HB, Mount V, Humm SP, Kingsford DW (April 2017). "A systematic review and meta-analysis of treatments for acrophobia". The Medical Journal of Australia. 206 (6): 263–267. doi:10.5694/mja16.00540. PMID   28359010. S2CID   9559825.
  19. 1 2 Reus VI (2018). "Anxiety Disorders". In Jameson JL, Fauci AS, Kasper GL, Hauser SL (eds.). Harrison's Principles of Internal Medicine (20 ed.). New York, NY: McGraw-Hill Education. Retrieved 2021-11-29.
  20. 1 2 3 Baldwin DS, Anderson IM, Nutt DJ, Allgulander C, Bandelow B, den Boer JA, et al. (May 2014). "Evidence-based pharmacological treatment of anxiety disorders, post-traumatic stress disorder and obsessive-compulsive disorder: a revision of the 2005 guidelines from the British Association for Psychopharmacology". Journal of Psychopharmacology. 28 (5): 403–439. doi:10.1177/0269881114525674. PMID   24713617. S2CID   28893331.
  21. ↑ Hendriks SM, Spijker J, Licht CM, Beekman AT, Penninx BW (September 2013). "Two-year course of anxiety disorders: different across disorders or dimensions?". Acta Psychiatrica Scandinavica. 128 (3): 212–221. doi:10.1111/acps.12024. PMID   23106669. S2CID   8009247.
  22. 1 2 Wardenaar KJ, Lim CC, Al-Hamzawi AO, Alonso J, Andrade LH, Benjet C, et al. (July 2017). "The cross-national epidemiology of specific phobia in the World Mental Health Surveys". Psychological Medicine. 47 (10): 1744–1760. doi:10.1017/S0033291717000174. PMC   5674525 . PMID   28222820.
  23. ↑ Katzman MA, Bleau P, Blier P, Chokka P, Kjernisted K, Van Ameringen M, et al. (2014). "Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders". BMC Psychiatry. 14 (Suppl 1): S1. doi: 10.1186/1471-244X-14-S1-S1 . PMC   4120194 . PMID   25081580.
  24. ↑ "Specific Phobia". National Institute of Mental Health (NIMH). Retrieved 2021-11-29.
This page is based on this Wikipedia article
Text is available under the CC BY-SA 4.0 license; additional terms may apply.
Images, videos and audio are available under their respective licenses.