Approach
Diagnosis can be made through self-report, clinical interview, and behavioural observation of response to stimuli.[1] Several empirically validated self-report questionnaires are available to assess baseline functioning and to track response to treatment across time.[38]
Identification of pathophysiological markers through laboratory testing is not indicated.
Historical factors
Symptoms usually begin during mid- to late childhood; however, phobias can develop at any age. The median age of onset is 7 to 11 years, with declining probabilities of onset into later adulthood.[1][3][4] Most animal phobias develop before the age of 6 years, while situational phobias often develop in adolescence or early adulthood.[39]
Many patients do not recall specific events relating to the development of their phobias and often delay seeking treatment for several years after displaying marked avoidance behaviour. Descriptions of symptoms include experiences of intense anxiety or panic during anticipated or direct exposure to specific objects or situations. Sleep disruption, depression, and/or extreme anticipatory anxiety may co-occur. Up to 80% of patients with blood-injection-injury phobias experience vasovagal syncope.[27] Coping behaviours often include avoidance, safety seeking, or substance misuse. These behaviours may lead to phobia maintenance across time.
Social history often reveals functional impairments in personal, social, and occupational domains. Family history may reveal symptomatic first-degree relatives, particularly in patients with blood-injection-injury phobias who often describe familial vasovagal syncope. Medical histories are usually unremarkable.
Screening
Guidelines on screening for panic disorder vary according to country of practice. The US Preventive Services Task Force (USPSTF) recommends screening for anxiety disorders in all adults aged 19-64, including pregnant and postnatal people. The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for anxiety disorders in adults aged 65 and over.[40] The USPSTF also recommends universal screening in primary care for anxiety in children and adolescents aged 8-18 years.[41] The Women's Preventive Services Initiative in the US recommends that clinicians screen women and adolescent girls aged 13 years and over for anxiety (including those without a diagnosis of anxiety disorder and those who are pregnant or postnatal). Optimal screening intervals are unknown and clinical judgment is required to determine frequency.[42]
Ask the following set of questions to recognise phobic cues, symptoms, and behaviours:
Do you feel intense anxiety or fear when confronted by certain animals, objects, or situations?
Are you avoiding these animals, objects, or situations because of your fear?
In what ways has this anxiety or fear interfered with your life?
How would you react if you were exposed to the animal, object, or situation right now?
Have you ever fainted or almost fainted around blood, injuries, or needles?
Diagnostic interview
Structured and semi-structured interview schedules are commonly used in the research setting but may not be necessary to make a diagnosis in clinical practice. Validated structured and semi-structured interview schedules to assess patients reporting phobic symptoms include:
The Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders (DSM)-5 (SCID-5-CV)[43]
The Anxiety Disorders Interview Schedule for DSM-5 (ADIS-5): Adult and Lifetime[44]
The Anxiety Disorders Interview Schedule (ADIS-IV): Child and Parent.[45]
The ADIS-IV interview schedule is based upon DSM-IV criteria and consists of discrete semi-structured interviews for the child and the child’s parent.
Interview with family and/or close friends
Assessments may be supplemented with interviews with family members or close supporters. This is particularly important when evaluating children with phobias.
Physical examination
There are usually no objective findings, although patients may become noticeably anxious or nervous when discussing their phobias. Signs of heightened sympathetic nervous system activity may be present (e.g., tachycardia, hyperventilation, sweating, flushing). Vasovagal fainting may also be present, especially when people with blood-injection-injury phobia are exposed to medical situations or procedures. The physician may wish to assess these patients for other medical conditions associated with fainting risk (including low blood glucose levels and orthostatic hypotension).
Behavioural approach tasks
Assessments using behavioural approach tasks involve observing the willingness of patients to come into direct proximity with phobic cues: for example, measuring how close a person with spider phobia would be willing to approach a sealed jar containing a live spider.
Children
Childhood fears are common and usually transient. Fears that persist are considered phobias if impairments in developmentally appropriate functioning are observed (e.g., refusing to play outdoors due to fears of dogs; refusing to turn lights off at bedtime due to fears of the dark). Phobic anxieties in children may be expressed by crying, tantrums, freezing, or clinging but children themselves may not recognise their fears as unreasonable. Parents describe either acute, traumatic onsets (e.g., dog bites) or gradual onsets in the absence of aversive experiences (e.g., fears of the dark).
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