How Do You Differentiate Fears and Phobias?

Patient Presentation
A 7-year-old female came to clinic with her mother for her health maintenance visit. They had no concerns but her mother wanted to know what she could do to comfort her daughter during thunderstorms.
The previous spring, there had been a series of thunderstorms that had made the girl very upset. Since then, the girl has become very afraid during thunderstorms and is very anxious even during rainstorms.
Her mother states that if she even hears that there may be a thunderstorm she begins to become upset. She also does not like to read books where thunderstorms or rainstorms occur.
During the storms, she is comforted by her mother, siblings or other adults. She continues with her activities but does remains vigilant.
If it is actively lightening and thundering though she sometimes wants to cover up under a blanket or pillow.
If the storms occur at night, she comes to her mother’s bed for comfort, and falls back to sleep without much difficulty.
If it is just raining, but the storms continue for a long period of time, she is less anxious overall and becomes less so with time.
She is not scared of other weather conditions and has no other exaggerated fears.
The symptoms are not increasing and possibly may be slightly better according to her mother.
The social history shows a second grader doing well in school, with many friends, who likes swimming and drawing.
The family history is negative for any psychiatric illness
The pertinent physical exam shows a normal healthy female, who simply states, “I don’t like storms!”After consulting an electronic version of the Diagnostic and Statistical Manual of Mental Disorders to review the criteria for a phobia, the diagnosis of an exaggerated fear is made. Since the symptoms are limited only to various storms, are not increasing in quantity or quality, and the current emotional support seems to help the child,
the mother was reassured to just continue to comfort the girl during storms. However, the mother was told to call if the symptoms seem to be worsening and potentially short term counseling would be beneficial.

Fears are protective. They help to keep people safe from a variety of potentially harmful factors in the environment.
“Fear is an unpleasant emotion with cognitive, behavioral, and psychological components. It occurs in response to a consciously recognized source of danger, either real or imaginary.””Phobia [or a specific phobia] is a persistent and compulsive dread of and preoccupation with the feared object or event.” Phobias interfere with a child’s functioning.

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria for a specific phobia includes:

  • The patient has persistent or irrational fear that is unreasonable or excessive and is triggered by the presence or anticipation of a specific object or situation.
  • Exposure to the above noted event or object almost always results in an immediate anxiety response.
  • The person acknowledges this response to be unreasonable or excessive.
  • The person either avoids such situations or objects or else experiences exposure with intensive anxiety or distress.
  • The avoidance or distressful response significantly interferes with a person’s daily functioning.
  • Duration is at least 6 months for individuals younger than 18 years.
  • The anxiety, distressful response, or avoidance is not accounted for by other mental disorders .
  • The patient must have 1 of the following 5 subtypes that best describe phobias: animal, natural environment, blood-injection injury, situation or other (which must be distinguished from normal fear and anxiety).

Often there is a triggering event for a fear or phobia, e.g. thunderstorm. The fear can build because the child is not developmentally old enough to allay the fear or be able to be emotionally comforted with a reasonable explanation.
Cognitively and emotionally the child may not be able to understand that the current situation is safe or that the situation is not likely to be repeated. For example, a large dog knocks over a 3 year old boy and he has a few scratches.
The child may not be old enough to understand that he is now safe with an adult and the dog is unlikely to come back and hurt him again.
Instead the next time the boy encounters a dog, he seeks an adult, climbs play equipment or runs behind an object. These actions would be protective. But if he would cry uncontrollably after the dog was gone, and after a reasonable time of being comforted, then he may be having an exaggerated fear or even a phobia.

Fears are normal and occur in all children. Phobias occur in 7-9% of children. Different fears occur at different ages:

  • Infant and Toddler – separation, noises, falling, animals, toilet training, bath, bedtime
  • Preschoolers – animals, bedtime, monsters/ghosts, getting lost
  • School age (5-9 years) – separation, noises, falling, animals, bedtime, monsters/ghosts, divorce, getting lost, loss of parent
  • School age (9-12 years) – falling, social rejection, war, new situation, adoption, burglars
  • Teenagers – adoption, burglars, injections, sexual relations

Treatment is generally supportive. Parents need to understand that the fear is real to the child and that the child wants to withdraw from the feared object or situation.
Over time with support, the child will gain increased skill at handling the feared object or situation.
Counseling is recommended when a fear becomes more generalized, is impeding activities or if the fears are a realistic response to a threatening environment.
Medication is sometime recommended for phobias.

Learning Point
Diagnostic and Statistical Manual of Mental Disorders should be consulted when symptoms may be more than a simple fear. In general, fears and phobias can be differentiated based upon the following:

				Fear	Phobia
Reasonable triggering
  event as likely cause		Yes	No
Responds to reassurance		Yes	No
Is distractible			Yes	No
Interferes with activities	No	Yes

Questions for Further Discussion
1. What other disease/problems should be considered in the differential diagnosis of a fear or phobia?
2. What are the other anxiety disorders in the Diagnostic and Statistical Manual of Mental Disorders?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Information prescriptions for patients can be found at MedlinePlus for these topics: Anxiety and Phobias

To view current news articles on this topic check Google News.

Augustyn M. Fears. In Behavioral and Developmental Pediatrics. Parker S, Zuckerman B. Little, Brown and Company. Boston, MA. 1995;140-142.

Friedman SL, Munir KM.
Anxiety Disorder: Specific Phobia. eMedicine.
Available from the Internet at (rev.8/7/2006, cited 1/31/2007).

American Psychiatric Association. Specific Phobia. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Available from the Internet at: 2000, cited 1/31/2007)

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    6. Information technology to support patient care decisions and patient education is used.

    8. Health care services aimed at preventing health problems or maintaining health are provided.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    12. Evidence from scientific studies related to the patients’ health problems is located, appraised and assimilated.
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
    15. Information technology to manage information, access on-line medical information and support the healthcare professional’s own education is used.

    Donna M. D’Alessandro, MD
    Associate Professor of Pediatrics, Children’s Hospital of Iowa

    February 26, 2007