Testing the Paleolithic-human-warfare hypothesis of blood-injection phobia in the Baltimore ECA Follow-up Study--towards a more etiologically-based conceptualization for DSM-V

An ethologically based view into human fear

The quality of the defensive response to a threat depends on the elements that trigger the fear response. The current classification system of phobias does not account for this. Here, we analyze the fear-eliciting elements and discern the different types of fears that originate from them. We propose Pain, Disgust, Vasovagal response, Visual-vestibular and postural interactions, Movement and Speed, Distance and Size, Low and mid-level visual features, Smell, and Territory and social status. We subdivide phobias according to the fear-eliciting elements most frequently triggered by them and their impact on behavior. We discuss the implications of a clinical conceptualization of phobias in humans by reconsidering the current nosology. This conceptualization will facilitate finding etiological factors in defensive behavior expression, fine-tuning exposure techniques, and challenging preconceived notions of preparedness. This approach to phobias leads to surprising discoveries and shows how specific responses bear little relation to the interpretation we might later give to them. Dividing fears into their potentially fear-eliciting elements can also help in applying the research principles formulated by the Research Domain Criteria initiative.

Combined Fainting and Psychogenic Non-epileptic Seizures as Significant Therapy Hurdles in Blood-Injury-Injection Phobia: A Mini-Review and Case Report

BACKGROUND

Anxiety disorders are the most frequent mental disorders. Among the different subtypes, specific phobias are the commonest. Due to the ongoing SARS-CoV-19 pandemic, blood-injury-injection phobia (BII) has gained wider attention in the context of large-scale vaccination campaigns and public health. In this BII phobia mini-review and case report, we describe the successful treatment of a severe BII phobia case with combined fainting and psychogenic non-epileptic seizures (PNES) and demonstrate the role of specialized outpatient care.

CASE REPORT

The patient was a 28-year-old woman. She suffered from intense fear and recurrent fainting with regard to needles, injections, injuries, and at the sight of blood since early childhood. Medical history revealed infrequent events suggestive of PNES following panic attacks after sustained exposure to phobic stimuli. Family history was positive for circulation problems and BII fears. Psychopathological evaluation confirmed BII phobia symptoms and diagnosis was made according to the DSM-5. The Multidimensional Blood/Injury Phobia Inventory short version (MBPI-K) revealed severe manifestation of the disease. Neurological examination was ordinary. Repeated electroencephalography detected no epileptic pattern. Cranial magnetic resonance imaging showed normal morphology. Treatment was carried out by a seasoned, multidisciplinary team. Cognitive behavior therapy and exposure were performed. Modification of standard treatment protocol was necessary due to hurdles posed by recurrent fainting and a severe panic-triggered dissociative PNES during in vivo exposure. Modification was implemented by limiting in vivo exposure intensity to moderate anxiety levels. In addition to applied muscle tension and ventilation techniques, increased psychoeducation, cognitive restructuring, and distress tolerance skills (e.g., ice pack, verbal self-instructions) were used to strengthen the patient's situational control during in vivo exposure. A total of 15 sessions were performed. Therapy success was proven by 83% reduction in MBPI-K rating, SARS-CoV-19 vaccination, and a blood draw without psychological assistance, fainting, or seizure.

CONCLUSION

Taken together, this case demonstrates the potential of and need for specialized outpatient care and individualized treatment for severe BII phobia patients in order to provide them the perspective to have necessary medical procedures done and get vaccinated.

Confirming the factor structure and improving the screening function of the Medical Fear Survey - short in a Hungarian community sample

Medical Fear Survey (MFS) was designed to assess the fear of medical treatments and related factors through five dimensions including fears of injections and blood draws, sharp objects, blood, mutilation, medical examination and physical symptoms. We analysed the factor structure and validity of a short version of MFS in Hungarian, on a large sample (2631 participants; 558 men, 2067 women) focusing on possible age and gender differences (aged Mean = 30.4, SD = 13.4), which were not reported for the original version. Furthermore, using discriminant analysis, potential screening function of the MFS-short was examined. Results supported construct and convergent validity and scale-reliability for the five-factor structure of the MFS-short. Further analyses demonstrated excellent discriminatory power for four subscales, while one subscale had acceptable power. Our findings provide implications for the utility of MFS-short as a screening measure in assessing the severity of medical fears controlling for gender differences and age-biases.

A Diagnostic-Oriented Screening Scale for Anxiety Disorders: The Center for Epidemiologic Studies Anxiety Scale (CESA)

Objectives

This paper introduces a new diagnostically oriented screening scale for anxiety disorders, the Center for Epidemiologic Studies Anxiety scale (CESA), designed in parallel to the revised Center for Epidemiologic Studies Depression scale (CESD-R). In this study, the CESA was used as a diagnostic screening tool for detecting the presence of anxiety disorder symptomatology ascertained by a clinical psychiatric evaluation based on the DSM-5 criteria. The CESA is designed to provide an overall evaluation of anxiety as well as to screen for four important anxiety disorders (agoraphobia, social phobia, blood-illness phobia, and panic disorder).

Methods

The test sample was composed of 80 adults seeking treatment for mental problems in a general psychiatric clinic. We assessed the receiver operating characteristic (ROC) curve of the CESA in comparison to the psychiatric interview.

Results

The main findings suggest that the CESA is useful for screening for anxiety in general (alpha coefficient of 0.83), as well as for the four common anxiety disorders. The criterion validation confirmed a high level of compatibility between the CESA and the psychiatric evaluation.

Conclusion

This is the initial report regarding the CESA and future research will focus on specific aspects of criterion validity for each disorder.

Specific phobias

Anxiety disorders are among the most prevalent mental disorders, but the subcategory of specific phobias has not been well studied. Phobias involve both fear and avoidance. For people who have specific phobias, avoidance can reduce the constancy and severity of distress and impairment. However, these phobias are important because of their early onset and strong persistence over time. Studies indicate that the lifetime prevalence of specific phobias around the world ranges from 3% to 15%, with fears and phobias concerning heights and animals being the most common. The developmental course of phobias, which progress from fear to avoidance and then to diagnosis, suggests the possibility that interrupting the course of phobias could reduce their prevalence. Although specific phobias often begin in childhood, their incidence peaks during midlife and old age. Phobias persist for several years or even decades in 10-30% of cases, and are strongly predictive of onset of other anxiety, mood, and substance-use disorders. Their high comorbidity with other mental disorders, especially after onset of the phobia, suggests that early treatment of phobias could also alter the risk of other disorders. Exposure therapy remains the treatment of choice, although this approach might be less effective in the long term than previously believed. This Review discusses the literature regarding the prevalence, incidence, course, risk factors, and treatment of specific phobias, and presents epidemiological data from several population-based surveys.

Blood-injection-injury phobia in older adults

BACKGROUND

This study aims to (i) estimate the prevalence of blood-injection-injury phobia (BIIP) diagnosed as present at any time during the life prior to the interview, with or without another Specific Phobia diagnosed as present during the 12 months prior to the interview, (ii) characterize types and frequencies of co-occurring fears, (iii) evaluate the association with chronic medical conditions and lifetime psychiatric comorbidity, and (iv) explore medical service use associations in a nationally representative sample of older adults.

METHODS

A sample of 8,205 older adults, aged 65 years or older, was derived from Wave 1 of the National Epidemiological Survey on Alcohol and Related Conditions (NESARC).

RESULTS

The weighted lifetime prevalence of BIIP with and without 12-month Specific Phobia was 0.6% (95% CI: 0.4-0.8) and 4.2% (95% CI: 3.7-4.8), respectively, and these two groups ranked similarly in terms of sociodemographic, health, and psychiatric characteristics. BIIP most frequently co-occurred with other lifetime fears, and was positively associated with hypertension and lifetime history of anxiety and personality disorders after controlling for sociodemographic and psychiatric confounders.

CONCLUSIONS

Our findings suggest that lifetime BIIP may bear mental and physical health significance in older adults.

Neurostructural correlates of two subtypes of specific phobia: a voxel-based morphometry study

The animal and blood-injection-injury (BII) subtypes of specific phobia are both characterized by subjective fear but distinct autonomic reactions to threat. Previous functional neuroimaging studies have related these characteristic responses to shared and non-shared neural underpinnings. However, no comparative structural data are available. This study aims to fill this gap by comparing the two subtypes and also comparing them with a non-phobic control group. Gray and white matter data of 33 snake phobia subjects (SP), 26 dental phobia subjects (DP), and 37 healthy control (HC) subjects were analyzed with voxel-based morphometry. Especially DP differed from HC and SP by showing significantly increased grey matter volumes in widespread areas including the right subgenual anterior cingulate gyrus, left insula, left orbitofrontal and left prefrontal (PFC) cortices. In addition, white matter volume was significantly increased in the left PFC in DP compared with SP. These results are in line with functional changes observed in dental phobia and point toward those brain circuits associated with emotional processing and regulation. Future studies should aim to further delineate functional and structural connectivity alterations in specific phobia.

The structure of genetic and environmental risk factors for phobias in women

BACKGROUND

To explore the genetic and environmental factors underlying the co-occurrence of lifetime diagnoses of DSM-IV phobia.

METHOD

Female twins (n=1430) from the population-based Norwegian Institute of Public Health Twin Panel were assessed at personal interview for DSM-IV lifetime specific phobia, social phobia and agoraphobia. Comorbidity between the phobias were assessed by odds ratios (ORs) and polychoric correlations and multivariate twin models were fitted in Mx.

RESULTS

Phenotypic correlations of lifetime phobia diagnoses ranged from 0.55 (agoraphobia and social phobia, OR 10.95) to 0.06 (animal phobia and social phobia, OR 1.21). In the best fitting twin model, which did not include shared environmental factors, heritability estimates for the phobias ranged from 0.43 to 0.63. Comorbidity between the phobias was accounted for by two common liability factors. The first loaded principally on animal phobia and did not influence the complex phobias (agoraphobia and social phobia). The second liability factor strongly influenced the complex phobias, but also loaded weak to moderate on all the other phobias. Blood phobia was mainly influenced by a specific genetic factor, which accounted for 51% of the total and 81% of the genetic variance.

CONCLUSIONS

Phobias are highly co-morbid and heritable. Our results suggest that the co-morbidity between phobias is best explained by two distinct liability factors rather than a single factor, as has been assumed in most previous multivariate twin analyses. One of these factors was specific to the simple phobias, while the other was more general. Blood phobia was mainly influenced by disorder specific genetic factors.

The psychophysiology of blood-injection-injury phobia: looking beyond the diphasic response paradigm

Blood-injection-injury (BII) phobia is an anxiety disorder that may be accompanied by vasovagal fainting during confrontation with the feared stimuli. The underlying pattern of autonomic regulation has been characterized as a diphasic response, with initial increases in heart rate and blood pressure that are typical of a fight-flight response, and subsequent drops in blood pressure and/or heart rate that may precipitate vasovagal fainting. Tensing skeletal muscles of the arms, legs, and trunk (applied tension) has been proposed as a technique to cope with this dysregulation. This review critically examines the empirical basis for the diphasic response and its treatment by applied tension in BII phobia. An alternative perspective on the psychophysiology of BII phobia and vasovagal fainting is offered by focusing on hypocapnia that leads to cerebral blood flow reductions, a perspective supported by research on neurocardiogenic and orthostatically-induced syncope. The evidence may indicate a role for respiration-focused coping techniques in BII phobia.

Tomophobia, the phobic fear caused by an invasive medical procedure - an emerging anxiety disorder: a case report

Introduction

Tomophobia refers to fear or anxiety caused by forthcoming surgical procedures and/or medical interventions.

Case presentation

We present the case of a 69-year-old Caucasian man who refused urgently indicated medical intervention because of severe tomophobia.

Conclusion

Due to the rising number of surgical interventions in modern medicine, as well as the high number of unrecognised cases of tomophobia, this common but underdiagnosed anxiety disorder should be highlighted.

Recent trends in the study of specific phobias

PURPOSE OF REVIEW

Specific phobias are prevalent and often disabling anxiety disorders. The present review examines relevant investigations that have been published during the last 2 years on major aspects of this group of disorders.

RECENT FINDINGS

Recent studies have come mainly from epidemiology, brain imagery and cognitive-behavioral therapy, including virtual reality exposure therapy.

SUMMARY

Studies published in the last 2 years confirm the high prevalence of specific phobias in the general population and provide new insights into the mechanisms underlying the fear reaction after exposure to a phobic stimulus.

Human brain evolution and the "Neuroevolutionary Time-depth Principle:" Implications for the Reclassification of fear-circuitry-related traits in DSM-V and for studying resilience to warzone-related posttraumatic stress disorder

The DSM-III, DSM-IV, DSM-IV-TR and ICD-10 have judiciously minimized discussion of etiologies to distance clinical psychiatry from Freudian psychoanalysis. With this goal mostly achieved, discussion of etiological factors should be reintroduced into the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V). A research agenda for the DSM-V advocated the "development of a pathophysiologically based classification system". The author critically reviews the neuroevolutionary literature on stress-induced and fear circuitry disorders and related amygdala-driven, species-atypical fear behaviors of clinical severity in adult humans. Over 30 empirically testable/falsifiable predictions are presented. It is noted that in DSM-IV-TR and ICD-10, the classification of stress and fear circuitry disorders is neither mode-of-acquisition-based nor brain-evolution-based. For example, snake phobia (innate) and dog phobia (overconsolidational) are clustered together. Similarly, research on blood-injection-injury-type-specific phobia clusters two fears different in their innateness: 1) an arguably ontogenetic memory-trace-overconsolidation-based fear (hospital phobia) and 2) a hardwired (innate) fear of the sight of one's blood or a sharp object penetrating one's skin. Genetic architecture-charting of fear-circuitry-related traits has been challenging. Various, non-phenotype-based architectures can serve as targets for research. In this article, the author will propose one such alternative genetic architecture. This article was inspired by the following: A) Nesse's "Smoke-Detector Principle", B) the increasing suspicion that the "smooth" rather than "lumpy" distribution of complex psychiatric phenotypes (including fear-circuitry disorders) may in some cases be accounted for by oligogenic (and not necessarily polygenic) transmission, and C) insights from the initial sequence of the chimpanzee genome and comparison with the human genome by the Chimpanzee Sequencing and Analysis Consortium published in late 2005. Neuroevolutionary insights relevant to fear circuitry symptoms that primarily emerge overconsolidationally (especially Combat related Posttraumatic Stress Disorder) are presented. Also introduced is a human-evolution-based principle for clustering innate fear traits. The "Neuroevolutionary Time-depth Principle" of innate fears proposed in this article may be useful in the development of a neuroevolution-based taxonomic re-clustering of stress-triggered and fear-circuitry disorders in DSM-V. Four broad clusters of evolved fear circuits are proposed based on their time-depths: 1) Mesozoic (mammalian-wide) circuits hardwired by wild-type alleles driven to fixation by Mesozoic selective sweeps; 2) Cenozoic (simian-wide) circuits relevant to many specific phobias; 3) mid Paleolithic and upper Paleolithic (Homo sapiens-specific) circuits (arguably resulting mostly from mate-choice-driven stabilizing selection); 4) Neolithic circuits (arguably mostly related to stabilizing selection driven by gene-culture co-evolution). More importantly, the author presents evolutionary perspectives on warzone-related PTSD, Combat-Stress Reaction, Combat-related Stress, Operational-Stress, and other deployment-stress-induced symptoms. The Neuroevolutionary Time-depth Principle presented in this article may help explain the dissimilar stress-resilience levels following different types of acute threat to survival of oneself or one's progency (aka DSM-III and DSM-V PTSD Criterion-A events). PTSD rates following exposure to lethal inter-group violence (combat, warzone exposure or intentionally caused disasters such as terrorism) are usually 5-10 times higher than rates following large-scale natural disasters such as forest fires, floods, hurricanes, volcanic eruptions, and earthquakes. The author predicts that both intentionally-caused large-scale bioevent-disasters, as well as natural bioevents such as SARS and avian flu pandemics will be an exception and are likely to be followed by PTSD rates approaching those that follow warzone exposure. During bioevents, Amygdala-driven and locus-coeruleus-driven epidemic pseudosomatic symptoms may be an order of magnitude more common than infection-caused cytokine-driven symptoms. Implications for the red cross and FEMA are discussed. It is also argued that hospital phobia as well as dog phobia, bird phobia and bat phobia require re-taxonomization in DSM-V in a new "overconsolidational disorders" category anchored around PTSD. The overconsolidational spectrum category may be conceptualized as straddling the fear circuitry spectrum disorders and the affective spectrum disorders categories, and may be a category for which Pitman's secondary prevention propranolol regimen may be specifically indicated as a "morning after pill" intervention. Predictions are presented regarding obsessive-compulsive disorder (OCD) (e.g., female-pattern hoarding vs. male-pattern hoarding) and "culture-bound" acute anxiety symptoms (taijin-kyofusho, koro, shuk yang, shook yong, suo yang, rok-joo, jinjinia-bemar, karoshi, gwarosa, Voodoo death). Also discussed are insights relevant to pseudoneurological symptoms and to the forthcoming Dissociative-Conversive disorders category in DSM-V, including what the author terms fright-triggered acute pseudo-localized symptoms (i.e., pseudoparalysis, pseudocerebellar imbalance, psychogenic blindness, pseudoseizures, and epidemic sociogenic illness). Speculations based on studies of the human abnormal-spindle-like, microcephaly-associated (ASPM) gene, the microcephaly primary autosomal recessive (MCPH) gene, and the forkhead box p2 (FOXP2) gene are made and incorporated into what is termed "The pre-FOXP2 Hypothesis of Blood-Injection-Injury Phobia." Finally, the author argues for a non-reductionistic fusion of "distal (evolutionary) neurobiology" with clinical "proximal neurobiology," utilizing neurological heuristics. It is noted that the value of re-clustering fear traits based on behavioral ethology, human-phylogenomics-derived endophenotypes and on ontogenomics (gene-environment interactions) can be confirmed or disconfirmed using epidemiological or twin studies and psychiatric genomics.