Guidance on the Possible Inclusion of Fear of Harm Disorder into DSM-5 and Psychiatric Practice

October, 2021

Martin Teicher, Harvard Medical School
Demitri Papolos
, Albert Einstein College of Medicine

There is a substantial group of aggressive youths who frequently fail to benefit from treatment and have a particularly poor prognosis. Papolos and colleagues identified a potentially unique syndrome, termed Fear of Harm (FOH), that includes many of these individuals. Key features of this syndrome include a characteristic problem in thermoregulation and heat dissipation and the emergence in childhood of recurrent horrific nightmares with themes of pursuit and abandonment. This leads to a sequence of fear based defensive behaviors that include obsessive bedtime rituals, fear of the dark, separation anxiety, contamination fears, hypervigilance, misperception of neutral stimuli as threatening, reactive aggression, and an inability to attend school and sustain friendships. Children with this syndrome typically receive multiple psychiatric diagnoses and are frequently hospitalized. The one treatment that appears efficacious is off label use of intranasal ketamine, though only a handful of clinicians are aware of this and are comfortable prescribing it. Our overriding aim is to improve the lives of these children and their families by convening a panel of experts to identify the strength of the available science and to help determine whether this is a unique diagnostic disorder or a subtype of an existing disorder. Further, we seek to create a framework to incorporate this into DSM and ICD to increase awareness, foster appropriate training, and stimulate research into alternative methods for treating this disorder or preempting its development, and to help children with FOH engage in school and social settings as well as academic and vocational programs.