What to Know About Fear of Harm (FOH) in Bipolar Disorder

Woman with bipolar disorder with her head in her hands.

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Fear of harm, or FOH, is a syndrome sometimes seen in children with bipolar disorder. This syndrome can cause separation anxiety, obsessions, trouble sleeping, overheating at night, and poorer response to treatment.

FOH is also related to more severe mania and depression, and a more severe and lengthy course of illness in general. Children with bipolar disorder may be especially susceptible to FOH during manic episodes.

Symptoms of Fear of Harm (FOH) in Bipolar Disorder

Fear of harm is not currently listed as a distinct diagnosis in the DSM-5-TR. Instead, it is considered through research to be a “syndrome” related to bipolar disorder, which means that it is a way to describe a certain manifestation of the disorder. In addition, the Juvenile Bipolar Research Foundation has outlined proposed diagnostic criteria for fear of harm in pediatric bipolar disorder.

Below are some of the symptoms of fear of harm in bipolar disorder in children:

  • Separation anxiety: A child with FOH may experience significant anxiety when separated from a parent or caregiver. They may cry, have trouble sleeping, and refuse to go to school or participate in activities away from home.
  • Intrusive thoughts: A child with FOH may have intrusive, unwanted thoughts about harm coming to him or her. These thoughts may be so severe that they interfere with the child’s ability to function.
  • Obsessions: A child with FOH may become fixated on certain objects or ideas and experience significant distress related to these obsessions.
  • Trouble sleeping: A child with FOH may have difficulty falling asleep or staying asleep due to anxiety. They may also wake up frequently during the night and have nightmares.
  • Trouble waking up: A child with FOH may have difficulty waking up in the morning and may seem “foggy” or disoriented when they do wake up.
  • Overheating at night: A child with FOH may perspire excessively at night and have difficulty regulating their body temperature. This can lead to disturbed sleep and fatigue during the day.
  • Poorer response to treatment: Children with FOH may be less responsive to treatments for bipolar disorder, such as medication and therapy. This may be due to the fact that FOH is associated with more severe illness.
  • Feeling threatened: A child with FOH may feel like he or she is in danger, even when there is no apparent threat. As a result, the child may react with anger or fear to seemingly innocuous situations.
  • Self-harm: A child with FOH may engage in self-harming behaviors or make suicide attempts. If your child is experiencing suicidal thoughts or behaviors, it is important to seek immediate medical attention. Call 911 or take your child to the nearest emergency room.

Causes of Fear of Harm (FOH) in Bipolar Disorder

The causes of fear of harm in pediatric bipolar disorder are not fully understood. However, FOH is thought to be related to genetic factors and alterations in brain development and function. Neural pathways that are responsible for fear and anxiety may also be overactive in children with FOH.

Treatment for Fear of Harm (FOH) in Bipolar Disorder

If your child is experiencing symptoms of fear of harm, it is important to seek professional help. There is no specific treatment for fear of harm in bipolar disorder. However, treatment for bipolar disorder, in general, may help to reduce symptoms of FOH. Medication and psychotherapy are the two main treatment options for bipolar disorder.

  • Medication: Medications that may be used to treat fear of harm include antidepressants, anti-anxiety medications, and mood stabilizers. These medications can help to relieve symptoms of anxiety and depression, which may be contributing to FOH.
  • Cognitive behavioral therapy (CBT): Cognitive behavioral therapy (CBT) is a type of therapy that has been shown to be particularly helpful in treating anxiety disorders. CBT can help people to identify and change negative thoughts and beliefs that are contributing to their anxiety. It can also teach people skills for managing anxiety and improving coping.

In addition, new research indicates that ketamine may be a promising new treatment for fear of harm in children.

In a study conducted in 2018 and published in the Journal of Affective Disorders, children with bipolar disorder who were treated with ketamine showed a decrease in symptoms of anxiety and depression, as well as a decrease in fear of harm. However, more research is needed to confirm these findings.

Coping with Fear of Harm (FOH) in Bipolar Disorder

There are a number of things you can do to help your child with bipolar disorder cope with FOH.

  • Encourage your child to express his or her feelings: It is important to encourage your child to express his or her feelings, both positive and negative. This will help your child to feel supported and understood.
  • Encourage your child to be active and social: Staying active and social can help your child to combat symptoms of anxiety and depression. Participating in activities that he or she enjoys can also help to boost self-esteem, which is important for those with bipolar disorder.
  • Make sure your child is getting enough sleep: Getting enough sleep is crucial for managing symptoms of bipolar disorder. Try to establish a regular sleep schedule for your child and make sure that he or she is getting enough rest.
  • Teach your child relaxation techniques: There are a number of relaxation techniques that can help to reduce symptoms of anxiety. Some examples include deep breathing, progressive muscle relaxation, and visualization.

If you are struggling to cope with your child’s FOH, it is important to seek professional help. A mental health professional can provide you with support and guidance.

A Word From Verywell

It can be difficult coping if your child is experiencing fear of harm as part of bipolar disorder. However, there are treatments and coping strategies that can help. If you are struggling to cope, it is important to seek professional help. A mental health professional can provide you with support and guidance.

10 Sources
Verywell Mind uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
  1. Papolos D, Mattis S, Golshan S, Molay F. Fear of harm, a possible phenotype of pediatric bipolar disorder: a dimensional approach to diagnosis for genotyping psychiatric syndromesJ Affect Disord. 2009;118(1-3):28-38. doi:10.1016/j.jad.2009.06.016

  2. Juvenile Bipolar Research Foundation. Treatment Protocol for Fear of Harm.

  3. The Bipolar Child. Fear of Harm: Novel syndrome, novel treatment.

  4. Yee CS, Hawken ER, Baldessarini RJ, Vázquez GH. Maintenance Pharmacological Treatment of Juvenile Bipolar Disorder: Review and Meta-AnalysesInt J Neuropsychopharmacol. 2019;22(8):531-540. doi:10.1093/ijnp/pyz034

  5. Miklowitz DJ, Efthimiou O, Furukawa TA, et al. Adjunctive Psychotherapy for Bipolar Disorder: A Systematic Review and Component Network Meta-analysisJAMA Psychiatry. 2021;78(2):141-150. doi:10.1001/jamapsychiatry.2020.2993

  6. Papolos D, Frei M, Rossignol D, Mattis S, Hernandez-Garcia LC, Teicher MH. Clinical experience using intranasal ketamine in the longitudinal treatment of juvenile bipolar disorder with fear of harm phenotypeJ Affect Disord. 2018;225:545-551. doi:10.1016/j.jad.2017.08.081

  7. Sohal M, Singh P, Dhillon BS, Gill HS. Efficacy of journaling in the management of mental illness: a systematic review and meta-analysisFam Med Community Health. 2022;10(1):e001154. doi:10.1136/fmch-2021-001154

  8. Ironside ML, Johnson SL, Carver CS. Identity in bipolar disorder: Self-worth and achievementJ Pers. 2020;88(1):45-58. doi:10.1111/jopy.12461

  9. Kaplan KA. Sleep and sleep treatments in bipolar disorderCurr Opin Psychol. 2020;34:117-122. doi:10.1016/j.copsyc.2020.02.001

  10. Tarsha MS, Park S, Tortora S. Body-Centered Interventions for Psychopathological Conditions: A ReviewFront Psychol. 2020;10:2907. Published 2020 Jan 24. doi:10.3389/fpsyg.2019.02907

By Arlin Cuncic
Arlin Cuncic, MA, is the author of "Therapy in Focus: What to Expect from CBT for Social Anxiety Disorder" and "7 Weeks to Reduce Anxiety."