October 30, 2016

Halloween is Ripe for ICD-10 Coding Phobias, Except Fear of Clowns

Since August, scary clown activities and sightings started to escalate in the United States, and they have spread internationally. In response, McDonald’s announced that it was giving its clown mascot, Ronald McDonald, a break, and Target took some clown masks and costumes off the market.

Some of these sightings have turned out to be hoaxes or pranks. This suggests that a hysteric crowd component may have crept into this phenomenon.

At its extreme, fear of clowns can become a fear not based on reality, making it a phobia called coulrophobia. Though not in ICD-10, it can be diagnosed as a specific phobia in our psychiatric DSM-5.

There are, however, 23 codes for phobias in the ICD-10-CM guidelines for the 2017 fiscal year, according to Laurie Johnson with Panacea Healthcare Solutions.  Phobias are found in category F40 and include agoraphobia, social phobias, specific phobias (such as fear of animals, blood/injections, claustrophobia, bridges, flying, or medical care), other specified phobias, other phobic anxiety disorders, and phobic anxiety disorder, unspecified. 

Although fears of clowns have existed in many countries over history, clowns also have a reputation for being positive, humorous, and comforting. Children, though they can be easily scared by clowns, have enjoyed them in circuses. In hospitals, the presence of a therapy clown has reduced pre-operative anxiety in children, and those with respiratory illnesses got better faster.

For adults, the clowns of the hit shows put on by Cirque du Soleil have enchanted families for years. Humanitarian clowns, over a hundred of them, including my colleague and friend, Carl Hammerschlag, have gone to Peru annually to provide clown therapy, even addressing suicidal ideation in the streets of a community where there are no mental healthcare professionals. Carl has noted that “the clown as a fool, jester, or trickster is a universal character in the human unconscious mind, who . . . has served the purpose of lightening the mood, defusing anxiety, and making public our secrets.”

Humor in any form can have healing aspects, including for the stress and burnout of working in our field. 

Clowns can also convey other emotions. They can be poignant, awkward, and loveable, yet clever, as was Charlie Chaplin in his movies.

Whether clowns are entertaining or even therapeutic versus being scary and harmful depends on their features and actions. They generally interact with us nonverbally, a way of communicating we often ignore, via exaggerated gestures and makeup that still reminds us of ourselves. A bit of clown-produced anxiety can actually make one feel relieved, and reassured once it is over.

So, why might we be more concerned about the scary ones at this time? This Halloween is close to our presidential election, and the increasingly contentious nature of the race seems to be unsettling the country, eliciting hate, anger, and threats. Such primitive, aggressive emotions may also be disguised and expressed by clowns.

On Halloween itself, we are sure to see many wearing masks of both candidates. What I will be wearing is not my clown suit or candidate masks, but a T-shirt exclaiming “Make America Sane Again.” This is what we really need to do to make “America great again.”

Of course, whether the election results will prove to be a trick or treat depends on whom you are for, what the next president actually does, and whether there will be some healing after all the animosity. There should be no clowning around as we try to make things right.

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