Specific Phobias

Overview
Specific Phobia is defined in the DSM 5 as a consistent,“intense or severe”… “marked fear or anxiety” in response to a “specific object or situation” that persists for 6 months or more. The amount of fear experienced is “out of proportion to the actual danger posed by the specific object” and is usually related to the “proximity” to the phobic object or situation and can range in intensity from moderate to intense symptoms of panic. Oftentimes, in fact, the phobic object or situation presents no objective danger whatsoever. Nonetheless, the “fear, anxiety” experienced “causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.”, and consequently is avoided if possible or “endured with intense fear”. To meet criteria it is important that symptoms NOT be the product of another condition such as the type of “fear, anxiety, and avoidance” from “panic-like symptoms (as in agoraphobia), or related to obsessions (as in obsessive-compulsive disorder), “reminders of traumatic events, separation from home or attachment figures or social situations (as in social anxiety disorder).”
Fears
In specific phobia there is many types of objects or situations feared. Examples of the most common include:
  • Animal (e.g., spiders, insects, dogs)
  • Natural environment (e.g., heights, storms, water)
  • Blood-injection-injury (e.g., needles, invasive medical procedures)
  • Fear of blood
  • Fear of injections and transfusions
  • Fear of other medical care fear of injury
  • Situational (airplanes, elevators, enclosed places). The clinical features of this phobia depend on the specific situation, and can be complex. More information on fear of flying and driving phobia can be found on separate pages on this site
  • Fear of choking
  • Fear of vomiting (emetophobia). This phobia, however, is complex, and, in my opinion, could almost deserve to be a separate diagnostic category. There is some data that correlates emetophobia with the contamination subtype of obsessive compulsive disorder. There are also factors of “disgust” ( as can occur with blood or needle phobia) in emetophobia. Onset is typically durning childhood, and oftentimes can persist into or even throughout adulthood. Emetophobics are ferociously avoidant and therefore can be quite resistant to treatment. Emetophobia can be mild or debilitating. Additional information about this “phobia” will be added to this page over time. The treatment methods, I have found useful with emetophobia are similar to those used with obsessive compulsive disorder.

Prevalence

In the United States, the 12-month community prevalence estimate for specific phobia is approximately 7%-9%.

Treatment
Systematic desensitization is an established, effective treatment for phobias. It is important to first gather a thorough history or the person’s anxiety and co-existing conditions. It is also important to “unpack’” the specific components of the phobia which can be unique to the person. A hierarchy of exposure steps with progressive difficulty is created. Often there are irrational beliefs about the situation or object that need to be discovered and reframed. It is important to have a decastrophized path to travel when desensitizing.

For example, a phobia of elevators could be driven by fear of a life- threatening accident; or there could be a fear suffocation in the elevator. The cognitive strategies and even the way exposures are organized would vary depending what exactly what is feared in a given situation. Thorough interviewing is the only way to reveal the specificity of meaning necessary to design a treatment plan tailored to the person’s needs.

If is also important to identify the “safety behaviors” that are leaned on when facing fears. In the world of anxiety treatment, a safety behavior is anything a person does to avoid or minimize fear. I have nothing but respect for the creativity at work in the invention of safety behaviors. These which can take the form of simple, straight ahead avoidance or elaborate mental devices such as calculating the seconds until an elevator door opens, scanning a flight attendant’s expression or the clever hunt for reassurance. Safety behaviors have a stealth quality, as there is an intuitive sympathy for such maneuvers. After all , what is wrong with lessening anxiety ? Nothing, actually. The only problem is that if there is no real threat to seek safety from. That is, nothing needs to be done to keep you safe. But if you behave “as if” there were danger, such as praying in the elevator, then the illusion of danger is reinforced and perpetuated. This is why it is important to identify and then progressively drop safety behaviors when desensitizing or overcoming any fear.

Self-soothing and calming strategies, such as breathing retraining, recalled relaxation and mindfulness training are also components the treatment of phobias. Dialing down “anxious reactivity” increases the tolerance of the distress experienced during exposure. It important to first practice and master these strategies in a non-threatening environment. In basketball you develop your shot and dribble in practice. Once skill is achieved, then you move on to a game situation. Self-soothing is also a skill that must be mastered in order for it to be effective in real time.

Desensitization indeed presents a paradox: it is both exquisitely simple and extraordinarily difficult. It requires a high level of what I call “motivational loading” together with a certain ability to tolerate distress. However, as one progresses up the hierarchy of tasks, a motivational momentum is generated that is paid forward at the next level of challenge. This progression also undermines the foundation of the phobia itself, setting the stage for “sudden gains” in treatment.

Return of fear is well described in the literature. Hence, it is important to maintain what I call “behavioral hygiene” once desensitization has been achieved. Meticulous and well executed cognitive and behavioral goals and methods are more likely to affect global changes, and these are the best defense against relapse. Unlike conditions such as OCD, where extended interval sessions are often necessary to maintain gains, treatment of phobia often ends when goals are met.