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 and 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” caused by “panic-like symptoms (as in agoraphobia), or those 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).”

Phobias are generously spread across situations and themes. Some of the most common:

The 12-month prevalence estimate, in the US, is approximately 7%-9%.

I treat phobias using a combination of graded exposures, systematic desensitization, Inference-based Cognitive Behavioral Therapy (I-CBT), emotional regulation strategies, that include selected principles from adapted from the Theory of Constructed Emotion, developed by Harvard Neuroscientist, Lisa Feldman-Barrett.

As a result of the prolonged COVID-19 Pandemic, remote, teletherapy has become the preferred behavioral health outpatient treatment modality. This has represented an obstacle of in-vivo, live exposure therapy. As a result, in April of 2022, I began to use Virtual Reality technology to treat phobias. Chance often gives birth to innovation, and this has certainly been the case with the use of VR in the treatment of phobias and other types of anxiety conditions

Regardless of the modality,It is also important to “unpack’” the specific components of the phobia, that are unique to the person.This then becomes the basis of the progressive hierarchy of exposure steps to be 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, reality-based 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 of 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.

Virtual reality (VR) for the treatment of phobias.

A key component of anxiety treatment is identifying and eliminating “safety behaviors”. In the treatment of anxiety, 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 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 from a loved one.

Safety behaviors have a stealth quality, as they seem so intuitive on the surface. After all, what is wrong with lessening anxiety ? Doesn't it make sense to do something to feel better? Paradoxically, it is this "natural" impulse to "protect" and relieve anxiety that makes these responses insidious obstacles to change. The problem with safety behaviors is that if there is no real threat (just one that that is imagined) then nothing needs to be done to keep you "safe". But if you behave “as if” there were danger- praying that you don't suffocate in an elevator- then the illusion of danger is made real, reinforced and perpetuated. This is why it is important to identify and then progressively drop safety behaviors when overcoming all phobic or obsessional fears.

The choice of safety behavior often lines up with the individual's personal narrative and with the specific fear and context in question. Nonetheless, many are universal in nature and not situation-specific. A short list of common safety behaviors would include:

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.