Psychotherapy for specific phobia in adults
- Randi E McCabe, PhD
Randi E McCabe, PhD
- Associate Professor of Psychiatry & Behavioural Neurosciences
- McMaster University
- Richard Swinson, MD
Richard Swinson, MD
- Professor Emeritus
- McMaster University
Specific phobia is an anxiety disorder characterized by clinically significant fear of a particular object or situation that typically leads to avoidance behavior. Phobic fears include animals, insects, heights, water, enclosed places, driving, flying, seeing blood, getting an injection, and choking or vomiting.
Specific phobias are among the most common mental disorders, and can be highly disabling [1,2]. However, they are also among the most treatable mental disorders [3-6]. Despite availability of efficacious treatments, the majority of individuals with specific phobias are hesitant to seek treatment . This may be due to lack of knowledge that the phobia is treatable, embarrassment to disclose the phobia to a health professional, accommodation of the phobia through avoidance, or fear of increased anxiety or discomfort in the course of treatment .
Psychotherapy for specific phobia in adults is discussed here. The epidemiology, pathogenesis, clinical manifestations, course, and diagnosis of specific phobia in adults are discussed separately. Pharmacotherapy for specific phobia in adults is also discussed separately. Specific phobias and other manifestations of acute anxiety experienced by patients undergoing clinical procedures are also discussed separately. Specific phobia and other fears in children are also discussed separately. (See "Specific phobia in adults: Epidemiology, clinical manifestations, course and diagnosis" and "Pharmacotherapy for specific phobia in adults" and "Overview of fears and phobias in children and adolescents".)
First-line treatment for specific phobia is cognitive-behavioral therapy (CBT) that includes exposure treatment . CBT consists of cognitive and behavioral strategies designed to alter maladaptive thoughts and behaviors that serve to maintain emotional distress. Different types of exposure and different combinations of CBT interventions are used to treat differing presentations of specific phobia .
Pharmacotherapy has a limited role in treatment of specific phobia. Medications are used when CBT is not available or when patients prefer medication to CBT despite the lack of comparably robust supporting evidence from clinical trials. Medications (most commonly benzodiazepines) may also be used when there is insufficient time to treat with CBT (eg, patient with fear of flying presents a week or two prior to anticipated flight) and/or when exposure to the feared stimulus is expected to be a rare occurrence (eg, city-dwelling patient with fear of horses needs to travel to a ranch for a family event). (See "Pharmacotherapy for specific phobia in adults".)
- Kessler RC, Berglund P, Demler O, et al. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 2005; 62:593.
- Stinson FS, Dawson DA, Patricia Chou S, et al. The epidemiology of DSM-IV specific phobia in the USA: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Psychol Med 2007; 37:1047.
- Davis TE 3rd, Ollendick TH, Ost LG. Intensive Treatment of Specific Phobias in Children and Adolescents. Cogn Behav Pract 2009; 16:294.
- Koerner N, Rogojanski J, Antony MM. Specific phobia. In: Cognitive-Behavioral Therapy with Adults: A Guide to Empirically-Informed Assessment and Intervention, Hofmann SG, Reinecke MA (Eds), Cambridge University Press, Cambridge 2010. p.60.
- Wolitzky-Taylor KB, Horowitz JD, Powers MB, Telch MJ. Psychological approaches in the treatment of specific phobias: a meta-analysis. Clin Psychol Rev 2008; 28:1021.
- Zlomke K, Davis TE 3rd. One-session treatment of specific phobias: a detailed description and review of treatment efficacy. Behav Ther 2008; 39:207.
- Regier DA, Narrow WE, Rae DS, et al. The de facto US mental and addictive disorders service system. Epidemiologic catchment area prospective 1-year prevalence rates of disorders and services. Arch Gen Psychiatry 1993; 50:85.
- Barlow DH, Allen LB, Basden SL. Psychological treatments for panic disorders, phobias, and generalized anxiety disorder. In: A Guide to Treatments That Work, 3rd ed., Nathan PE, Gorman JM. (Eds), Oxford University Press, New York 2007. p.351.
- Choy Y, Fyer AJ, Lipsitz JD. Treatment of specific phobia in adults. Clin Psychol Rev 2007; 27:266.
- Moscovitch DA, Antony MM, Swinson RP. Exposure-based treatments for anxiety disorders: Theory and process, Oxford University Press, New York 2009. p.461.
- Antony MM, Swinson RP. Phobic disorders and panic in adults: A guide to assessment and treatment, American Psychological Association, Washington, DC 2000.
- Gilroy LJ, Kirkby KC, Daniels BA, et al. Danger expectancies, self-efficacy and subjective anxiety as mediators of avoidance behaviour in spider phobia. Behav Change 2002; 19:129.
- Garcia-Palacios A, Botella C, Hoffman H, Fabregat S. Comparing acceptance and refusal rates of virtual reality exposure vs. in vivo exposure by patients with specific phobias. Cyberpsychol Behav 2007; 10:722.
- Hellström K, Ost LG. One-session therapist directed exposure vs two forms of manual directed self-exposure in the treatment of spider phobia. Behav Res Ther 1995; 33:959.
- Al-Kubaisy T, Marks IM, Logsdail S, Marks MP. Role of exposure homework in phobia reduction: A controlled study. Behav Ther 1992; 23:599.
- Michaliszyn D, Marchand A, Bouchard S, et al. A randomized, controlled clinical trial of in virtuo and in vivo exposure for spider phobia. Cyberpsychol Behav Soc Netw 2010; 13:689.
- Rothbaum BO. Using virtual reality to help our patients in the real world. Depress Anxiety 2009; 26:209.
- Gorrindo T, Groves JE. Computer simulation and virtual reality in the diagnosis and treatment of psychiatric disorders. Acad Psychiatry 2009; 33:413.
- Boyd D, Wetterneck C, Hart J. Potential utility of full motion flight simulators for treatment of individuals with a fear of flying. Aviat Space Environ Med 2013; 84:264.
- Shiban Y, Pauli P, Mühlberger A. Effect of multiple context exposure on renewal in spider phobia. Behav Res Ther 2013; 51:68.
- Roth A, Fonagy P. What works for whom?, Guilford Press, New York 2009.
- Koch EI, Spates CR, Himle JA. Comparison of behavioral and cognitive-behavioral one-session exposure treatments for small animal phobias. Behav Res Ther 2004; 42:1483.
- Ost LG, Fellenius J, Sterner U. Applied tension, exposure in vivo, and tension-only in the treatment of blood phobia. Behav Res Ther 1991; 29:561.
- Ost LG, Slakovskis P, Hellstrom K. One-session therapist-directed exposure vs. self-exposure in the treatment of spider phobia. Behav Ther 1991; 22:407.
- Ost LG, Brandberg M, Alm T. One versus five sessions of exposure in the treatment of flying phobia. Behav Res Ther 1997; 35:987.
- Menzies RG, Clarke JC. A comparison of in vivo and vicarious exposure in the treatment of childhood water phobia. Behav Res Ther 1993; 31:9.
- Rentz TO, Powers MB, Smits JA, et al. Active-imaginal exposure: examination of a new behavioral treatment for cynophobia (dog phobia). Behav Res Ther 2003; 41:1337.
- Powers MB, Emmelkamp PM. Virtual reality exposure therapy for anxiety disorders: A meta-analysis. J Anxiety Disord 2008; 22:561.
- Maltby N, Kirsch I, Mayers M, Allen GJ. Virtual reality exposure therapy for the treatment of fear of flying: a controlled investigation. J Consult Clin Psychol 2002; 70:1112.
- Marks IM, Kenwright M, McDonough M, et al. Saving clinicians' time by delegating routine aspects of therapy to a computer: a randomized controlled trial in phobia/panic disorder. Psychol Med 2004; 34:9.
- Coldwell SE, Getz T, Milgrom P, et al. CARL: a LabVIEW 3 computer program for conducting exposure therapy for the treatment of dental injection fear. Behav Res Ther 1998; 36:429.
- Olatunji BO, Ciesielski BG, Wolitzky-Taylor KB, et al. Effects of experienced disgust on habituation during repeated exposure to threat-relevant stimuli in blood-injection-injury phobia. Behav Ther 2012; 43:132.
- Newman MG, Erickson T, Przeworski A, Dzus E. Self-help and minimal-contact therapies for anxiety disorders: Is human contact necessary for therapeutic efficacy? J Clin Psychol 2003; 59:251.
- Price M, Anderson P, Rothbaum BO. Virtual reality as treatment for fear of flying: A review of recent research. Int J Behav Consult Ther 2008; 4:340.
- Krijn M, Emmelkamp PM, Olafsson RP, et al. Fear of flying treatment methods: virtual reality exposure vs. cognitive behavioral therapy. Aviat Space Environ Med 2007; 78:121.
- Craske MG. Anxiety disorders: Psychological approaches to theory and treatment, Westwood Press, Boulder, CO 1999.
- Van Gerwen LJ, Spinhoven P, Diekstra RFW, et al. Multicomponent standardized treatment program for fear of flying: Description and effectiveness. Cogn Behav Pract 2002; 9:138.
- Hamm AO. Specific phobias. Psychiatr Clin North Am 2009; 32:577.
- Craske MG, Sipsas A. Animal phobias versus claustrophobias: exteroceptive versus interoceptive cues. Behav Res Ther 1992; 30:569.
- Schmidt NB, Woolaway-Bickel K, Trakowski J, et al. Dismantling cognitive-behavioral treatment for panic disorder: questioning the utility of breathing retraining. J Consult Clin Psychol 2000; 68:417.
- Powers MB, Smits JA, Telch MJ. Disentangling the effects of safety-behavior utilization and safety-behavior availability during exposure-based treatment: a placebo-controlled trial. J Consult Clin Psychol 2004; 72:448.
- Milosevic I, Radomsky AS. Safety behaviour does not necessarily interfere with exposure therapy. Behav Res Ther 2008; 46:1111.
- Ost LG, Sterner U. Applied tension. A specific behavioral method for treatment of blood phobia. Behav Res Ther 1987; 25:25.
- Hellström K, Fellenius J, Ost LG. One versus five sessions of applied tension in the treatment of blood phobia. Behav Res Ther 1996; 34:101.
- Ayala ES, Meuret AE, Ritz T. Treatments for blood-injury-injection phobia: a critical review of current evidence. J Psychiatr Res 2009; 43:1235.
- Abramowitz JS, Deacon BJ, Whiteside SPH. Exposure therapy for anxiety, Guilford Press, New York 2011.
- Bandura A, Blahard EB, Ritter B. Relative efficacy of desensitization and modeling approaches for inducing behavioral, affective, and attitudinal changes. J Pers Soc Psychol 1969; 13:173.
- Egan S. Reduction of anxiety in aquaphobics. Can J Appl Sport Sci 1981; 6:68.
- Wolpe J. Psychotherapy by reciprocal inhibition. Cond Reflex 1968; 3:234.
- Pagoto SL, Kozak AT, Spates CR, Spring B. Systematic desensitization for an older woman with a severe specific phobia: An application of evidenced-based practice. Clin Gerontol 2006; 30:89.
- Doering S, Ohlmeier MC, de Jongh A, et al. Efficacy of a trauma-focused treatment approach for dental phobia: a randomized clinical trial. Eur J Oral Sci 2013; 121:584.
- TREATMENT OVERVIEW
- EXPOSURE THERAPY
- Types of exposure
- - In vivo exposure
- - Imaginal exposure
- - Virtual reality exposure
- - Other
- ADDITIONAL INTERVENTIONS
- Cognitive therapy
- Anxiety management
- Safety behaviors
- Applied tension
- Systematic desensitization
- Eye movement desensitization and reprocessing
- COMPARING CBT AND MEDICATION
- COMBINING CBT AND MEDICATION
- SUMMARY AND RECOMMENDATIONS