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Help for your patients
who suffer from specific
Unlike other anxiety
disorders, specific phobias
Specific phobias are the most prevalent and primordial of anx-
iety disorders. Long lists of phobias with myriad Greek rootsare often cited in consumer press articles on anxiety, but
generally do not respond
these terms are of little use to clinicians. The research and clinical
literature, as well as the Diagnostic and Statistical Manual of Mental
well to medication. Here Disorders, Fourth Edition, Text Revision (DSM-IV-TR),
suggest a much
is how primary care
more limited constellation of phobias.1
physicians can help their
Specific phobias are characterized by marked, persistent, and un-
reasonable anxiety or panic when a person is faced with specific situ-
phobic patients find relief
ations or objects (eg, flying, heights, animals, receiving an injection,
from their paralyzing fears.
seeing blood). Escape and avoidance are common. Individual specif-
ic phobias are highly comorbid with other anxiety disorders. TheDSM-IV-TR “clinical significance” criterion may be especially import-ant when you are diagnosing a specific phobia, since many phobiasare present for a lifetime without significant disruption of everyday
Article at a glance
life.2 When individuals with specific phobias do present for treatment,
it is usually because their education, health care, employment, rela-
tionships, or mobility is significantly disrupted by fearful avoidance.
sonable anxiety or panic whenfaced with specific situations orobjects.
Prevalence and course
Prevalence of a current specific phobia ranges over the life span from
10% of children in primary care to 8.9% in an urban, multiracial sam-
ple of people older than 55.3,4 Lifetime prevalence is 12.5%.5 Specific
phobia is twice as common in women than in men; women are more
prone to animal phobias, but men are more likely to fear heights.6
Three out of 4 people with a specific phobia have more than one, and
the “number of fears, independent of type, powerfully predicted
impairment, co-morbidity, illness course, demographic features, and
phobias is graduated exposure tothe phobic stimulus leading to
STEVEN L. SHEARER, PhD,
is Coordinator of Behavioral Science
Training, Family Medicine Residency Training Program, Franklin
Square Hospital Center, Baltimore, Md; and a founding partner of
the Anxiety and Stress Disorders Institute of Maryland,
assessment is unclear or self-conducted treatment proves
MICHAEL X. DWYER, MD,
is on the faculty, Family Medicine
Residency Training Program, Franklin Square Hospital Center,Baltimore, Md.
NEUROLOGY & PSYCHIATRY
most people who have specificphobias do not present for treat-ment. Those who do are more like-ly to fear commonly encounteredsituations (pets, elevators, trans-portation), to have multiple pho-bias, and to experience panicattacks in the context of their pho-bias. Untreated individuals aremore likely to have a single pho-bia, especially of the blood-injury-injection type, and are unlikely toexperience panic attacks.7
variability in their impact on mo-bility and quality of life. Someonewith a snake phobia may be able toarrange daily life to preclude virtually all potential
46% for situational phobias, 47% for animal pho-
exposures. In contrast, severe phobias related to
bias, and 59% for blood-injury-injection phobias.11
heights, transportation, pets, or insects may signifi-
Twin studies are compatible with genetic models,
cantly hamper mobility and social or employment
which postulate that the vulnerability to phobias is
possibilities. Dental phobia or blood-injury-injec-
largely innate and does not arise directly from envi-
tion phobia may lead to avoidance of needed health
ronmental experiences.12 From this viewpoint, pho-
care with its attendant complications. Poor diabetic
bias reflect genetically determined exaggerated fear
control has been reported among diabetics with
and/or disgust responses to evolutionary, survival-
relevant cues or a genetic deficiency in adaptation tosuch cues.
Differences in temperament (eg, neuroticism,
Understanding of phobias has traditionally been
introversion, behavioral inhibition, anxiety sensitiv-
based on fear-conditioning models. From this van-
ity) have been linked with vulnerability to fear con-
tage, a phobia develops when a person, consciously
ditioning. Identified brain substrates may underlie
or not, associates marked anxiety or panic with a
such individual differences; for example, thickness
specific trigger.9 Less often, phobias may be ac-
of the ventromedial prefrontal cortex may explain
quired vicariously by observation of the fearful be-
individual differences in fear modulation.13 Carriers
havior of others or by very salient misinformation
of the short allele of the serotonin transporter show
stronger amygdala reactivity both to frightening
All components of the fear-conditioning process
stimuli and to stressful, uncertain stimuli.14
in humans demonstrate moderate heritability (35%
Although the traditional stress-diathesis model
IMAGE: SINDI PRICE to 45%).10 Reported heritability estimates include
usually does not apply to specific phobias, it has
NEUROLOGY & PSYCHIATRY
tions, and, preferably, long-term follow-
up. Assessment of fear during exposure is
Phobias seen in primary care that often
are not specific phobias
distress (SUDS) from 0 (no distress) to100 (maximum distress). The SUDS con-
If the presentation is . . .
cept is useful for self-conducted exposure
bia, the primary care physician shouldclarify the course, distress, avoidance, and
should focus on 2 points:• Whether the symptoms and course are
anxiety disorders with different treatment
sure is indicated, either through patienteducation and self-conducted exposure
that apparent “phobias” seen in primary
care are often not specific phobias per se
and may have quite different implications
ADD, attention deficit disorder; OCD, obsessive-compulsive disorder; PTSD,
for treatment (see Table 1). For example,
a patient who has panic attacks only inresponse to a single specific phobic stim-
been reported that difficult-to-control childhood
ulus that is perceived as dangerous may well have a
experiences (such as chronic parental violence) can
specific phobia. Panic attacks in response to bodily
influence specific phobia onset.15 In summary, the
arousal that is perceived as dangerous and oc-
etiology of specific phobias is likely to be multifac-
curring in multiple situations suggest the diagnosis
torial with variation across phobia types and indi-
of panic disorder. In this case, a selective serotonin
reuptake inhibitor (SSRI) and/or cognitive behav-ioral treatment (CBT) that emphasizes interoceptive
exposure to bodily arousal is indicated. (Intero-
In addition to the Fear Survey Schedule, which is
ceptive exposure involves using other means to re-
available for screening, many other questionnaires
create the feared bodily sensations that occur in the
focus on particular specific phobias (eg, heights,
phobic situation—exercise for tachycardia, hyper-
claustrophobia, spiders, snakes, dental or medical
ventilation for lightheadedness, bodily spinning for
procedures).16 However, none of these is likely to be
Similarly, panic attacks in response to intrusive
Outcome studies assess the actual behavioral ap-
thought content (“What if I lose control of myself
proach to the phobic stimulus in analogue situations
and drive my car off the bridge?”) may indicate ob-
(eg, video, pictures, virtual reality), real world situa-
sessive-compulsive disorder rather than a specific
NEUROLOGY & PSYCHIATRY
phobia of bridges or heights. Depending on thephobic content, (eg, fear of the dark, assault, or dri-
ving), screen for a trauma history that could be rel-
Cognitive behavioral treatment
The hallmark of CBT for specific phobias is gradu-ated exposure to the feared situation or object.
Graduated exposure may be imaginal or in vivo,
acceptance of distress without escape or distraction
self-conducted or specialist-directed, via actual or
in order to facilitate extinction. The emphasis in
virtual reality cues, and/or interoceptive. Typically,
CBT has shifted to encouraging willingness to seek
willingness to confront a hierarchy from lesser to
and accept anxiety rather than to control it through
greater fear-arousing situations leads to gradual
conscious effort or relaxation techniques.
habituation and, often, extinction of the fear re-
Both functional MRI and positron emission to-
sponse. Animal research suggests that extinction is
mography studies suggest that exposure-based CBT
not the erasure of fear-conditioned memories but
modifies the dysfunctional neural circuitry that
rather the formation of new, competing memories
underpins specific phobias.24,25 CBT has yielded
that dampen or eliminate the fear response.17
changes in brain areas associated with both auto-
Recent reviews have documented the effectiveness
matic processing (amygdala) and evaluatory pro-
of CBT for specific phobias in both children and
cessing of fear stimuli (insula and anterior cingulate
adults.18,19 For example, 14 controlled studies of in
vivo exposure for specific phobias have consistently
demonstrated benefit. Indeed, in vivo exposure re-
sults in good treatment outcome for most types of
specific phobias if it is sustained until a brief period of
• Deliberate distraction or substance use during
Although in vivo exposure is the standard, a large
study of dog phobics suggested that imaginal expo-
• Sporadic rather than repetitive exposure.
sure was equally effective.20 Two studies suggested no
Relapse after successful treatment is likely if inter-
difference between in vivo and virtual reality expo-
mittent self-conducted exposure is abandoned.
sure, but the latter may be helpful for phobias inwhich repetitive in vivo exposure is difficult (eg, fly-
Blood-injury-injection phobia: A special case
ing).19 Outcomes may be comparable whether ex-
In contrast to the bodily arousal (eg, tachycardia) ob-
posure treatment is self- or specialist-conducted.21
served in response to most phobic stimuli, exposure
Self-help approaches yield greater benefit for specific
to blood-injury-injection cues provokes the opposite
phobias than for other anxiety disorders (see “Treat-
bodily response: Initial hyperarousal (perhaps cou-
ment resources for specific phobias,” page 24).22,23
pled with disgust), followed moments later by abrupt
Facing one’s distress may be less daunting with
bradycardia and hypotension. This response is prob-
preparatory cognitive therapy that addresses distort-
ably the remnant of evolutionary adaptation compa-
ed risk assessments, anxiety-escalating self-talk, feel-
rable to the reflexive immobility of a rabbit caught in
ings of being overwhelmed, and the demoralization
the jaws of a fox (in which the absence of movement
that accompanies chronic avoidance. Anxiety man-
and stanched blood flow promote survival). If the
agement skills (eg, diaphragmatic breathing, staying
vasovagal response is marked, syncope can result and
in the moment, observing fluctuations in anxiety,
may contribute to subsequent phobic conditioning.
letting go of the need to control anxiety) encourage
Exposure treatment is also utilized for blood-
NEUROLOGY & PSYCHIATRY
Treatment resources for specific phobias
self-talk that notices and ac-cepts anxious thoughts and
Self-directed or parent-directed exposure treatment
Antony MM, Craske MG, Barlow DH. Mastering Your Fears and Phobias:
2nd ed. New York, NY: Oxford University Press; 2006.
Antony MM, McCabe RE. Overcoming Animal and Insect Phobias.
Antony MM, Watling M. Overcoming Medical Phobias.
Oakland, CA: New
Bourne EJ. Overcoming Specific Phobia: A Hierarchy and Exposure-
Based Protocol for the Treatment of All Specific Phobias (Client Manual).
Oakland, CA: New Harbinger; 1998.
Anxiety Disorders Association of America: http://www.ADAA.org
Association for Behavioral and Cognitive Therapies: http://www.aabt.org
State Psychological Associations: http://www.apa.org/practice/refer.html
macologic treatment rarelyhas a place in the treatmentof specific phobias. Benzo-
injury-injection phobias, often beginning with ver-
diazepines may detract from exposure and inhibit
bal descriptions or pictures, but progressing to di-
extinction.31 However, pragmatism is the rule (eg,
rect exposure to the relevant cues (eg, donating
“But doctor, I have a flight next week.”) Some pho-
blood). The unique bodily response in these pho-
bic individuals will not consider initial exposure
bias requires special adaptation. Patients are in-
without feeling bolstered by preemptive use of a
structed to increase muscle tension or to stimulate
benzodiazepine. However, habituation and extinc-
memories of angry feelings that can counter the
tion are context-dependent; that is, patients who
bradycardia and hypotension that occur during ex-
attribute their success to medication are less likely to
posure.28 When making a referral for CBT, primary
experience durable extinction of the phobia.
care physicians should confirm that the therapist
SSRIs and other antidepressants have demonstrat-
understands this disorder and how it is usually
ed anxiolytic effects for all the other anxiety disorders
but are not an established treatment for specific pho-bias. A single, small, double-blinded, placebo-con-
Special considerations for children
trolled study reported the effectiveness of a 4-week
Most children have normal, transient fears (dark-
trial of paroxetine, 20 mg/d, for specific phobia.32
ness, intruders, water) that do not lead to the persis-
However, in the 7 years since publication, no repli-
tent avoidance and distress that characterize pho-
cations or supporting data have appeared.
bias. However, onset of most specific phobias does
A new approach that seeks to augment exposure
occur during childhood. In one study, 17.6% of
treatment has received preliminary support.33 Both
children met the criteria for a specific phobia.29
animal and human studies report that acute admin-
The efficacy of graduated exposure treatment for
istration of D-cycloserine shortly before exposure
childhood phobias is well established, sometimes
can enhance the new learning that is necessary for
with a single session of exposure treatment.18,30 Treat-
extinction. Two placebo-controlled studies have
ment may require specialist-directed exposure or, in
reported the efficacy of D-cycloserine, 50 mg, in
some cases, facilitation by a supportive and well-
augmenting exposure treatment for fear of heights
informed parent. Modeling of gradual approach
and for social anxiety disorder.34,35 However, other
NEUROLOGY & PSYCHIATRY
recent human studies raise questions about the ef-
ioral specialist. Referral may be indicated when the
fectiveness and durability of D-cycloserine augmen-
initial assessment is unclear or when self-conducted
tation.36,37 Despite these intriguing findings, no clin-
treatment for a phobia is insufficient.
ical protocols for use of D-cycloserine have beenpublished.
This article was contributed by Drs Shearer andDwyer and edited by Peter D’Epiro, PhD.
Drs Shearer and Dwyer disclose that they have no
Primary care physicians should consider referring
financial relationship with any manufacturer in this
certain phobic patients to a skilled cognitive behav-
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➤ Click-through links to the Internet
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NEUROLOGY & PSYCHIATRY
Roll of Successful Examinees in the C.P.A. LICENSURE EXAMINATION Held on MAY 16, 2010 & FF. DAYS Page: 2 of 39 Released on MAY 25, 2010 Seq. No. N a m e 1 ABAD, MICHELLE RAMIREZ 2 ABAD, MYRLA MELCHOR 3 ABAD, SHEE ANN PORRAS 4 ABAD, VERNIEDECK BUTIHEN 5 ABALDE, SHELDON BARANGAY 6 ABALOS, JACQUELINE BAUTISTA 7 ABANGAN, ROSE MARIE LOBO 8 ABAPO, LEA MARIE BEBING 9 ABARCA, MICHELLE BISNAR 10 ABARQ
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