Specific Phobia

Background

• Specific phobia is an anxiety disorder characterized by an intense fear of a specific situation or object accompanied by clinically significant distress or impairment due to the fear or associated avoidant behaviors.
• Types of specific phobias include animal phobias (such as spiders, snakes, insects, or dogs), blood-injection-injury phobias, situational phobias (such as of airplanes, elevators, or enclosed places), and other phobias (such as loud noises or costumed characters).
• Onset typically occurs in childhood or early adolescence, with age 8 years reported as median age of onset.
• Estimated lifetime prevalence of specific phobias is 7.2% in adults (ranging from 3% to 15% worldwide). Estimated prevalence in children and adolescents varies widely based on use of self-report or parental report, from 1.3% to 27.3%.
• Up to one-third of specific phobias reported to persist at 10- to 12-year follow-up.
• Specific phobias are strongly associated with other anxiety disorders, mood disorders, and substance use disorders.

Evaluation

• Diagnosis is based on Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-5) criteria:
  • marked fear or anxiety about a specific object or situation
  • phobic object or situation almost always provokes immediate fear or anxiety
  • phobic object or situation is actively avoided or endured with intense fear or anxiety
  • fear or anxiety is out of proportion to actual danger posed, within sociocultural context
  • fear, anxiety, and/or avoidance cause clinically significant distress or impairment in social, occupational, or other important areas of function
  • duration ≥ 6 months
  • disturbance is not better explained by symptoms of another mental disorder, such as
    • avoidance of situations associated with panic-like or other incapacitating symptoms (as in agoraphobia)
    • objects or situations related to obsessions (as in obsessive-compulsive disorder)
    • reminders of traumatic events (as in posttraumatic stress disorder)
    • social situation (as in social anxiety disorder)
    • separation from home or attachment figures (as in separation anxiety disorder)
• Provide thorough, multi-method evaluation, assessing cognitive and behavioral aspects of phobic response. Assessment may include semi-structured clinical diagnostic interview (such as Anxiety and Related Disorders Interview Schedule), additional questionnaires, and behavioral observation.

Management

• Exposure therapies are the first-line treatment for specific phobia.
  • In vivo and virtual exposure therapies appear effective in treatment of specific phobia.
  • Exposure therapy appears to remain effective at > 6 months after treatment for animal phobias, height phobias, and claustrophobia.
• Cognitive therapy that focuses on threat predictions and defensive behaviors to develop memories of safety without exposure element may reduce fear in adults with fear of heights.
• The role of medications is limited but may provide symptomatic relief:
  • Consider benzodiazepines to allow patient to cope during exposure to feared situation or object, but benzodiazepines do not appear to cure irrational fear.
  • Pharmacological augmentation of exposure therapy with D-cycloserine does not appear to improve treatment response in patients with phobia.