INTRODUCTION — 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, and choking or vomiting. Some specific phobias involve responses to medical procedures, such as injections, dental work, or blood. (See "Treatment of specific phobias of clinical procedures in adults".)
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 [7]. 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 [5].
Psychotherapy for specific phobia in adults is discussed here. The epidemiology, pathogenesis, clinical manifestations, course, and diagnosis of specific phobia in adults are reviewed separately. Pharmacotherapy for specific phobia in adults is also reviewed 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 reviewed separately. Social anxiety disorder (previously called social phobia), including the performance-only subtype, is also reviewed separately. (See "Specific phobia in adults: Epidemiology, clinical manifestations, course and diagnosis" and "Pharmacotherapy for specific phobia in adults" and "Acute procedure anxiety in adults: Epidemiology, clinical manifestations, and course" and "Overview of fears and phobias in children and adolescents" and "Approach to treating social anxiety disorder in adults".)
APPROACH TO TREATMENT — Our approach to selecting treatments for specific phobia in adults is reviewed separately. (See "Approach to treating specific phobia in adults".)
COGNITIVE-BEHAVIORAL THERAPY — Cognitive-behavioral therapy (CBT) for specific phobia consists of cognitive and behavioral strategies designed to alter maladaptive thoughts and behaviors that serve to maintain emotional distress. The principal behavioral approach used in the treatment of specific phobia is exposure, which is combined with other CBT components to treat differing presentations of specific phobia [8].
Exposure therapy — Exposure-based strategies involve repeated, systematic confrontation of the feared stimulus to facilitate fear reduction through extinction learning [9] and inhibitory learning [10]. Patients are exposed to feared situations organized in an exposure hierarchy from least to most feared and avoided, based on their ratings of each situation (table 1).
Over the course of treatment, exposure practice progresses up the hierarchy as anxiety reduction occurs at each step. Subjective fear level is measured based on the individual’s self-report, typically on a scale from 0 to 100, where 0 represents “no fear/anxiety at all” and 100 represents “extreme fear/anxiety.” In general, exposure practice on a particular step should be repeated until the fear rating is reduced before moving up to the next step on the hierarchy [11]. Exposures are designed to target avoidance across contexts, challenge anxious predictions, reduce and eliminate safety behaviors, and encourage learning new ways of responding to fear cues [10]. Subjective fear has been found to be a significant predictor of avoidance behavior during exposure [12].
As an example of an exposure hierarchy, a patient with a fear of snakes might begin by saying the word snake, followed by looking at a picture of a snake. A more moderate exposure would be for the patient to stand within three feet of an aquarium holding a live snake. A maximal exposure would be for the patient to hold a live snake. A table shows a 13-step exposure hierarchy developed for a patient with this fear (table 1).
Exposure-based strategies vary by the nature of the exposure (imaginal, in vivo, or virtual) and by the addition of other treatment strategies that are provided in combination with the exposure technique, such as cognitive therapy or anxiety management. (See 'Other cognitive and behavioral interventions' below.)
Types of exposure
In vivo exposure — With in vivo exposure, the clinician assists the individual in confronting the feared stimulus in real world situations (eg, working with a live animal, experiencing an enclosed space, driving a car) in a safe and controlled manner.
In vivo exposure is the most taxing emotionally because it requires the individual to tolerate increased levels of anxiety in the actual feared situation. As a consequence, it may not appeal to some individuals who may refuse the treatment or drop out prematurely. Possible avoidance of treatment may be offset by ensuring that the individual fully understands the rationale for treatment and its high rate of effectiveness, and by having the treatment starting point and pace be set by the individual so that it begins and proceeds at a manageable level.
Although the rates vary based on research methods and samples, the refusal rate for in vivo exposure has been reported to range from 14 to 27 percent [13]. Reported drop-out rates include 0 percent [14], 14 percent [15], and 44 percent [16]. It is likely that the way the rationale for exposure is presented and the quality of the clinician-patient relationship play a role in treatment acceptance and completion.
Imaginal exposure — Imaginal exposure involves mentally confronting the feared stimulus in imagination. It is typically guided by a script or description of the feared scenario that is repeatedly reviewed by the patient in his or her imagination and processed with the clinician in session until fear reduction occurs.
Virtual reality exposure — Virtual reality exposure (VRE, also termed “in virtuo exposure”) enables individuals to experience situations through computer simulation that may be difficult or expensive to produce in a live situation, such as exposure to an airplane for fear of flying [17]. It has been studied as a treatment for phobias of spiders, driving fears, flying, storms, and heights, as well as blood-injection-injury phobia. VRE may be used on its own or as a treatment component prior to conducting in vivo exposure. Patient access to clinicians providing VRE is limited, primarily due to the expense of the technology [18]. A drawback of VRE is that participants may experience nausea (cyber-sickness) following their treatment session [19].
Exposure in a flight simulator has been proposed for treating people with a fear of flying [20]. Flight simulators, used in pilot training, are motion generating platforms that simulate the effects of flight, including turbulence, gravitational force, and sounds of landing gear and flap movements. Patient access to flight simulators is likely to be very limited.
Administration — The duration of exposure treatment for specific phobia varies depending on the severity of the phobia and the length of each treatment session. One-session exposure treatment consists of a single two- to three-hour session of prolonged exposure. Multi-session treatment sessions are typically 60 to 90 minutes in length and the duration of treatment is determined by progress in fear reduction, but typically ranges from five to eight sessions.
Varying the exposure situations during treatment is recommended to enhance the generalizability of fear reduction when an individual encounters the phobic stimulus in a new context. As an example, a trial of 30 patients with spider phobia found that VRE conducted in multiple contexts (eg, different sizes and types of spiders encountered in different places) was better at reducing a form of relapse known as renewal of fear compared with VRE in a single context [21].
Although exposure treatment is typically administered by a trained therapist, computer programs have been used to guide patients through self-administered exposure treatment, with limited evidence of effectiveness in specific phobia [22,23]. A trial found that computer-guided self-administered exposure was associated with a high rate of drop outs among participants [22,24].
Efficacy — Exposure is an effective treatment for specific phobia. Meta-analyses of randomized trials found that exposure-based treatment was effective for reducing symptoms of specific phobia compared with a waitlist control (18 trials, large effect size), placebo treatments (five trials, moderate to large effect size), and active nonexposure interventions (six trials, large effect size) [5]. The response rates to exposure were high, with 70 to 85 percent of patients showing clinically significant improvement [25].
Research suggests that one session of prolonged exposure (three hours) is roughly equivalent in efficacy to five sessions over six hours of gradual exposure for flying phobia [26]. However, a meta-analysis of clinical trials showed that multi-session treatments slightly outperformed single session treatments on measures of phobic dysfunction in specific phobia [5]. Effective exposure treatment of specific phobia of a greater phobic severity (ie, more severe fear and avoidance) has been found to require a greater number of sessions. (See 'Administration' above.)
A 2018 small clinical trial examining the use of virtual reality exposure therapy in 10 patients with dental phobia found that patients receiving VRE had reduced dental anxiety and an increased likelihood of making an appointment to see the dentist compared with patients who were assigned to an informational pamphlet control condition [19]. VRE enabled a virtual participant avatar to interact with a virtual dentist avatar and provided exposure to a number of phobic cues including sitting in the dental chair, inspection of the oral cavity, seeing an injection, and seeing the drill with and without sound. Despite the promising benefits of VRE, a 2019 meta-analysis of four randomized trials (pooled n = 153) comparing VRE with in vivo exposure therapy for specific phobia (flying, heights, and spider phobia) found no advantage of VRE over in vivo exposure, with effect sizes varying across studies [27].
Follow-up — Treatment gains from exposure therapy appear to be maintained for at least one year [28-30]. There is a lack of data on longer-term outcomes. Continued self-exposure on a regular basis is important for maintaining treatment gains [15]. As an example, a person treated for a snake phobia could post a picture of a snake on the fridge to maintain daily self-exposure to snakes. Continued exposure would optimally be almost daily and at a minimum on a weekly basis. Lack of continued exposure to feared situations has been associated with return of fear in longer term follow up [26].
Other CBT components — Several cognitive and behavioral strategies have been used in combination with exposure treatment. The evidence for these multi-modal treatments in specific phobia is limited.
Psychoeducation — Background information to correct misattributions or faulty beliefs regarding the feared stimulus is a key treatment component in combination with exposure. As an example, individuals with animal phobias often hold the belief that the animal wants to hurt or attack them, when in fact the animal is scared of humans and prefers to stay away from them. Numerous self-help workbooks provide a detailed background on the nature of various phobias as well as treatment strategies. These resources can be used by patients in either a self-directed or clinician-assisted exposure treatment [31].
Cognitive therapy — In cognitive therapy, treatment focuses on helping an individual identify maladaptive thoughts and appraisals that trigger and maintain the phobic fear, with the goal of promoting more realistic thoughts and appraisals. As an example, an individual with a specific phobia of elevators may believe that the chances of getting stuck in an elevator are very high (ie, 90 percent likelihood per elevator ride) when in fact the likelihood of getting stuck in an elevator is extremely low. In the individual’s own experience he or she may have had hundreds of elevator rides but only been stuck a small handful of times, if at all. The individual may also believe that if he or she gets stuck he or she will not be able to cope or will not be able to ever get out. Addressing these cognitive distortions through therapy greatly reduces fear levels.
A meta-analysis of five trials of treatment for specific phobia compared exposure treatment alone with exposure treatment plus a cognitive intervention, finding no advantage to the addition of the cognitive component [5]. Considerable heterogeneity was seen in these findings, suggesting more research on this question is needed.
VRE that includes a cognitive component has shown greater benefit compared with VRE alone for treatment of flying phobia [32]. A randomized trial comparing VRE, cognitive therapy, and bibliotherapy in 86 patients with flying phobia found that both the VRE group and VRE plus cognitive therapy group had significantly reduced anxiety compared with the bibliotherapy group [33]. The magnitude of the effect size of improvement seen in the VRE only group was markedly smaller than other trials that examined VRE plus cognitive therapy.
The addition of cognitive interventions may increase the palatability of exposure for patients who may initially refuse exposure treatment alone, but its role in patient acceptance of exposure has not been tested in clinical trials.
The benefit of adding cognitive therapy to in vivo exposure therapy may also depend on the type of phobia [11]. As an example, cognitive therapy was found to enhance the effects of in vivo exposure for claustrophobia [34] but not for animal phobia [28]. These differences may be due to ceiling effects for the effectiveness of the exposure component [35] or to the degree to which cognitive symptoms are a central component of the phobia [36].
A randomized clinical trial examined a 12-session CBT protocol tailored to patients with specific phobia of vomiting. In this study, CBT (including psychoeducation, cognitive therapy, exposure therapy, and safety behavior reduction) was superior to waitlist on specific phobia of vomiting outcome measures with 50 percent of those receiving CBT achieving clinically significant change compared with 16 percent of the waitlist group [37].
Anxiety management — Anxiety management techniques that promote arousal reduction, such as breathing retraining, progressive muscle relaxation and imaginal relaxation are sometimes used in combination with exposure for individuals who present with high levels of distress that interferes with his or her ability to engage in treatment [5].
There is a lack of data comparing exposure with or without anxiety management techniques in specific phobia but data from other anxiety disorders suggest that anxiety management is not an essential treatment component [38]. Anxiety management techniques are not generally considered to be effective treatments when delivered in the absence of exposure treatment [5].
Safety behaviors — Safety behaviors are a series of strategies used by individuals with specific phobia to cope with the phobic stimulus. Safety behaviors include:
●Cognitive distraction
●Thought suppression
●Carrying an item that increases feelings of safety
Clinical trials of the effects of safety behaviors on outcomes of exposure treatment have shown mixed findings. Some trials suggested safety behaviors may hinder therapeutic outcome [39,40], possibly by enabling avoidance of feared outcomes in anxiety-provoking situations. However, other trials have found that safety behaviors may not interfere with treatment outcome and may actually improve willingness to encounter the feared stimulus at a closer distance [41].
The effects of safety behaviors on exposure treatment may be dependent on the type of phobia. Trials of dog phobia and claustrophobia found that safety behaviors reduced treatment efficacy. A trial of spider phobia found safety behaviors to increase treatment efficacy.
OTHER COGNITIVE AND BEHAVIORAL INTERVENTIONS — Applied tension, systematic desensitization, and eye movement desensitization and reprocessing therapy combine exposure with additional components.
Systematic desensitization — A precursor to in vivo exposure, systematic desensitization uses imaginal exposure to a hierarchy of feared scenarios in combination with progressive muscle relaxation that is postulated to inhibit the fear response [42].
Clinical trials suggest that systematic desensitization is more efficacious than a control condition, but less efficacious than in vivo exposure in specific phobia [8,43,44]. Systematic desensitization has largely been supplanted by contemporary exposure therapies [45]. Systematic desensitization provides a treatment option for individuals who refuse in vivo exposure [46]. However, it is recommended that imaginal or virtual exposure be used prior to systematic desensitization as they are simpler and do not require the additional teaching of the relaxation component. In addition, the relaxation component may serve as a safety behavior that inhibits the patient from learning that the anxiety response is not dangerous and can be tolerated.
Applied tension — In applied tension, muscle tensing is performed in combination with in vivo exposure. This combination is effective for blood-injection-injury phobia, and other phobias that involve fainting. Patients are trained to use muscle tension to increase their blood pressure and counteract the vasovagal fainting response [47-49]. The efficacy and administration of applied tension for blood-injection-injury phobia are described separately. (See "Treatment of specific phobias of clinical procedures in adults", section on 'Applied tension'.)
Eye movement desensitization and reprocessing — Eye movement desensitization and reprocessing (EMDR) is a psychotherapeutic approach initially developed to treat posttraumatic stress disorder. EMDR is a variation of exposure that incorporates exposure to traumatic memories with simultaneous focus on external stimuli such as therapist-directed bilateral eye movements, hand-tapping, or audio stimulation. A trial comparing EMDR with a waitlist control condition in 31 patients with dental phobia found that EMDR focused on processing traumatic dental memories reduced dental anxiety and avoidance behavior compared with the control group after one year [50]. Additional research is needed to confirm these findings and to determine whether EMDR offers incremental benefit over imaginal or in vivo exposure.
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Anxiety and anxiety disorders in adults".)
SUMMARY
●Our approach to selecting treatments for specific phobia in adults is reviewed separately. (See "Approach to treating specific phobia in adults".)
●Exposure-based strategies involve repeated, systematic confrontation of the feared stimulus to facilitate fear reduction through extinction learning. Types of exposure include in vivo (the stimulus is encountered directly in real life under safe and controlled circumstances), imaginal (the stimulus is encountered in the imagination), and facilitated with virtual reality. (See 'Exposure therapy' above.)
●Exposure treatment can be provided in one prolonged two- to three-hour session or in several 90-minute sessions. (See 'Administration' above.)
●Exposure can be combined with other cognitive or behavioral approaches, including psychoeducation, cognitive therapy, anxiety management, and training in use of safety behaviors. Cognitive approaches help the patient to identify maladaptive thoughts and appraisals that trigger and maintain the phobic fear, with the goal of promoting more realistic thoughts and appraisals. (See 'Other cognitive and behavioral interventions' above.)
