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 CONTRIBUTORS
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.
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. Etiology
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 PATIENT CARE 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 Key: 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 Assessment
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 PATIENT CARE 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- PATIENT CARE 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: Workbook. 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 PATIENT CARE 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. Referral
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- REFERENCES
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