Continuing Education Activity

Patients with specific phobias experience anxiety and panic attacks along with unreasonable fear of exposure or anticipated exposure to a feared stimulus. According to some theories, specific phobias may develop due to an association of an object or situation with emotions such as fear and panic. This activity describes the evaluation and management of specific phobias and reviews the role of the interprofessional team in improving care for patients with this disorder.

Objectives:

• Explain when a specific phobia should be considered on differential diagnosis.
• Review the criteria used to diagnose specific phobias.
• Describe the considerations that influence the management of specific phobias.
• Review the importance of communication and cooperation among members of the interprofessional team in providing behavioral therapy as a first line treatment for patients with specific phobias.

Introduction

Patients with a specific phobia experience high levels of anxiety along with excessive and unreasonable fear due to either exposure to a phobic stimulus, the anticipation of exposure to a phobic stimulus, and even speaking about the feared stimulus. As a result, these patients will try to avoid the anxiety-provoking stimulus to any extent possible. Many patients have a strong family history of specific phobia. However, more studies need to be conducted to rule out the nongenetic transmission of specific phobias. [1][2][3]There is a high familial tendency in the blood injection injury type of phobia. Specific phobias can be categorized into the following subcategories: 

• Animals (spiders, insects, dogs)
• Natural environment type (heights, storms, water)
• Blood injection injury type (needles, invasive medical procedures)
• Situational type (airplanes, elevators, enclosed spaces)
• Other types of phobias that do not fit into the previous 4 categories

Etiology

The exact etiology of specific phobias is not known. However, some theories suggest that specific phobia may also develop due to an association of a specific object or situation with emotions such as fear and panic. Two theories have been proposed to show this pairing. The most common theory--classical conditioning model--postulates that a phobia precipitates when an event that provokes fear or anxiety is paired with a neutral event. An example of this would be in which a specific event such as driving is paired with an emotional experience such as an accident. As a result, the person is susceptible to a chronic emotional association between driving and anxiety. Although a person may not experience a panic attack or meet the criteria for a panic disorder, they may develop a fear that is expressed as having a specific phobia. Another mechanism of association is through modeling, in which a person observes a reaction in another person and internalizes that other person’s fears or warnings about the dangers of a specific object or situation.[4][5][6][7]

Epidemiology

Specific phobia affects about 5% to 10% of the US population. A bimodal distribution of onset can be seen with specific phobias. Animal phobia, natural environment phobia, and blood injection injury type of phobia tend to have a childhood peak, whereas, there is an early adulthood peak for situational phobia.

History and Physical

There is marked fear or anxiety regarding a specific object or situation, often including the following features:

• The specific object or situation almost always provokes immediate fear or anxiety
• Children may express the fear or anxiety by crying, tantrums, freezing, or by clinging
• The phobic object or situation is actively and persistently avoided for 6 months or more
• The fear or anxiety experienced is out of proportion to the actual danger posed by the specific object or situation
• Notable, clinical distress or impairment in social, occupational, or other important areas of functioning is evident
• The symptoms cannot be explained by another psychiatric disorder such as obsessive-compulsive disorder (OCD), post-traumatic stress disorder (PTSD), separation anxiety disorder, or social anxiety disorder

Evaluation

Evaluation is usually limited to a detailed psychiatric assessment along with an elaborate psychosocial history to determine the chronicity of the symptomatology.

Treatment / Management

One of the most effective treatment modalities to mitigate specific phobias is behavioral therapy. Behavioral therapy includes implementing the principles of operant conditioning and extinction learning via systematic desensitization and flooding. In methodical desensitization, the patient is exposed to a list of stimuli ranking from the least to the most anxiety-provoking. With this method, patients are taught various techniques to deal with anxiety such as relaxation, breathing control, and alternative cognitive approaches. The cognitive-behavioral approach includes reinforcing the realization that the phobic stimulus is safe. As the patient masters these techniques, they are taught to use them in the face of anxiety-provoking stimuli and induce relaxation. As the patients become desensitized to each stimulus on the scale, they keep moving up until the most anxiety-provoking stimuli no longer elicit any fear or anxiety.[8][9][10][11] Flooding, also known as implosion, is another behavioral technique that can be used to treat specific phobias. This technique involves increasing exposure to the stimulus to induce habituation and decrease anxiety. To be successful, behavioral therapy requires that patient be committed to the treatment, there are distinctly identified problems and objectives, and there are alternative strategies for dealing with the patient’s feelings.

Patients with a blood injection injury phobia are advised to tense their bodies and remain seated during the exposure to avoid the possibility of fainting from a vasovagal reaction. Also, beta-blockers and benzodiazepines can be used in patients when the phobia is associated with panic attacks. 

Other forms of treatment that may also be considered include virtual therapy in which the patient is exposed to or interacts with the phobic stimulus on a computer screen. This field of treatment is relatively novel and requires more research. Other treatment modalities include hypnosis, supportive therapy, and family therapy. The goal of all forms of therapy is to help the patient recognize that the feared stimulus is not dangerous and to provide emotional support.

Differential Diagnosis

• Medical conditions that can result in the development of a phobia include substance use particularly hallucinogens and sympathomimetics, central nervous system (CNS) tumors, and cerebrovascular diseases. However, in these conditions, phobic symptoms are unlikely in the absence of additional findings on physical, neurological, and mental status examinations.
• Schizophrenic patients may also present with phobic symptoms. However,  patients with a phobia have intact insight into their irrational fears and lack psychotic symptoms associated with schizophrenia.
• It is also important to rule out panic disorder, agoraphobia, and avoidant personality disorder. It can be difficult to distinguish specific phobia from panic disorder, agoraphobia, and avoidant personality disorder. However, in specific phobias, these patients tend to experience anxiety or fear immediately upon exposure to the phobic stimulus. In addition, patients with specific phobia do not exhibit signs of fear or anxiety when they are not facing or anticipating the phobic stimulus.
• It is important to rule out other conditions such as hypochondriasis, obsessive-compulsive disorder, and paranoid personality disorder. There is a subtle difference between hypochondriasis and specific phobia. For example, patients with hypochondriasis fear having the disease, and patients with specific phobia fear contracting the disease. The same holds true for the difference between obsessive-compulsive disorder and specific phobia. For example, patients with OCD may avoid knives because they have compulsive thoughts of harming their children; whereas, patients with a specific phobia may avoid knives because they fear cutting themselves. Patients with paranoid personality disorder have generalized fear, which is not found in patients with specific phobia.

Prognosis

When left untreated, phobias can be lifelong, however, studies show that phobias tend to spontaneously attenuate over time. With the appropriate behavioral techniques and medications, the prognosis is good.

Complications

Left untreated, specific phobias can significantly impair functioning. If a patient is unable to engage in normative social dynamics due to debilitating anxiety, the patient may end up isolated away from society. 

Deterrence and Patient Education

Patients are advised to see a psychiatrist when symptoms are affecting their daily activities and quality of life. With proper behavioral therapy, patients can retrain their association cortices to mitigate the conditioned fear response.

Pearls and Other Issues

The most common signs/symptoms that can be seen in specific phobia are:

• Feeling nauseous, dizzy, or fainting
• Difficulty breathing, chest tightness, or fast heartbeat
• The fear or anxiety out of proportion to the real danger posed by the specific object or situation

Common modalities of treatment include:

• Systematic desensitization
• Flooding
• Medications such as beta-blockers and benzodiazepines

The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.

The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other relevant areas of functioning.

Enhancing Healthcare Team Outcomes

The management of phobias is usually with an interprofessional team that includes a mental health nurse, psychiatrist, psychotherapist, and primary care provider. In most cases, behavior therapy is the first-line treatment and does work. However, the period of desensitization can take weeks or even months.

To be successful, behavioral therapy requires that the patient be committed to the treatment, there are distinctly identified problems and objectives, and there are alternative strategies for dealing with the patient’s feelings.

Other forms of treatment that may also be considered are virtual therapy in which the patient is exposed to or interact with the phobic object or situation on the computer screen. This field of treatment is relatively new and requires more research. Other treatment modalities include hypnosis, supportive therapy, and family therapy. The goal of all 3 forms of therapy is to help the patient recognize that the feared stimulus is not dangerous and to provide emotional support.

Overall, the prognosis for most patients is fair because relapses are common. [12][13] (level V)