Specific Phobia


Article Author:
Chandan Samra


Article Editor:
Sara Abdijadid


Editors In Chief:
Sherry Gossman


Managing Editors:
Frank Smeeks
Scott Dulebohn
Erin Hughes
Sobhan Daneshfar
William Gossman
Pritesh Sheth
John Shell
Matthew Varacallo
Mark Pellegrini
James Hughes
Richard Ciresi
Phillip Hynes


Updated:
10/27/2018 12:31:53 PM

Introduction

Patients with a specific phobia experience high levels of anxiety and panic attacks along with excessive and unreasonable fear due to either exposure or anticipation of exposure to a 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 nongenetic transmission of specific phobias. 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 is when a specific event that provokes fear or anxiety is paired with an emotional experience. 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, a person is susceptible to a permanent emotional association between driving or cars and fear or anxiety. Although a person may not experience a panic attack or meet the criteria for a panic disorder, they may develop a generalized 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.

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 the following:

  • 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 history and physical.

Treatment / Management

Behavior therapy is the most effective treatment for phobias is behavioral therapy. This includes 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 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.

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. 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.

Other forms of treatment that may also be considered are virtual therapy in which 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.

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 phobia have intact insight to 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 phobia, these patients tend to experience anxiety or fear immediately upon exposure of 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 to contract the disease. 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

With the appropriate behavioral techniques and medications, the prognosis is well.

Deterrence and Patient Education

Patients are advised to see a psychiatrist when symptoms are affecting their daily activities and quality of life.

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.


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Specific Phobia - Questions

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There is a disorder in which there is a permanent irrational apprehension about an object or situation. The sufferer goes to great lengths to avoid, disproportionate to the actual danger. If it cannot be evaded, one will endure with great distress. What is the condition?



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Select the true statement about specific phobias.



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A 46-year-old man sitting next to you on an airplane tells you that he is "very afraid of airplanes," and may "freak out" as soon as the captain states that they are ready for departure. What symptoms or signs will you not see in this patient?



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Which of the following would be found while performing a history and physical on a patient with a specific phobia?



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The fear of flying in a plane, falls in which of the following subcategories of specific phobia?



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Specific Phobia - References

References

Placebo effects in spider phobia: an eye-tracking experiment., Gremsl A,Schwab D,Höfler C,Schienle A,, Cognition & emotion, 2018 Jan 5     [PubMed]
Access to information about harm and safety in spider fearful and nonfearful individuals: when they were good they were very very good but when they were bad they were horrid., Cavanagh K,Davey G,, Journal of behavior therapy and experimental psychiatry, 2003 Sep-Dec     [PubMed]
Integrating Hypnosis with Other Therapies for Treating Specific Phobias: A Case Series., Hirsch JA,, The American journal of clinical hypnosis, 2018 Apr     [PubMed]
Integrating Hypnosis with Other Therapies for Treating Specific Phobias: A Case Series., Hirsch JA,, The American journal of clinical hypnosis, 2018 Apr     [PubMed]
Short versions of two specific phobia measures: The snake and the spider questionnaires., Zsido AN,Arato N,Inhof O,Janszky J,Darnai G,, Journal of anxiety disorders, 2018 Mar     [PubMed]
Relating experimentally-induced fear to pre-existing phobic fear in the human brain., Levine SM,Pfaller M,Reichenberger J,Shiban Y,Mühlberger A,Rupprecht R,Schwarzbach JV,, Social cognitive and affective neuroscience, 2017 Dec 21     [PubMed]
Phenomenology, epidemiology, co-morbidity and treatment of a specific phobia of vomiting: A systematic review of an understudied disorder., Keyes A,Gilpin HR,Veale D,, Clinical psychology review, 2017 Dec 12     [PubMed]
Outcome of depressive and anxiety disorders among young adults: Results from the Longitudinal Finnish Health 2011 Study., Kasteenpohja T,Marttunen M,Aalto-Setälä T,Perälä J,Saarni SI,Suvisaari J,, Nordic journal of psychiatry, 2018 Apr     [PubMed]
[Psychopathology of anxiety-phobic disorders that led to hospitalization in a psychiatric hospital]., Chugunov DA,Schmilovitch AA,, Zhurnal nevrologii i psikhiatrii imeni S.S. Korsakova, 2017     [PubMed]
Association between attention bias to threat and anxiety symptoms in children and adolescents., Abend R,de Voogd L,Salemink E,Wiers RW,Pérez-Edgar K,Fitzgerald A,White LK,Salum GA,He J,Silverman WK,Pettit JW,Pine DS,Bar-Haim Y,, Depression and anxiety, 2018 Mar     [PubMed]
Error-related brain activity and anxiety symptoms in youth with autism spectrum disorder., Rosen TE,Lerner MD,, Autism research : official journal of the International Society for Autism Research, 2018 Feb     [PubMed]
Does the presence of multiple sclerosis impact on symptom profile in depressed patients?, Boeschoten RE,Schaakxs R,Dekker J,Uitdehaag BMJ,Beekman ATF,Smit JH,Penninx BWJH,van Oppen P,, Journal of psychosomatic research, 2017 Dec     [PubMed]
We prefer what we fear: A response preference bias mimics attentional capture in spider fear., Haberkamp A,Biafora M,Schmidt T,Weiß K,, Journal of anxiety disorders, 2018 Jan     [PubMed]

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