11/6/2021 Approach to treating specific phobia in adults - UpToDate

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Approach to treating specific phobia in adults

Authors: Randi E McCabe, PhD, Eric Bui, MD, PhD
Section Editor: Murray B Stein, MD, MPH
Deputy Editor: Michael Friedman, MD

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: May 2021. | This topic last updated: Apr 07, 2021.

INTRODUCTION

Specific phobia is an anxiety disorder characterized by clinically significant fear of a particular

object or situation that typically leads to avoidance behaviors. 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.

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].

Our approach to selecting treatments for specific phobia in adults is reviewed here. The
epidemiology, pathogenesis, clinical manifestations, course, and diagnosis of specific phobia in
adults are reviewed separately. Pharmacotherapy and psychosocial interventions for specific
phobia in adults are 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 discussed separately. (See
"Specific phobia in adults: Epidemiology, clinical manifestations, course and diagnosis" and
"Pharmacotherapy for specific phobia in adults" and "Cognitive-behavioral therapies for specific
phobia in adults" and "Overview of fears and phobias in children and adolescents".)

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INITIAL TREATMENT

Deciding to treat — The decision to treat a person’s specific phobia requires a discussion of the
impact of the phobia in terms of daily distress, interference with functioning, and overall quality
of life. An individual with a recent diagnosis of specific phobia is often very motivated to seek
treatment once they learn that effective treatments are available. However, in the case of a very
mild specific phobia, the patient may decide they do not wish to pursue treatment.

Often, the presenting problem is another anxiety disorder that is causing more distress and
impairment in the person’s life and thus motivating them to seek treatment. If a person is
having significant distress or impairment from the combination of a specific phobia and
concurrent mental disorder, it is often likely that the decision will be made to treat the comorbid
disorders first, as they may be exerting a more significant life impact. Some specific phobias
may be severe, even life threatening (eg, choking, fear of medical procedures), and thus
warrant clinical priority for treatment.

In other cases, a person’s job may be on the line if the phobia limits the patient’s ability to fly or
drive a car.

CBT as preferred initial therapy — For most patients newly diagnosed with specific phobia, we
suggest first-line treatment with cognitive-behavioral therapy (CBT) that includes exposure
rather than other treatments [8].

There are no randomized clinical trials directly comparing CBT and medication for specific
phobia. Several clinical trials show efficacy for CBT compared with control conditions, while
trials comparing medications with placebo are limited and show mixed results:

● Among psychosocial interventions tested in specific phobia, CBT with exposure has been
the most extensively tested in clinical trials and has showed the greatest reduction in
symptoms. A meta-analysis of 10 clinical trials comparing one or more exposure treatments
with a nonexposure treatment found that exposure led to greater improvement
posttreatment with moderate effect sizes [5]. In another meta-analysis of 11 studies
including 744 patients with generalized anxiety disorder, the effects of CBT were
maintained for up to 12 months [9]. (See "Cognitive-behavioral therapies for specific phobia
in adults", section on 'Efficacy'.)

● Trials of selective serotonin reuptake inhibitors [10,11] and benzodiazepines [12] in specific
phobia are of insufficient number and quality to clearly demonstrate benefit compared with
placebo.

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● Although there are no clinical trials comparing treatment with CBT versus medication for
specific phobia, there are several emerging trials investigating the benefit of augmenting
CBT with pharmacotherapy. (See "Pharmacotherapy for specific phobia in adults", section
on 'Medications'.)

Patients who are reluctant to undergo CBT — Some patients are reluctant to participate in
cognitive-behavioral therapy (CBT) and encounter the phobic stimulus during exposure. This
may be overcome with a number of clinical strategies including:

● Ensuring the patient has a good understanding of the rationale for CBT and exposure
strategies specifically so that they are on board with the chosen intervention.

● Underscoring that control for progress in exposure is fully in the hands of the patient and
that therapeutic progress happens as slowly or as quickly as the patient chooses.

● Engaging in a thorough discussion of the costs and benefits of living with the specific
phobia versus engaging in treatment with the idea that short-term pain (mild discomfort
during exposure) is worth the effort for the long-term gain (increase in freedom due to the
elimination of the specific phobia).

In our clinical experience, benzodiazepines can be useful for specific phobia in the short term
(eg, the length of a flight) for patients who cannot tolerate exposure, prefer medication to CBT
despite being informed about the relative risks, benefits, and supporting evidence; and when
exposure is unavailable. As an example, benzodiazepines appear to reduce flight-associated
anxiety and enable travel for patients with flying phobia who are unable to access CBT before
the flight.

For some patients, the knowledge that they have the medication enables them to overcome the
avoidance of flying. The use of medication, however, may undermine the efficacy of CBT as
patients feel that they “need” the medication to engage with the phobic stimulus and thus may
be at increased risk of relapse if the medication is discontinued.

TREATMENT OPTIONS

CBT with exposure — 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. Exposure, the main behavioral component of CBT for
specific phobia, involves repeated, systematic confrontation of the feared stimulus to facilitate
fear reduction through extinction and inhibitory learning [13,14].

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Types of exposure — Exposure is typically graded so that the patient starts practicing with
encounters that are less anxiety provoking. The patient works up a hierarchy to more
challenging encounters as anxiety reduces at each step. (See "Cognitive-behavioral therapies
for specific phobia in adults", section on 'Cognitive-behavioral therapy'.)

In vivo exposure, confronting the feared stimulus in real world situations in a safe and
controlled manner, is the most commonly used type of exposure. Imaginal exposure,
confronting the stimulus in the patient’s imagination, may be part of a hierarchy leading to in
vivo exposure, but is not used routinely for most phobic stimuli as a standalone treatment.
Imaginal exposure can be useful when the stimulus is too costly or infrequent to recreate (eg, a
fear of flying or a storm phobia). Exposure via virtual reality (ie, computer simulation) is
promising; however, its availability is limited primarily due to the expense of the technology
[15]. (See "Cognitive-behavioral therapies for specific phobia in adults", section on 'Types of
exposure'.)

In vivo exposure is the most effective of the three types of exposure. A meta-analysis of seven
clinical trials in specific phobia found that, at the completion of treatment, in vivo exposure was
more effective compared with other types of exposure [5]. No differences were seen by
exposure type at follow-up. Considerable heterogeneity was seen in these findings, suggesting
more research on this question is needed. Randomized trials comparing virtual reality exposure
with in vivo exposure for specific phobia have had mixed findings, with some studies
suggesting equivalence and other studies suggesting an advantage for in vivo exposure [5,16-
18].

As an example, a trial of 82 patients with dog phobia compared imaginal exposure, active-
imaginal exposure (where the individuals engaged in imaginal exposure while acting out coping
behaviors), and in vivo exposure found response rates of 51.9, 62.1, and 73.1 percent
respectively; however, the differences among groups were not statistically significant, possibly
because of the relatively small sample sizes [19]. (See "Cognitive-behavioral therapies for
specific phobia in adults", section on 'Exposure therapy'.)

Other CBT components — Psychoeducation, cognitive therapy, anxiety management, and

reduction of safety behaviors, can be used in various combinations with exposure, to treat
differing patient presentations [12]. A meta-analysis of five clinical trials comparing exposure
with an additional cognitive approach to exposure alone did not find a difference between
them. However, in our clinical experience, finding the right combination and sequence of
approaches for an individual patient can be central to the patient’s tolerance of the treatment
and its effectiveness. (See "Cognitive-behavioral therapies for specific phobia in adults", section
on 'Other CBT components'.)
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Common presentations and approaches — Examples of common presentations and

approaches include:

● Patients who can tolerate the mild to moderate anxiety induced by graded exposure are
treated principally with the behavioral approach; however, all exposure includes some
cognitive work, as behavior change directly leads to cognitive change. During the exposure
session and following completion of the exposure session, the clinician discusses the
patient’s observations and the evidence gathered in relation to the patient’s fearful
predictions regarding the feared stimulus. This process is known as emotional processing
of the phobic stimulus and leads to the development of new, more adaptive beliefs about
the feared stimulus. (See "Cognitive-behavioral therapies for specific phobia in adults",
section on 'Exposure therapy'.)

● In some cases, patients may be willing to engage in exposure, but there is difficulty grading
the exposure due to high levels of anxiety across situations. In this instance, the
introduction of cognitive strategies may help the patient to identify maladaptive thoughts
and appraisals that trigger phobic fear and promote more realistic thoughts and
appraisals. This may help reduce the patient’s anxiety so that graded exposure is facilitated.
(See "Cognitive-behavioral therapies for specific phobia in adults", section on
'Psychoeducation' and "Cognitive-behavioral therapies for specific phobia in adults", section
on 'Cognitive therapy'.)

● Patients too anxious and distressed to engage in exposure may be helped through the use
of anxiety management techniques that promote arousal reduction, such as breathing
retraining, progressive muscle relaxation, or imaginal relaxation. (See "Cognitive-behavioral
therapies for specific phobia in adults", section on 'Anxiety management'.)

● Patients who present with particularly severe fear and anxiety may have difficulty engaging
in exposure without the use of safety behaviors that they perform to manage their anxiety,
such as cognitive distraction. Incorporating safety behaviors into the exposure practice may
assist the patient in engaging with the phobic stimulus. As the patient becomes more
comfortable, the safety behavior can then be faded out [20]. (See "Cognitive-behavioral
therapies for specific phobia in adults", section on 'Safety behaviors'.)

The duration of exposure treatment for specific phobia, which typically ranges from five to eight
90-minute sessions, is based on the severity of the phobia and progress in fear reduction.
Exposure may also be provided in a more condensed format as a single two- to three-hour
session. The addition of cognitive strategies, anxiety management strategies, or applied tension
(as described above) may add an additional two to four sessions at the front end.

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Investigational approaches to CBT augmentation — Several augmenting approaches to

improve outcomes with cognitive-behavioral therapy (CBT) are under evaluation; however, they
remain limited to research settings and further data are needed before recommending them
for clinical use.

Clinical trials have shown possible benefits for D-cycloserine, a partial N-methyl-D-aspartate
receptor agonist, in the augmentation of exposure based therapy for specific phobia and other
anxiety disorders [21]. Other treatments being investigated in the treatment of specific phobias
include transcranial direct current stimulation, methylene blue, and quetiapine. These agents
have shown some benefit in small trials; however, the effects sizes were very small and
heterogeneity of subjects was noted [22,23]. (See "Pharmacotherapy for specific phobia in
adults", section on 'Investigational medications'.)

Medication — Medication is not a first-line treatment for specific phobia; however, if CBT with
exposure is not available or accessible to the patient, or he or she prefers medication to CBT
despite education about relative risks and benefits, then a benzodiazepine can be used.

As an example, benzodiazepine would be preferred for patient who rarely flies presents with
fear of flying a week prior to his/her anticipated flight. We would favor a benzodiazepine with a
relatively short onset (eg, lorazepam 0.5 to 2 mg) with instructions to take the medication 30
minutes boarding the plane. Benzodiazepines have an onset of action of minutes to hours.

Side effects of benzodiazepines include sedation, impaired psychomotor performance,

amnesia, and abuse, as well as dependence and withdrawal symptoms after long-term
treatment [24]. Patients should be encouraged to take a test dose to gauge the duration and
degree to which the medication may affect performance (eg, getting on and off the plane) and
to avoid alcohol and driving during the hours after taking the medication.

The efficacy and administration of benzodiazepines in specific phobia, including their use in
patients with a history of a substance use disorder, is reviewed in greater detail separately. (See
"Pharmacotherapy for specific phobia in adults", section on 'Medications'.)

TREATMENT RESPONSE

Robust — Treatment gains from exposure therapy appear to be maintained for at least one
year [25-27]. Continued self-exposure on a regular basis is important for maintaining treatment
gains [28]. (See "Cognitive-behavioral therapies for specific phobia in adults", section on 'Follow-
up'.)

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Treatment gains from benzodiazepines last only as long as the patient continues to take the
medication.

Inadequate — There are no clinical trials of strategies to treat specific phobia that does not
respond to initial treatment with exposure and other cognitive-behavioral therapy components,
but in our experience, several approaches can be useful:

● Patients who drop out of initial treatment due to anxiety and inability tolerate exposure
may benefit from the addition of training in the use of anxiety management strategies or
fading of safety behaviors, as described earlier and separately. (See 'Common
presentations and approaches' above and "Cognitive-behavioral therapies for specific
phobia in adults", section on 'Anxiety management' and "Cognitive-behavioral therapies for
specific phobia in adults", section on 'Safety behaviors'.)

● Patients who fail to progress adequately with exposure may benefit from the addition of
more cognitive strategies, or if that is not effective, from the addition of a benzodiazepine.
(See 'Common presentations and approaches' above and 'Medication' above and
"Cognitive-behavioral therapies for specific phobia in adults", section on 'Cognitive therapy'
and "Pharmacotherapy for specific phobia in adults" and 'Investigational approaches to
CBT augmentation' above.)

● Patients who respond inadequately to a benzodiazepine can be treated with cognitive-

behavioral therapy/exposure. (See 'CBT with exposure' above.)

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 AND RECOMMENDATIONS

● For most patients newly diagnosed with specific phobia, we suggest first-line treatment
with cognitive-behavioral therapy (CBT) that includes exposure rather than other
treatments (Grade 2C). In vivo exposure is the most commonly used and effective type of
exposure; imaginal exposure can be useful when the phobic stimulus is too costly or
infrequent to recreate. (See 'CBT as preferred initial therapy' above and "Cognitive-
behavioral therapies for specific phobia in adults", section on 'Efficacy'.)

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● Other CBT components, such as psychoeducation, cognitive therapy, anxiety management,

and training in the fading of safety behaviors, can be used in various combinations with
exposure, to treat differing patient presentations. In our clinical experience, finding the
right combination and sequence of approaches for an individual patient can be central to
the patient’s tolerance of the treatment and its effectiveness. (See 'Common presentations
and approaches' above and "Cognitive-behavioral therapies for specific phobia in adults",
section on 'Other CBT components'.)

● Exposure treatment can be provided in one two- to three-hour session or in several 90-
minute sessions. (See "Cognitive-behavioral therapies for specific phobia in adults", section
on 'Administration'.)

● Cognitive strategies can help patients to tolerate the anxiety induced by exposure,
including education to correct misunderstood aspects of the stimulus, and helping the
patient to identify maladaptive thoughts and appraisals that trigger phobic fear, to
promote more realistic thoughts and appraisals. (See 'Common presentations and
approaches' above and "Cognitive-behavioral therapies for specific phobia in adults",
section on 'Other CBT components'.)

● We suggest treatment of specific phobia with a benzodiazepine rather than CBT when CBT
with exposure is unavailable and when patients cannot tolerate exposure or prefer
medication to CBT despite education on their relative risks and benefits (Grade 2C). (See
'CBT as preferred initial therapy' above and "Pharmacotherapy for specific phobia in
adults".)

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Contributor Disclosures
Randi E McCabe, PhD Nothing to disclose Eric Bui, MD, PhD Nothing to disclose Murray B Stein, MD,
MPH Equity Ownership/Stock Options: Oxeia Biopharmaceuticals [Traumatic Brain Injury]; Epivaro
[Substance use disorders and PTSD]. Consultant/Advisory Boards: Acadia Pharmaceuticals [Anxiety and
traumatic stress-related disorders]; Aptinyx [Anxiety and traumatic stress-related disorders]; Bionomics
[Anxiety and traumatic stress-related disorders]; BioXcel Therapeutics [Anxiety and traumatic stress-
related disorders]; Clexio [Anxiety and traumatic stress-related disorders]; EmpowerPharm [Anxiety and
traumatic stress-related disorders]; GW Pharma [Anxiety and traumatic stress-related disorders]; GABA
Therapeutics [Anxiety and traumatic stress-related disorders]; Janssen [Anxiety and traumatic stress-

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related disorders]; Jazz Pharmaceuticals [Anxiety and traumatic stress-related disorders]; Oxeia
Biopharmaceuticals [Traumatic brain injury]. Michael Friedman, MD Nothing to disclose

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
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