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Phobias Treatment

20 Minutes

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CONTENTS

A phobia is an implausible and overwhelming fear response. An individual suffering from a phobia may feel a strong sense of dread or panic when confronted with the cause of the fear. Fear can be directed toward a specific situation, place, or item. In contrast to generalized anxiety disorders, phobias are typically associated with something distinct.

A phobia’s effects might range from mildly unpleasant to profoundly crippling. Individuals suffering from phobias frequently recognize their dread is unjustified (have insight), but are powerless to change it. These anxieties can cause disruptions at the workplace, school, and interpersonal relationships.

The various components of any type of phobia include sensations of overwhelming anxiousness when a person is being confronted with the source of fear, a conviction that the source of one’s fear should be avoided at all costs, being unable to function normally in the presence of the trigger, and acknowledgment of the fear’s irrationality, obtuseness, and exaggeration, along with an incapacity to manage the emotions. The common symptoms are irregular breathing, sweating, rapid heartbeat, a sense of suffocation, tightness of the chest, dizziness, nausea, and disorientation. The American Psychiatric Association (APA) recognizes three distinct forms of phobia. These include the following:

Specific phobia: This is an abnormally strong, irrational fear of a certain trigger.
Social anxiety, or social phobia: This is a serious fear of public embarrassment and being singled out or assessed in a social environment by others. For someone who suffers from social anxiety, the prospect of huge social gatherings is daunting. This is not synonymous with shyness.
Agoraphobia: This is an anxiety-related situation from which a person would be unable to flee in the event of intense panics, such as being in an elevator or being outside the home. It is frequently misinterpreted as a fear of open spaces, although it can also refer to being confined to a small area, such as an elevator, or using public transportation. Individuals who suffer from agoraphobia are at a greater risk of developing panic disorder.

The American Psychiatric Association (APA) recognizes three distinct forms of phobia. These include the following:

Specific phobia: This is an abnormally strong, irrational fear of a certain trigger.
Social anxiety, or social phobia: This is a serious fear of public embarrassment and being singled out or assessed in a social environment by others. For someone who suffers from social anxiety, the prospect of huge social gatherings is daunting. This is not synonymous with shyness.
Agoraphobia: This is an anxiety-related situation from which a person would be unable to flee in the event of intense panics, such as being in an elevator or being outside the home. It is frequently misinterpreted as a fear of open spaces, although it can also refer to being confined to a small area, such as an elevator, or using public transportation. Individuals who suffer from agoraphobia are at a greater risk of developing panic disorder.

The most frequently encountered phobias in clinical practice are those that significantly limit performance and lifestyle (e.g., flying, driving) or have a negative influence on health (blood injection injury, choking, vomiting, closed spaces). For instance, an individual who has a fear of confined spaces will have tremendous difficulty having a necessary MRI, which will be brought to the knowledge of the physician ordering the investigation.

Assessment of symptoms and associated behaviors — It is critical for the evaluating clinician to know that the assessment technique may provoke anxiety by itself. Simply uttering the phobic word loudly or reading and writing it on paper may elicit an anxious response. Thus, it is critical to express both the necessity of diagnosing the problem and the therapeutic value of directly addressing the anxiety.

A comprehensive evaluation strategy should incorporate precise information about the following:

The anxiety-provoking stimulus in a particular situation and the rationale for avoidance – These include fear of imminent harm or danger (e.g., a plane crashing in flight phobia), biological symptoms of anxiety (e.g., fainting due to fear of blood injection injury), and worries about mental control (losing control in a driving phobia by having a panic attack).

Fear predictability – Typically, the fear response related to a given phobia is elicited consistently following exposure to the stimulus of phobia.

Fearful events and variables affecting fear intensity – Phobias may be connected with a conceivable situation (e.g., flying phobia) or with a broad range of situations related to the particular phobic concern. As an example of a phobia manifesting itself in a variety of contexts, a person afraid of snakes may avoid mentioning the term “snake,” watching some wildlife television programs, wandering through forests, and visiting toy stores. Multiple factors might affect the level of fear and are unique to each individual’s experience. For instance, a person suffering from a driving phobia may claim that their anxiety is influenced by the time of day, the amount of traffic, the type of terrain, the traffic speed limit, the climate, and the presence of other passengers in the car.

Safety behaviors are employed to alleviate anxiety – Safety behaviors are acts taken by an individual to avoid a feared consequence or to deal with potential danger. Individuals who suffer from a specific phobia frequently engage in safety behaviors in order to cope with their fear. Escape and avoidance are two overt safety actions. Intricate safety behaviors are more difficult to identify and may include mental diversion and cognitive repression, as well as the carrying of perceived comfort or protective item. Following are some examples:

A person who is afraid of dogs may cross the street in order to avoid strolling past one and may carry capsicum spray for safety.
An individual who has a phobia of flying may consume excessive amounts of alcohol in order to alleviate anxiety during a flight.
A person who suffers from a fear of heights may refuse to visit others who live in a high-floor apartment or building and may also avoid looking out the window.
A person who is afraid of thunderstorms may feel safe in the basement during a storm.
A person who is afraid of thunderstorms may feel safe in the basement during a storm.

Skills deficiencies that may contribute to the specific phobia – This is especially true for a specific fear of driving. A person may lack basic driving skills, particularly if they have avoided driving for a long period, and so some of the anxiety may be justified. A person may lack basic driving skills, particularly if they have avoided driving for a long period, and so some of the anxiety may be justified. Additional factors to be considered in older individuals include the effect of age-related sensory loss on symptom communication, the presence of medical illnesses that could elevate the stress levels and anxiety, and factors contributing to underreporting of symptoms, such as failure to recognize the experience of anxiety symptoms and misinterpretation of anxiety to physical symptoms.

Diagnostic criteria — The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) of the American Psychiatric Association (APA) defines the following criteria for a particular phobia:

Severe apprehension or anxiety about a certain situation or an object (e.g., administration of an intravenous or intramuscular injection, heights, flying in an airplane, seeing blood, animals). Children may express fear or worry by weeping, outbursts, freezing, or grasping onto something.
Invariably, the phobic situation or object elicits instant anxiety or worry.
The phobic item or scenario is deliberately avoided or tolerated in the face of overwhelming fear or anxiety.
The fear or anxiety is disproportionate to the real risk offered by the entity or a place in question, as well as in the sociocultural context.
The fear, worry, or aversion is prolonged, lasting typically 6 months or longer.
The worry, anxiety, or avoidance results in clinically substantial suffering or functional limitations in critical dimensions of life such as social, professional, and others.
The disruption is not best explained by symptomatology of another mental disorder, such as anxiety, fear, and avoidance of situations associated with panic-like symptoms or other debilitating symptoms (as in agoraphobia); “things” or situations associated with obsessive thoughts (as in obsessive-compulsive disorder); reminders of traumatic experiences (as in posttraumatic stress disorder); detachment from home or sense of belonging to a particular thing or a person (as in separation anxiety disorder); or social silencing (as in social anxiety disorder).

Differential diagnoses include Agoraphobia, Post-traumatic stress disorder, Social anxiety disorder, Panic disorder, Separation anxiety disorder, Eating disorders, and illness anxiety disorder.

It is our tendency to shun feelings that fear us. Who would want to walk immediately into what looks to be an unpleasant experience? Except that by repeatedly avoiding staring at the ‘scapegoat’ within, people remain captive to their fears. This typically includes avoiding any potential stressor that can create discomfort and indulging in endless diversions. By doing that, people with a phobia are also retreating from potential challenges that can contribute to their development and happiness. Also, you cannot hide forever from terror. It is going to knock repeatedly, regardless of your best attempts to prevent it. And it will probably hit at a moment when you most need emotional steadiness.

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It is pertinent to advise people with a situational phobia to consider talking with a therapist. Furthermore, the following tips have benefited many patients on a self-help basis in overcoming their fears:

1Allow yourself 2-3 minutes at a time to dwell on your fear. Take deep breaths and tell yourself, “It’s all right. It feels terrible, but emotions are like the waves of the ocean—they rise and fall.” Plan for something comforting to do following your 2-3 minute resting period: Call the good friend who has been looking forward to hearing from you; engage in an activity you know will be fun and absorbing.
Make a list of the things for which you are thankful. When you’re in a terrible mood, refer to the list. Keep adding to the list.
Remind yourself that your worry contains a wealth of information about yourself. Write a self-note, “I am no longer frightened by you, my dear phobia. Tell me what are you capable of teaching me?”
Exercise. Exercise can help you refocus. Whether you take a brief stroll, visit a gym for an intense workout session, or simply switch on a fifteen-minute yoga video at home, exercise is beneficial and will make you feel more grounded and capable.
Utilize humor to assuage your greatest worries. Consider the worst that could occur if you accept an offer to deliver a speech before a crowd of 500, and visualize a humorous scenario over it. It will not only help to prepare you for the unexpected but also help you feel relatively comfortable about anything going wrong.
Admire your courage of facing your fears and build on this slowly and steadily.

Phobias are one of the most prevalent mental illnesses and can be extremely debilitating. They are, however, one of the most curable mental diseases. Despite the availability of effective therapies, the majority of people who suffer from phobias are averse to seeking help. This may be due to a lack of awareness that the phobia is treatable, embarrassment at the prospect of disclosing it to a health professional, adaptation of the phobia by avoidance, or fear of increasing anxiety or discomfort during treatment.

The decision to manage specific phobia — Deciding to treat a person’s specific phobia needs an examination of the phobia’s impact on daily distress, functional impairment, and general quality of life. When an individual with a recent diagnosis of a particular phobia learns that effective treatments are available, they are usually highly motivated to seek treatment. However, if the patient has a relatively mild specific phobia, they may choose not to seek treatment.

Generally, the presenting symptoms might be due to another anxiety disorder that is causing the individual further anguish and impairment in their lives, leading them to seek therapy. If a person is experiencing considerable suffering or impairment as a result of the combination of a specific phobia and a concurrent mental disorder, it is usually the case that the comorbid disorders will be treated first, as they may be having a greater influence on the person’s life. Certain types of phobias can be severe, even life-threatening (e.g., fear of suffocation, fear of medical treatments), and hence require clinical priority for treatment. In some situations, a person’s career may be endangered, for instance, if the phobia prevents the sufferer from flying or driving a car.

Cognitive-behavioral therapy (CBT) as the preferred initial therapy — For the majority of patients clinically diagnosed with a particular phobia, we recommend CBT with exposure as the first line of treatment instead of other treatments.

There are no direct comparisons between CBT and medication for specific phobias in randomized clinical trials. Numerous clinical trials demonstrate the efficacy of CBT when compared to control settings, but trials comparing drugs to placebo have a limited number of participants and provide variable results:

Among psychosocial therapies explored in specific phobias, CBT with exposure has been the most widely studied in clinical trials and has demonstrated the largest improvement in symptoms. A meta-analysis of ten clinical trials comparing one or more exposure treatments to a controlled group discovered that exposure resulted in better post-treatment improvement with moderate effect sizes. The effects of CBT were sustained for up to 12 months in another meta-analysis of 11 studies involving 744 individuals with generalized anxiety disorder. Exposure therapy can be given in a single two- to three-hour session or in a series of 90-minute courses.

Selected serotonin reuptake inhibitors and benzodiazepines trials in specific phobia are insufficient in number and quality to conclusively establish an advantage over placebo. Although no clinical trials have been conducted comparing CBT to medicine for specific phobias, some developing trials are evaluating the benefit of complementing CBT with pharmacotherapy.

Patients who are hesitant to undergo CBT — Some patients are averse to CBT as they might come across the phobic stimulus during exposure treatment. This can be overcome using a variety of treatment strategies, including the following:

Assuring that the patient understands the rationale for CBT, and exposure tactics in particular, for them to accept the chosen strategy.
Reiterating that the patient maintains complete control over the progress of exposure and that treatment progress can be as slow or as rapid as the patient desires.
Engaging the patient in a detailed discussion of the cost of living with the specific phobia against treating it with the notion that the short-term pain (moderate annoyance during exposure) is worth the time and effort for the long-term benefit (increase in freedom due to the management of their specific phobia).

Benzodiazepines can be beneficial for specific phobias in the short term (e.g., the duration of a flight) for patients who cannot withstand exposure, prefer medication to CBT despite being informed about the benefits, relative risks, and verifiable evidence, and when exposure is inaccessible. For instance, benzodiazepines appear to alleviate flight-related anxiety and allow patients with a flying phobia who are unable to undergo CBT before the flight to travel.

For other individuals, simply knowing they have the prescription helps them overcome their reluctance to flying. However, the use of medication may compromise the efficacy of CBT since patients may feel as though they “need” the drug in order to engage with the phobic stimulus and hence may be more prone to relapse if the medication is removed.

Medication – Pharmacotherapy is not a first-line treatment option for specific phobias; nonetheless, if CBT with exposure is inaccessible, or if the patient chooses medicine over CBT despite counseling on the comparative risks and benefits, a benzodiazepine could be used.

For instance, benzodiazepine would be chosen if a patient who rarely flies appears with the anxiety of flying a week before his or her expected flight. We would prefer a benzodiazepine with a brief onset (e.g., lorazepam 0.5 to 2 mg) with directions to take the drug 30 minutes before getting on the plane. Benzodiazepines take minutes to hours to take effect.

Sedation, diminished psychomotor performance, forgetfulness, and addiction are all possible side effects of benzodiazepines, as are dependency and withdrawal symptoms following long-term usage. Patients should be advised to take a test dosage to determine the duration and extent to which the medicine may impede performance (e.g., boarding and departing from a plane) and to abstain from alcohol and driving in the hours after the dose of medication. Furthermore, the administration and efficacy of benzodiazepines in certain phobias are discussed in further detail, including their usage in individuals with a history of substance abuse.

Behavioral therapies for particular phobias entail the use of cognitive and behavioral interventions to alter maladaptive actions and beliefs that contribute to the development of emotional distress. The primary behavioral method used to treat particular phobia is exposure, which is supplemented with other CBT components to address a variety of specific forms of phobia.

Exposure therapy – Exposure-based techniques entail repeated, systematic encounters with the feared stimulus in order to allow fear minimization via suppression and inhibition learning. Patients are exposed to fearful events in a hierarchy from least to most feared and that which are avoided based on their assessments of each situation.

Throughout treatment, exposure practice progresses up the hierarchy, with each level resulting in a decrease in anxiety. Subjective fear is assessed using the individual’s self-report, typically on a scale of 0 to 100, with 0 indicating “no feelings of apprehension at all” and 100 indicating “severe fear/anxiety.” In general, exposure practice on a given step should be performed until the fear rating decreases significantly before progressing to the next step in the hierarchy. Exposures are intended to target avoidance across various settings, test fearful beliefs, minimize and remove safety behaviors, and promote the acquisition of new methods of responding to fear stimuli. Subjective fear is a strong predictor of exposure avoidance behavior.

As an illustration of an exposure hierarchy, a patient with a fear of snakes would begin by speaking the word snake and then viewing a picture of a snake. A more acceptable level of exposure would be for the patient to remain within three feet of an enclosure with a live snake. A patient’s maximum exposure would be to grasp a live snake.

Psychoeducation – Providing background information to address misattributions or erroneous perceptions about phobic situations is a critical component of treatment when combined with exposure. For instance, individuals suffering from animal phobias frequently believe that the animal intends to harm or attack them, whereas in reality the animal is fearful of humans and seeks to avoid them. Numerous self-help manuals discuss the nature and treatment of numerous phobias. Patients may use these materials in either a self-directed or clinician-assisted exposure treatment.

Cognitive therapy — Cognitive therapy focuses on assisting an individual in identifying maladaptive beliefs and judgments that contribute to and maintain phobic anxiety, to encourage more reasonable thoughts and assessments. For instance, an individual who has a specific fear of elevators may believe that the possibility of becoming trapped in an elevator is extraordinarily high (90 percent likelihood per elevator journey), whereas in reality, the probability is extremely low. In his or her own experience, the individual may have taken countless elevator rides but been trapped only a few times, if at all. Additionally, the individual may assume that if he or she becomes trapped, he or she would be unable of coping or will never be able to escape. By addressing these cognitive errors in therapy, fear levels are significantly reduced.

A meta-analysis of five studies of treatment for particular phobia compared exposure therapy alone to exposure therapy with a cognitive intervention, concluding that the cognitive component added no benefit. These data demonstrate considerable variation, implying the need for additional research on this subject.

Virtual reality exposure (VRE) with a cognitive component has been proven to be more beneficial than VRE alone in the treatment of flying fear. In a randomized experiment comparing VRE, cognitive treatment, and bibliotherapy in 86 patients with a flying phobia, it was discovered that both the VRE and VRE + cognitive therapy groups experienced much less anxiety than the bibliotherapy group. The extent of the impact size observed in the VRE-only group was significantly smaller than in prior trials examining VRE in combination with cognitive treatment.

Although cognitive therapies may improve the palatability of exposure for patients who first refuse exposure treatment alone, their effect on patient acceptance has not been evaluated in clinical trials. The benefit of augmenting in vivo exposure therapy with cognitive therapy may also depend on the type of phobia. For instance, cognitive therapy has been shown to improve the effects of in vivo exposure in the treatment of claustrophobia, but not in the treatment of animal phobia. These disparities could be explained by ceiling effects on the exposure component’s effectiveness or by the extent to which cognitive symptoms are a fundamental component of the phobia.

Randomized clinical research evaluated a 12-session cognitive-behavioral therapy (CBT) procedure targeted to patients with a specific fear of vomiting. CBT (which included psychoeducation, cognitive therapy, exposure therapy, and safety behavior modification) proved to be better to waitlist on a specific phobia of vomiting outcome measures, with 50% of those taking CBT achieving clinically significant change in comparison with 16% of those on the waitlist.

Anxiety management — techniques that help reduce an excessive and irrational response, such as breathing, muscle relaxation exercises, and introspective relaxation (mental imagery), are occasionally used in conjunction with exposure for individuals who present with severe distress that impairs their ability to participate in treatment.

Although there is a dearth of data comparing exposure with or without anxiety management approaches in specific phobias, data from other anxiety disorders indicate that management of anxiety is not a necessary component of treatment. In the absence of exposure treatment, anxiety management approaches are generally not considered to be effective treatments.

Safety behaviors — Safety behaviors refer to a collection of methods adopted by individuals suffering from a certain phobia to cope with the phobic trigger. Among the safe behaviors are the following:

Distraction of the mind
Suppression of thought
Carrying an object that enhances one’s sense of security

Clinical investigations examining the effects of safety behaviors on exposure therapy outcomes have shown inconsistent results. Certain trials indicated that safety behaviors may impair therapeutic outcomes by allowing for avoidance of feared events in anxiety-provoking settings. Other investigations, however, have discovered that safety behaviors may not impair treatment outcomes but may increase readiness to face the fearful stimuli at a closer distance.

Systematic desensitization — As a prerequisite to in vivo exposure, systematic desensitization employs imagined exposure to a hierarchy of feared events in conjunction with gradual muscular relaxation, which is hypothesized to suppress the fear response.

Clinical research indicates that systematic desensitization is more effective than a control condition but less effective than in vivo exposure in the treatment of certain phobias. Contemporary exposure therapies have largely overtaken systematic desensitization. Individuals who resist in vivo exposure have a therapy option in the form of systematic desensitization. However, it is recommended that imagined or virtual exposure be utilized before systematic desensitization because they are less time-consuming and do not require further training in the relaxation component. Additionally, the relaxation component may act as a safeguard, preventing the patient from learning that the anxiety reaction is harmless and tolerable.

Lifestyle modifications are easy but effective techniques for treating Phobia along with depression and anxiety, and they are a necessary component of a comprehensive treatment approach. In some contexts, lifestyle adjustments can alleviate phobic stress or anxiety on their own, so it stands to reason to begin immediately with lifestyle changes. However, if you are experiencing moderate to severe specific or social phobia, you should seek immediate professional care. And, similarly, if you do not see alleviation from minor symptoms within a few months, seek professional help. The below lifestyle modifications may be beneficial.

Exercise. Regular physical activity is one of the most effective ways to alleviate phobic anxiety and promote healing. Exercise increases mood, sleep quality, decreases tension and alleviates stress. Additionally, it provides an opportunity for mindless distraction from your problems and fears. And when you exercise consistently, you gain energy, which can benefit you in a variety of ways, including your ability to focus on your treatment goals. Yoga has been related to a reduction in phobia symptoms in particular.

Eat and drink healthy. No single meal or drink will alleviate stress or phobic anxiety. However, a balanced diet, consistent meal and snack times, and awareness of any food sensitivities will best support your mood and energy. Maintain good hydration and limit your coffee and alcohol intake, as both can cause anxiety-like symptoms in the body.

Get plenty of sleep. When you are concerned or stressed, your body will naturally want additional sleep and rest. However, stress and sleep are incompatible bedfellows. On the one hand, the worry of specific phobia can keep you up at night and rob you of valuable sleep hours and on the other side, sleep loss can exacerbate anxiety symptoms. Individuals who suffer from persistent sleeplessness are at an even greater risk.

If you have difficulty sleeping, take steps to enhance your sleep patterns, which are commonly referred to as “sleep hygiene.” Establish and adhere to a peaceful night ritual, as well as a sleep-friendly bedroom. Avoid over-stimulating activities such as watching television, using a laptop and cellphone, or taking nicotine and coffee just before night.

Cultivate a state of tranquility. As with the body, an anxious mind need additional rest. Apart from sleep, consider active waking relaxation techniques like yoga, meditation, or tai chi to help you concentrate on a single particular task at a time and shut off distracting fears that typically overwhelm your thoughts. Other less structured hobbies, such as sitting with your pet, reading a book, listening to music, or taking a stroll, may also give peace of mind.

Restore your composure. With a phobic anxiety illness, life can easily become out of whack, thrown off balance by mistaken priorities, persistent anxieties, and excessive time spent thinking about useless worries. To reintroduce some perspective and balance into your life, take a day off – or, better yet, a trip or vacation – and spend time recognizing your blessings and reconnecting with what truly counts.

Allow the phobic responses to escape. Phobia can become unbearable, and burying it does not help. Communicate your frustrations with a phobia to a buddy who is a decent, patient listener. Additionally, journaling or blogging about your fears may be beneficial. Laughter has also been reported to relieve tension. Seek out events that are entertaining and engage in activities that make you laugh, chuckle, or at the very least crack an amusing smile.

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Phobia Insights

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Emetophobia

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Phobias Treatment