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PSYCHIATRY BOARD REVIEW MANUAL
STATEMENT OF
EDITORIAL PURPOSE
The Hospital Physician Psychiatry Board Review
Manual is a study guide for residents and
practicing physicians preparing for board
examinations in psychiatry. Each quarterly
manual reviews a topic essential to the current practice of psychiatry.
PUBLISHING STAFF
PRESIDENT, GROUP PUBLISHER
Bruce M. White
EDITORIAL DIRECTOR
Debra Dreger
SENIOR EDITOR
Bobbie Lewis
ASSISTANT EDITOR
Tricia Faggioli
Specific Phobias
Series Editor:
Jerald Kay, MD
Professor and Chair
Department of Psychiatry
Wright State University School of Medicine
Dayton, OH
Contributor:
Ann Kerr Morrison, MD
Assistant Professor
Director of Community Psychiatry
Department of Psychiatry
Wright State University School of Medicine
Dayton, OH
EXECUTIVE VICE PRESIDENT
Barbara T. White
EXECUTIVE DIRECTOR
OF OPERATIONS
Jean M. Gaul
PRODUCTION DIRECTOR
Suzanne S. Banish
Table of Contents
PRODUCTION ASSISTANT
Kathryn K. Johnson
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
ADVERTISING/PROJECT MANAGER
Patricia Payne Castle
Background and Features. . . . . . . . . . . . . . . . . . 2
SALES & MARKETING MANAGER
Deborah D. Chavis
NOTE FROM THE PUBLISHER:
This publication has been developed without involvement of or review by the American Board of Psychiatry and Neurology.
Case 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Case 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
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Psychiatry Volume 8, Part 4 1
PSYCHIATRY BOARD REVIEW MANUAL
Specific Phobias
Ann Kerr Morrison, MD
INTRODUCTION
The description and treatment of specific phobias, or
fear of specific objects or situations, are embedded in
the history of psychiatry and psychology. Indeed,
Freud’s classic analytic case of “Little Hans” illustrated a
common form of specific phobia (animal type).1 As
opposed to psychodynamic theories or techniques, however, the behavioral concepts of conditioned response,
operant learning, and exposure principles developed by
early pioneers in psychology such as Skinner, Watson,
and Wolpe more closely approximate our current understanding of the origin of phobias and pointed to
some of the first effective treatments. More recently,
work by Donald Klein,2 Isaac Marks,3 and others helped
to define specific phobias and to distinguish them from
each other and from other anxiety disorders. In general, the feared object or situation rather than anxiety
symptoms themselves is the focus; however, especially for
blood-injury-injection phobias and situational phobias,
many patients report fear or sensitivity to anxiety symptoms or the consequence of these symptoms.
DSM-IV-TR4 criteria for specific phobia are listed in
Table 1. The DSM-IV-TR also defines 5 subtypes that are
based on type of feared object/situation: animal, natural environment, blood-injection-injury, situational, and
other. Some have argued that the factors that distinguish
a situational from a natural environment stimulus are
unclear and that these 2 subtypes may be more similar
than different, with only 3 main subtypes being needed.5
Indeed, some hold that simply naming the phobia is
more helpful than sorting them into subtypes.5
BACKGROUND AND FEATURES
DIFFERENTIAL DIAGNOSIS
Specific phobias are distinguished from other anxiety
disorders primarily by the circumscribed nature of the
feared object or situation and by the focus of the fear. In
agoraphobia, the fear is generated by concern that one
will experience a panic attack and be unable to escape
2 Hospital Physician Board Review Manual
or be embarrassed by this. One then avoids situations in
which panic attacks have occurred. Since panic disorder
attacks occur spontaneously, eventually the person may
have few places in which they are comfortable. In social
phobia, the focus is on being evaluated by others and
leads to avoidance of social situations in which they feel
scrutinized and fear embarrassment. In obsessivecompulsive disorder, common fears include contamination or disease, harming others, inappropriate behavior,
and safety. People with obsessive-compulsive disorder
may avoid situations or stimuli that seem to provoke
these obsessions and/or in which they will be compelled
to perform rituals. In generalized anxiety disorder, the
fears are exaggerated and pervasive worry about real life
circumstance is present. In posttraumatic stress disorder,
the person by definition has experienced a traumatic
event and avoidance is to thoughts or situations that are
associated with this experience.
EPIDEMIOLOGY
Specific phobias represent an oddity among psychiatric illnesses, for although they are very common they
are seen relatively infrequently in the clinical setting.
The National Comorbidity Survey (NCS)6 found an
overall lifetime prevalence of 11.3% (Table 2). Analysis
by Curtis’ group7 revealed the most common phobias to
be animals, heights, closed spaces, and blood-injury,
affecting from 4.5% to 5.7% of people (Table 3). Despite being common, well understood, and very treatable, only 12.5% of people with specific phobia in the
NCS sought treatment during the previous year.8
The age of onset of specific phobias varies with the
type of phobia. Antony and McCabe,9 summarizing prior
studies, reported that children develop animal, bloodinjury, storm, and water phobias; acrophobia appears in
teenagers; and other situational phobias typically occur
in young adults (Table 4). In the development of specific phobia, there is an average lag time of 9 years between
the individual’s first fear of the stimulus and the development of distress and impairment sufficient to warrant
a diagnosis of phobia.10 As with many other anxiety disorders, women are more often affected than men, with
NCS rates of 15.7% versus 6.7% respectively;6 however,
for some types of phobias, such as mutilation, heights,
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Specific Phobias
Table 1. Diagnostic Criteria for 300.29 Specific Phobia
Table 2. Lifetime Prevalence of UM-CIDI/DSM-III-R
Disorders
Marked and persistent fear that is excessive or unreasonable,
cued by the presence or anticipation of a specific object or
situation (eg, flying, heights, animals, receiving an injection,
seeing blood).
Exposure to the phobic stimulus almost invariably provokes
an immediate anxiety response, which may take the form
of a situationally bound or situationally predisposed panic
attack. Note: In children, the anxiety may be expressed by
crying, tantrums, freezing, or clinging.
The person recognizes that the fear is excessive or unreasonable. Note: In children, this feature may be absent.
The phobic situation(s) is avoided or else is endured with
intense anxiety or distress.
The avoidance, anxious anticipation, or distress in the feared
situations(s) interferes significantly with the person’s normal routine, occupational or academic functioning, or social
activities or relationships, or there is marked distress about
having the phobia.
In individuals under age 18 years, the duration is at least
6 months.
The anxiety, panic attacks, or phobic avoidance associated
with the specific object or situation are not better accounted for by another mental disorder, such as obsessivecompulsive disorder (eg, fear of dirt in someone with an
obsession about contaminations), posttraumatic stress disorder (eg, avoidance of stimuli associated with a severe
stressor), separation anxiety disorder (eg, avoidance of
school), social phobia (eg, avoidance of social situations
because of fear of embarrassment), panic disorder with agoraphobia, or agoraphobia without history of panic disorder.
Specify type:
Animal type
Natural environment type (eg, heights, storms, water)
Blood-injection-injury type
Situational type (eg, airplanes, elevators, enclosed places)
Other type (eg, fear of choking, vomiting, or contracting an illness; in children, fear of loud sounds or costumed characters)
Adapted with permission from American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed., text revision.
Washington (DC): The Association; 2000:449–50. Copyright © 2000,
American Psychiatric Association.
and flying, no gender differences are noted.11
The epidemiology of psychiatric disorders among
African Americans and other racial and ethnic groups
remains an understudied field. African Americans had
the highest lifetime prevalence of simple phobia compared with other groups studied in the Epidemiologic
Catchments Area study,12 although Neal and Turner13
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Lifetime
Prevalence
Male, %
Lifetime
Prevalence
Female, %
Total
Lifetime
Prevalence, %
19.2
30.5
24.90
Panic disorder
02.0
05.0
3.5
Agoraphobia
without panic
disorder
03.5
07.0
5.3
Social phobia
11.1
15.5
13.30
Simple phobia
06.7
15.7
11.30
Generalized
anxiety disorder
03.6
06.6
5.1
Any affective disorder
14.7
23.9
19.30
Any substance
abuse/dependence
35.4
17.9
26.60
Nonaffective
psychosis*
00.6
00.8
0.7
Disorders
Any anxiety
disorder
UM-CIDI = University of Michigan Composite International Diagnostic
Interview. (Adapted with permission from Kessler RC, McGonagle KA,
Zhao S, et al. Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States. Arch Gen Psychiatry 1994;51:12.)
*Nonaffective psychosis includes schizophrenia disorder, schizoaffective disorder, delusional disorder, and atypical psychosis.
caution that the sampling problems in this study were
magnified in the African American subsample. In the
Epidemiologic Catchments Area study, recent phobias
occurred in 15.8% of blacks versus 9.8% of whites in
Baltimore and 8.5% blacks versus 4.1% whites in St. Louis.
An earlier study by Warheit et al14 showed the same trend,
with African Americans reporting simple phobia 3 times
more often than white Americans.
COMORBIDITY AND COVARIATON
Specific phobias frequently co-occur with other
mental disorders. Community sample rates of cooccurrence with other disorders range from 50% to
80%.4 Brown et al15 reported that 33% of individuals
presenting with specific phobia had an additional
mood or anxiety disorder. Curtis et al7 reported that the
likelihood of an individual with specific phobia having
another anxiety disorder (agoraphobia, generalized
anxiety disorder, panic disorder, or social phobia) was
especially high, ranging from 42% of those with a single
fear to 84.1% of those who had 6 to 8 fears.
Psychiatry Volume 8, Part 4 3
Specific Phobias
Table 3. Lifetime Prevalence of Specific Fears With
and Without Simple Phobia
Specific
Fear
Lifetime
Fears, %*
Lifetime Phobia with
Specific Fears, %†
Heights
20.4
5.3
Flying
13.2
3.5
Close spaces
11.9
4.2
Being alone
07.3
3.1
Storms
08.7
2.9
Animals
22.2
5.7
Blood
13.9
4.5
Water
09.4
3.4
Any fear
49.5
11.30
Adapted with permission from Curtis GC, Magee WJ, Eaton WW, et
al. Specific fears and phobias. Epidemiology and classification. Br J Psychiatry 1993;173:213.
*Prevalence of lifetime fears in the total sample.
†Percentage of people in total sample with simple phobia and each lifetime fear (ie, 5.3% of total sample have lifetime simple phobia and a
height fear).
Not surprisingly, people with specific phobias frequently have more than one. Curtis et al7 reported that
fewer than one quarter of people with lifetime simple
phobias had only a single fear. The additional phobias
tend to cluster within a subtype, although there remains
disagreement about how clear this sorting is.9
FAMILIAL AND GENETIC STUDIES
In general, family studies have reported that an individual with one type of anxiety disorder tends to have
that particular type of disorder overrepresented among
their relatives. Fyer’s16 group compared family members of individuals with specific phobias to those of individuals without mental illness. Thirty-one percent of
the relatives of people with specific phobia were diagnosed with specific phobias compared with 11% in the
control group. Other mental disorders were not found
more often among relatives of people with specific phobia. The researchers then compared relatives of individuals with specific phobia, social phobia, panic disorder with agoraphobia, and individuals without mental
illness.17 In this later study, the relatives were at increased risk principally for the same type of anxiety disorder as the proband.
More recently, Barlow18 reported that his group’s
preliminary results studying family aggregation of specific phobia and its subtypes confirm the earlier finding
4 Hospital Physician Board Review Manual
that relatives of people with specific phobia are more
frequently diagnosed with specific phobia than relatives
of controls (28% versus 10%). No difference in the
rates of other anxiety disorders in the 2 groups of relatives was found. Of additional interest, there appears to
be further aggregation by subtype for at least animal
and blood-injection-injury phobias. For animal phobias, this appears to be specific; that is, the excess in
phobias was exclusively an increase in animal phobias.
Of course, familial aggregation does not separate
genetic from environmental contributions. For this, twin
studies provide more clarity. Unfortunately, twin studies
on specific phobias have provided mixed results. Additionally, many have dealt with fears rather than clinically
significant phobias. Two more recent twin studies that
focused on phobias had opposite findings. Kendler et
al19 reported greater concordance of monozygotic twins
for situational and blood-injury-injection phobias in
addition to the earlier finding of greater concordance in
the animal phobia groups.20 Skre et al in 199321 reported no significant difference in concordance rates beween monozygotic and dizygotic twins.
ETIOLOGY
While it is tempting to believe that specific phobias
develop in a simple, direct manner via conditioning following a traumatic experience, nearly all studies have
had significant number of individuals without any recall
of a traumatic event related to the development of their
phobia.22 Barlow22 notes that even the studies of Öst
and Hugdahl in the 1980s, which reported some of the
highest rates of recall of traumatic events associated
with phobias and also asked about vicarious or informational transmission, found between 10% to 20% of
people without any incident linked to their fears. In
addition to the role of vicarious conditioning, Barlow
asserts that the experience of a false alarm of anxiety
symptoms paired with an object or condition, especially when escape is difficult, may be part of the “missing
link” in the history of people who do not recall a direct
traumatic event associated with a feared object or situation. As always, biased recall needs to be considered as
an issue in retrospective studies in clinical populations.
In part to account for the fact that not all phobias
appear related to a direct conditioning experience, a
model of learning that includes other mechanisms, such
as vicarious conditioning through information and instruction, was proposed by Rachman.23 Still, this model
relies on the occurrence of some type of learning experience. Theories of nonassociative fear acquisition have
also been developed. These theories propose that some
fears that are biologically relevant are found in most
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Specific Phobias
Table 4. Gender and Age Difference for Specific Phobias
Any animal phobia
Snake
Spider
Average
Prevalence
Rate, %
Women, %
Younger
(Median,
29 yr), %
Older
(Median,
53.5 yr), %
Men, %
7.9
5.5
3.3
12.1
7.9
8.1
2.4
8.3
4.4
6.7
3.5
1.2
5.6
4.7
2.5
13.2
8.5
17.4
9.4
16.8
Lightning
2.1
0.3
3.7
0.9
3.3
Closed spaces
4.0
2.4
5.4
2.6
5.3
Darkness
2.3
0.0
4.3
2.1
2.2
Heights
7.5
6.3
8.6
5.3
9.9
Any situational phobia
Flying
Any mutilation phobia
2.6
1.8
3.2
1.8
3.3
3.0
2.7
3.2
3.8
2.2
Injections
1.6
1.2
1.9
1.8
1.4
Dentist
2.1
2.1
2.1
2.6
1.7
Injuries
3.3
2.4
4.0
2.1
4.5
Adapted from Fredrikson M, Annas P, Fisher H, Wik G. Gender and age differences in the prevalence of specific fears and phobias. Behav Res
Ther 1996;34:37, with permission from Elsevier.
members of a species.24 Individuals who go on to present
with fears and phobias are those who have failed to
unlearn this biologic predisposition via exposure/
habituation. Indeed, this theory is consistent with data
that acrophobic individuals have less relevant direct traumatic experiences (because presumably they are more
cautious) than those without fear of heights.25 Antony
and Swinson26 document no increase in learning events
found in individuals with dog phobias, water phobias,
and height phobias. Such evolutionary relevant fears
(eg, heights, water, strangers) would be expected to have
an early age of onset, often lack a trauma history, be
more influenced by early safe exposure to stimuli, and
be less influenced by personality traits.24
PATHOPHYSIOLOGY
Studies of the pathophysiology of specific phobias
reveal some similarities with other anxiety disorders as
well as differences. Similarly, within the specific phobia
disorders pathophysiologic similarities and differences
exist between the subtypes of these phobias. In specific
phobias, the most intense symptoms of anxiety (in
order) are27:
•
•
•
•
Fast heart rate
Muscle tightness
Urge to flee
Rapid breathing
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•
•
•
•
•
•
Feeling of doom
Feeling fidgety
Trembling
Shortness of breath
Cold extremities
Chest pounding sensation
These are similar to symptoms experienced during a
panic attack. In a study by Antony’s group,10 the percentage of people experiencing a panic attack with
exposure to the phobic stimulus ranged from 57% for
blood-injury-injection phobias to 20% for animal phobias. As already mentioned, specific phobias are subclassified in part due to a difference in physiologic response.
The blood-injury-injection type of phobia is unique
in that people report a vasovagal response with a primary symptom of fainting or feeling faint. In Öst’s study28
comparing people with blood phobia, injection phobia,
animal phobias, dental phobia, and claustrophobia,
only those with blood or injection phobias reported a
history of fainting with exposure to the phobic stimulus.
Fainting rates were 70% and 56%, respectively. For
most patients, this response occurs in 2 phases, with an
initial increase in heart rate and blood pressure lasting
seconds or minutes followed by a sudden decrease in
arousal with fainting or feeling faint.5 The question of
the stimulus and the response arises when one notes
Psychiatry Volume 8, Part 4 5
Specific Phobias
that 30% to 44% of people with this type of phobia did
not report a prior history of fainting. Antony and
Barlow5 hypothesize that perhaps fainting (in the presence of blood) is the stimulus, which then results in
anxiety over fainting which in turn contributes to the
phobia. This fear of an anxiety-related symptom (fainting) brings to mind the way in which individuals with
panic disorder develop phobic avoidance at least in
large part for fear of having a panic attack. Overall,
measures of anxiety sensitivity are lower in people with
specific phobias than in people with panic disorder.
The situational subtype of specific phobia is associated
with the greatest anxiety sensitivity and fear during
panic induction challengers (CO2 inhalation hyperventilation) within this disorder.5
In addition to fear and anxiety, another feature of
specific phobia is disgust. Disgust sensitivity seems to be
at work in certain animal phobias and blood injury
injection phobias. Disgust as well as fear decreases with
behavioral treatment.5 There is little research to date
focused on the physiology of specific phobias. Parameters measured have included heart rate, skin conductance, norepinephrine, epinephrine, insulin, cortisol,
and growth hormone. A few functional imaging and
electroencephalographic studies have also been attempted but have been inconclusive.5
CASE 1
INITIAL PRESENTATION AND HISTORY
Mrs. C. is a 38-year-old divorced white woman who
works as an accountant for a large multispecialty clinic.
She presents with symptoms of severe anxiety due to
2 changes in her work environment. Her company
recently completed construction of a corporate office in
the downtown of a midsized city. Now, rather than a
short commute to a suburban office park, she has to
drive 30 minutes, the last 15 minutes of which involves
driving in rush-hour traffic on a crowded interstate with
elevated interchanges. In addition, she has to park in a
large garage with a relatively low wall, a spiral ramp to
exit and, most alarmingly, her parking spot is on the
roof where she is afforded an unwelcome view of the
city from about 10 stories up. Thus far she has attempted to cope with this by leaving much earlier than she
needs to in the morning, staying much later at night,
and carpooling. She is developing more anxiety even
when driving in previously “safe” situations. She is forgoing routine trips to the grocery store and theatres,
ordering in food, and staying at home.
6 Hospital Physician Board Review Manual
In addition to anxiety while driving or thinking
about driving, she also experiences fear taking the glass
elevators to the new 15th-floor office. This anxiety is
similar whether she is on the elevator alone or in a
crowd. Standing near the glass increases her symptoms.
She discovered a freight elevator, but it is in an isolated
location. Although she has developed depression and
more general worry about the future of her job and
social life, Mrs. C. does not experience significant physiologic symptoms of anxiety except when driving, riding
in elevators, or thinking about these situations.
• What diagnosis would be given Mrs. C.?
• What other questions should be asked to help confirm the diagnosis?
Mrs. C. should be diagnosed with specific phobia, situational type (driving). Her additional problems with
elevators and the garage raise a more difficult diagnostic problem: while one could consider these additional
situational types of phobias, she also seems to be sensitive to height, a natural environment subtype. Further
history may help distinguish whether height itself is a
phobic stimulus or only when paired with the elevator
and driving situations. This illustrates why some believe
that a simpler classification scheme that lists the phobic
stimulus without grouping into subtypes would be more
useful. Since Mrs. C.’s anxiety is limited to specific situations and she does not have unexpected panic attacks
and her avoidance is limited to specific activities and situations, she would not qualify for a diagnosis of panic
disorder with agoraphobia. As described, she does not
meet criteria for major depression or generalized anxiety, but one would want to inquire about symptoms of
these disorders, such as sleep, appetite, energy, pervasive mood changes, and physical tension, to exclude an
additional mood or anxiety disorder.
PRESCRIPTION
Her doctor prescribes alprazolam 0.5 mg orally
3 times daily as needed. Mrs. C. fears taking this before
driving but she said she would try it before riding in the
elevator the next day. She reports some relief during
that trip, but another dose taken the next day provides
less relief. She says that she plans to carry the alprazolam in her purse “just in case I need it.”
• What treatment is recommended for specific phobia?
The primary treatment for specific phobia is behavior
therapy focused on exposure to the anxiety-provoking
stimulus (Table 5). Mrs. C. elected to work on the driving
phobia first as her carpooling friend was being transferred in 2 weeks. She was asked to develop a hierarchy
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Specific Phobias
Table 5. Treatments for Specific Phobias
Treatment
Rating
Advantages
Disadvantages
In vivo exposure
++++
Highly effective, early response, treatment
gains maintained at follow-up
May lead to temporary increases in discomfort
or fear
Applied tension
+++
Highly effective for patients with bloodinjection phobias who faint, early
response, treatment gains maintained at
follow-up
Treatment is relevant for small percentage of
patients with specific phobias
Applied relaxation
++
May be effective for some patients
Treatment has not been extensively researched
for specific phobias
Cognitive therapy
++
May help to reduce anxiety about conducting exposure exercises
Treatment has not been extensively researched
for specific phobias, treatment is probably not
effective alone
Benzodiazepines
++
May reduce anticipatory anxiety before
patient enters phobic situation, and may
reduce fear, particularly in situational
specific phobias
Treatment has not been extensively researched
for specific phobias, treatment is probably not
effective alone, in many cases, side effects (eg,
sedation) occur, discontinuation of symptoms
may undermine benefits of treatment
Selective serotonin
reuptake inhibitors
++
May reduce panic sensations for individuals with situational phobias that are similar to panic disorder (eg, claustrophobia)
Treatment has not been extensively researched
for specific phobias, there are a few studies
(primarily case reports) with promising
results, discontinuation of medication may
result in a return of fear
Adapted with permission from Antony MM, McCabe RE. Anxiety disorders: social and specific phobias. In: Tasman A, Kay J, Lieberman J, editors.
Psychiatry. 2nd ed. Hoboken (NJ): John Wiley & Sons; 2003:1298–330. Copyright © 2003 John Wiley & Sons Limited.
of exposure (Table 6). She found side streets close to
home the easiest and busy freeways—especially if they
were elevated and complicated—the most difficult. In
between she listed main surface streets, 2-lane but highspeed highways, and rural divided carriageways. As
might be expected, driving at busier times provoked
more anxiety. Having an adult passenger helped, but
driving one of her children worsened her anxiety. She
was asked to perform homework of resuming driving in
her neighborhood on side and busier surface streets,
gradually increasing time spent driving as well as moving
toward driving at busier times. At the second session, she
had been able to navigate throughout her neighborhood and even took a trip via the back highway to a
nearby city. At this session she was given the homework
assignment of resuming freeway driving. She was permitted to start with weekend driving and allow herself an
adult passenger if needed initially to move to the next
stage. She was able to resume some freeway driving and
even was able to drive herself to work but continued to
remain up to 2 hours past the office’s usual closing time
for the traffic to thin out. One night when a Monday
night football game increased the downtown traffic well
into the evening, she ended up staying in a hotel.
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During the next session, imagining driving onto the
entrance ramp closest to her work brought severe anxiety. She was reminded of the option to bring the friend
along and, if this was not feasible, the therapist was available to accompany her. She was encouraged to practice
using this particular entrance ramp first at quiet times
and then with more and more traffic. By the next session, she reported she had been able to master this task.
The next step was to tackle the anxiety provoked by
the elevator and heights. In the same manner, a hierarchical table was made and the patient was encouraged to
expose herself to these situations. As luck would have it,
the therapist’s office building had a restaurant on the
20th floor with an outdoor terrace, which allowed the
therapist to easily participate in directly exposing the
patient to the element of acrophobia present in the
patient’s history. Over a relatively brief but intensive
exposure, the patient first walked over to the windows,
looked down, and then was directed to proceed outdoors
to the terrace where only the railing stood between her
and the ground. In each case, the therapist accompanied
the patient and then gradually increased the distance
between them eventually leaving the patient alone with
instructions to return to the office when the anxiety had
Psychiatry Volume 8, Part 4 7
Specific Phobias
Table 6. Hierarchy (Driving)
Anxiety
Level*
Low
High
Table 7. Hierarchy (Elevators)
Fear Rating
(0–100)
Situation
60
Side streets
65
Main streets
70
Two-lane highways
75
Dual carriageway
80
Freeway (rural)
83
Freeway (suburban)
85
Freeway (city, at grade)
90
Freeway (elevated)
93
Closed in/walled freeways
95
Parking ramps
Fear
Anxiety Rating
Level
(0–100)
Low
High
Elevator Type
Duration
80
Standard elevator,
2–3 people
Short trip
83
Glass elevator,
2–3 people
85
Standard elevator alone
90
Standard elevator
crowded
93
Glass elevator alone
95
Glass elevator crowded,
≥ 6 people
Long trip
*Anxiety increased with the volume of traffic, decreased with an adult
passenger, and increased with a child passenger.
abated, about 20 minutes later. The therapist encouraged her to continue the exposure by walking to the
edge of the parking garage at his rooftop spot.
Since the freight elevators seemed an unrealistic longterm option, the patient was encouraged to focus her
exposure activity on the glass elevator. Again, she made a
more specific hierarchy of this situation (Table 7). Some
work had already been done with the therapist in getting
to the restaurant via elevator, but these conventional elevators did not elicit the same degree of anxiety as the glass
elevators. As the patient already had learned the principles
of exposure, she was able over the next week to ride the
elevator by herself with only minimal anxiety.
FOLLOW-UP
At her next appointment, Mrs. C. admits to feeling
ashamed when a friend noticed her bottle of alprazolam when it fell out of her purse. She has continued to
carry the alprazolam despite her prior experience of it
being ineffective. With further questioning it becomes
clear that the alprazolam has become a “safety” behavior and in fact is likely interfering with her becoming
more completely free of her fears.
than those given placebo during a first flight, but with a
second flight those who had taken the benzodiazepine
with the first flight had more fear and anxiety than
those who took placebo. Alprazolam also had no additional benefit when added to exposure with the treatment of spider phobias.30 A longer acting benzodiazepine, diazepam, was added to exposure therapy in
treating small animal phobias but did not decrease the
length of treatment time needed.31
As mentioned, often benzodiazepines are not so
much used by patients as active treatment but as reassurance. Despite little benefit beyond short-term symptom relief, patients will carry bottles, sometimes even
empty bottles with them. Other items sometimes carried
as part of safety behaviors are cell phones, water bottles,
and rosary beads. The role of these safety behaviors in
decreasing the effectiveness of exposure therapy has
long been theorized and demonstrated. The latest study
by Powers et al32 showed that not only was using safety
behaviors associated with poorer outcome but even having safety behaviors available similarly decreased the
effectiveness of exposure for individuals with claustrophobia. Safety behaviors are not limited to medications
but can include the use of relatives, friends, therapist,
coping cards, and other objects to help stave off anxiety.
• Do medications have a role to play in treatment?
Mrs. C.’s experience with the benzodiazepine illustrates 3 main points of the limits of pharmacotherapy in
the treatment of specific phobias. First, Mrs. C. experienced only temporary relief of anxiety and with the
next exposure felt the medicine was less effective. A
study by Wilhelm and Roth29 using alprazolam for fear
of flying showed less fear among those receiving drug
8 Hospital Physician Board Review Manual
CASE 2
INITIAL PRESENTATION
Mr. K., a 30-year-old married man, presents to his
family physician complaining of poor sleep, poor
appetite and increased anxiety over the past 2 months.
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Specific Phobias
His wife urged him to see his doctor and ask for a tranquilizer to help with his symptoms. After conducting a
brief history and physical examination, the physician
orders some routine laboratory studies and gives him a
prescription of lorazepam 0.5 mg to use at bedtime and
as needed for anxiety. The doctor considers depression
as an underlying problem, but Mr. K. adamantly denies
feeling sad or blue.
A 2-week follow-up call reveals little improvement
beyond a couple nights of better sleep. Mr. K. is urged to
come back to the office. At this time he discloses that his
symptoms began when his wife, now 7 1/2 months pregnant with their first child, enrolled them in a childbirth
class. At the first class 1 1/2 months ago, a movie about
childbirth resulted in his having an intense feeling of
anxiety with increased heart rate, flushing, and nausea.
Following these sensations, he felt faint, slumped in his
chair, and left the room as soon as he was able. A few
weeks later, his wife asked him to accompany her to a
routine obstetric appointment. He excused himself saying he had a meeting at work that he could not miss,
although the real reason was that he feared that procedures such as phlebotomy or injections might be required. He is now concerned that he will not only be
unable to accompany his wife to the class and future
appointments, but also that he will be unable to be present in the delivery room. Mr. K. reports that he has had
no contact with a physician since a high school sports
physical due to his fear of medical procedures.
His physician offers to continue the lorazepam until
after the delivery but Mr. K. feels it had been of limited
benefit. The doctor advises that Mr. K. avoid further
stress by insulating himself from prenatal classes and
appointments and to try not to think about the upcoming birth. With some doubt that there is sufficient time
to improve Mr. K.’s condition (estimated date confinement is now only 6 weeks away), the doctor refers him
to an anxiety disorders clinic.
and tolerate. For some phobias (eg, flying), practical
reasons may warrant exposure via imagery, using
movies and photographs or more recently, computerassisted “virtual” exposure. Antony and Swinson26 summarize that in treatment for many specific phobias such
as injection, animals, and dental treatment, single sessions of in vivo exposure lasting 2 to 3 hours may result
in improvement in up to 90% of patients. In general,
exposure over a short period has been considered more
effective at fear reduction; however, Rowe and Craske in
a 1998 study33 found less return of fear with an expanded schedule. It is also suggested that exposure happen
in a variety of locations and situations to promote generalization and decrease relapse.26
Behavior therapy clearly is an effective treatment for
specific phobia often in a remarkably brief period of
time. Lipsitz et al34 note most studies report sustained
benefit from 6 months to 1 year after treatment and a
few longer follow-up studies (1 to 4 years) also show low
rates of relapse. They caution however that a 10- to
16-year follow-up of 28 patients previously treated in
their program with 75% showing improvement with
treatment revealed that 75% had experienced clinically
significant impairment or marked distress during the
intervening years. However, the degree and duration of
the impairment was variable and importantly seemed to
result in little occupational impairment, with only 2 participants (7%) reporting missing a few days to a month
of work due to emotional problems in the 5 years prior
to the follow-up assessment. The types of treatment initially received included behavior therapy and imipramine (36%), behavior therapy and placebo (29%), and
supportive therapy and imipramine (36%). There was a
tendency (short of statistical trend) in those who received behavior therapy (with or without imipramine)
to be less symptomatic at follow-up. Systematic desensitization was the treatment rather than in vivo exposure,
which is now more widely used.
• How appropriate is this advice?
APPLIED MUSCLE TENSION
Applied muscle tension is used in blood-injuryinjection phobias to enhance the ability of people to
increase blood pressure and thereby prevent fainting.
The person then applies this technique during exposure to blood-injury-injection stimuli. Antony and
Swinson26 reviewed the applied tension/exposure studies and reported consistent improvement in 5 sessions,
and 1 study reported positive results with 1 session followed by self-directed exposure.
As previously mentioned, the primary mode of treatment for specific phobia is exposure therapy. In addition
to the clinic referral, rather than encouraging avoidance
of anxiety-provoking situations and thoughts, Mr. K.’s
doctor should give him information about anxiety,
reassure him that his symptoms are common, not lifethreatening, and treatable, and encourage him to participate with his wife in the birth preparations.
EXPOSURE THERAPY
The preferred mechanism of exposure is in vivo
exposure, usually as intensely as the patient will engage
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COGNITIVE THERAPY
Cognitive therapy may also be useful in treating
Psychiatry Volume 8, Part 4 9
Specific Phobias
phobias, either alone or in conjunction with exposure.
Summarizing some of these studies, Antony and Barlow5
report success of cognitive techniques in treating dental
phobias, claustrophobia, and spider and snake phobias.
EYE MOVEMENT DESENSITIZATION AND REPROCESSING
Eye movement desensitization and reprocessing
(EMDR) has also been studied with specific phobia.
Antony and Barlow5 summarized these studies stating
that the effectiveness of EMDR, which appears limited
to subjective fear ratings, is probably related to the
effects of the exposure component of the technique.
Moreover, since in vivo exposure is more effective than
EMDR, EMDR has little to offer in the treatment of specific phobia.
PHARMACOLOGIC TREATMENT
Generally, pharmacologic treatment has a limited
role in specific phobia due to the success of relatively
brief courses of exposure therapy. Antony and Barlow5
noted that Zoellner’s group in 1996 showed no effect of
alprozolam when added to exposure for spider phobia.
Wilhelm and Roth (1996) showed reduced anxiety in a
first flight but greater fear during a second. The additional concern that using or even carrying medication
may be safety behaviors that interfere with a robust
response to exposure and also limits their usefulness in
the treatment of specific phobia.32
Antidepressants, including selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants, and
monoamine oxidase inhibitors are commonly and
effectively used in the treatment of other anxiety disorders, such as panic disorder and social phobia.
Benjamin et al,35 using paroxetine in a double-blind,
placebo-controlled study of 11 patients in the treatment of specific phobias, reported only 1 of 6 patients
responded to placebo whereas 3 of 5 patients responded to paroxetine. The phobias included 2 animal phobias (1 in each group), 2 claustrophobias (1 in each
group), 2 storm phobias (both in the placebo group),
and 2 driving phobias (both in the paroxetine group).
Rounding out the placebo group was a flying phobia
and darkness phobia. The paroxetine group had 1 individual with acrophobia. It may be that SSRIs will have a
role in the future for treating specific phobias, especially those phobias that appear more similar to panic disorder (some situational phobias, such as driving phobias, and claustrophobia) where the stimuli are more
frequently encountered and may lead to more generalized phobic avoidance. Even if additional studies confirm the short-term effectiveness of paroxetine or other
SSRIs in the treatment of specific phobia, the rate of
10 Hospital Physician Board Review Manual
relapse with discontinuation of drug therapy in panic
disorder in contrast to the more enduring efficacy of
cognitive therapy would still warrant caution before
abandoning or indeed not offering an effective, lasting,
nondrug treatment for specific phobia.
FOLLOW-UP
Mr. K. goes for an assessment at the anxiety disorders
clinic the following week. The diagnosis of specific phobia, blood-injury-injection type, is made. A proposal is
made that Mr. K. return the next week for 2 days to begin
behavior therapy. Mr. K. is told that training in applied
muscle tension will take place on the first day. This
involves learning how to tense his muscles to increase
blood pressure and thereby prevent fainting. He is told
that after learning these techniques, rather than avoiding
thinking about and preparing for the birth as his physician advised, he will begin a program of exposure consisting of films of childbirth (vaginal and caesarian deliveries)
and other operations. The following week Mr. K. will be
urged to have his own blood drawn and to attend his
wife’s obstetric appointment in addition to his continued
exposure treatment using films. He also will be given
homework to do using the muscle tension exercises while
imagining the impending delivery watching the films.
The therapist also discusses attempting to arrange in
vivo exposure to deliveries or operations in the hospital.
If she is unable to arrange this, they would work with
additional video experiences. Mr. K. reluctantly agrees
to the muscle training but is concerned that the exposure therapy would just make matters worse. The cognitions interfering with his acceptance of therapy (that
matters would be worse, he would let his wife down, he
would faint during the next viewing of the movie) are
explored and alternative ideas and outcomes are suggested. He agrees to the sessions. Along the way, in addition to the applied muscle tension and exposure therapy, cognitive techniques continue to be necessary to
counteract his oversensitivity to anxiety symptoms, pessimism regarding the possibility of improvement, negative feelings about himself, and catastrophizing about
the future of his marriage should he not be able to conquer his anxiety. In the end, Mr. K. is able to attend the
delivery, although he did continue to experience some
apprehension; however, it was viewed as within the normal range of experiences for first-time fathers.
SUMMARY
Specific phobias are some of the most common and
treatable psychiatric conditions. Despite this, few
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Specific Phobias
people with specific phobias seek treatment. Phobias
are likely acquired through both learned and probably
evolutionary-based nonassociative mechanisms. Exposure therapy, in vivo when feasible, is the most effective
and enduring treatment. Applied muscle tension to
avoid fainting can be added to exposure to treat bloodinjury-injection subtype. Adding cognitive techniques
may also help with distorted beliefs about anxiety symptoms, negative perceptions about situational stimuli,
and comorbid depression and anxiety. At present, there
is little evidence to support pharmacologic treatments
including anxiolytics and antidepressants; however,
additional studies supporting some medications, such
as SSRIs, may be available in the future.
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Copyright 2005 by Turner White Communications Inc., Wayne, PA. All rights reserved.
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