Download Phobias

Clinical update
Amy Wenzel, PhD
S a b i n e P. S c h m i d , P h D
A a r o n T. B e c k , M D
Phobias
Scope of the Problem
A phobia is a persistent, excessive
fear of a particular object or situation that causes avoidance, distress, and life interference. Specific
phobias are among the most common psychiatric disorders, with
11% of the population meeting
diagnostic criteria for specific phobia at any time in their life (Kessler
et al., 1994) and 5.5% of the population meeting diagnostic criteria
for specific phobia within a 30-day
period (Magee, Eaton, Wittchen,
McGonagle, & Kessler, 1996). There
is little debate among clinicians
regarding the most straightforward way to treat phobias, as most
clinicians accept that treatment
involves some sort of systematic
exposure to the feared object
or situation in order to achieve
reasonable success (Antony &
Barlow, 2002). In fact, very shortterm treatment (one to five sessions) is associated with clinically
significant, long-lasting changes in
up to 90% of cases (Öst, 1989; Öst,
Brandberg, & Alm, 1997).
Despite the fact that specific
phobias are so common and that
well-articulated treatment protocols are readily available, practitioners often experience uncertainty
when they encounter a client with
a specific phobia. For example,
specific phobias are common in
the general population, but rarely
do individuals with specific phobias seek treatment for this problem (Kessler et al., 1999). Thus,
clinicians are infrequently called
upon to provide treatment. When
individuals with specific phobias
are indeed in treatment, it is usu-
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Fa m i ly Th e r a p y m a g a z i n e
ally for a psychiatric problem that
is judged to be of greater severity (Sanderson, DiNardo, Rapee, &
Barlow, 1990). It would follow that
these particular clients are likely
to present with a complex array
of psychiatric symptoms that may
or may not complicate the course
of standard treatment for specific
phobia.
Clinicians often operate under
the assumption that specific phobias are less severe than other
psychiatric disorders. Indeed, this
is often the case, as the fears are
circumscribed enough that most
individuals with specific phobias
can arrange their lives so that
they can easily avoid encounters with feared objects or situations (Antony & Barlow, 2002).
Nevertheless, it is important for clinicians to be aware of the potential for pervasive life interference
that can result if specific phobias
are untreated. The consequences
of specific phobias often manifest
themselves more saliently when
an individual experiences a major
life transition where he or she
can no longer avoid the phobic
object or situation. For example, an
individual with a driving phobia
might suddenly spend hours to
avoid certain highways or bridges
when she takes on a new job at a
different location. A dental phobic
might develop major dental problems because he avoided routine
maintenance for several years.
There is very little research
and discourse on the effects of
specific phobias on relationships
and family functioning. However,
our clinical experience suggests
that specific phobias can take on
a profound role in a relationship
culture or family system. Many of
our adult clients with specific phobias describe conflicts with their
partners over avoidance of phobic
objects or situations. In extreme
cases (e.g., a housebound agoraphobic woman whose husband
assumes the role of care provider),
a power imbalance can emerge
which enables the partner of the
phobic individual to assume substantial control in the relationship
and the phobic individual to continue his or her passive avoidance
under the guise of being “cared for”
by the partner (Jackson & Wenzel,
2002). Many families of children
with specific phobias have created
elaborate, time-consuming rituals
to structure the phobic child’s environment so that the child either
successfully learns to deal with
the phobia, or so that the family
can avoid a “scene” involving the
phobic stimulus. Thus, a specific
phobia in any one family member has the potential to complicate family interactions, roles, and
dynamics. Following is up-to-date
information about the nature,
assessment, and treatment of specific phobias, with consideration
of the manner in which specific
phobias affect close relationships
and can be addressed from an
interpersonal approach.
Etiology
It is important to understand the
current thinking on the etiology
of specific phobias, as many clients ask questions such as, “How
did I [or my child] get this?” or
“Why am I [or is my child] like
this?” Historically, and from a behavioral perspective, it was thought
that phobias developed through a
two-stage process (Mowrer, 1939).
That is, first the individual associates an aversive stimulus with a
previously neutral stimulus, such
that the neutral stimulus now is
associated with a fear response
(i.e., classical conditioning). Second,
the individual avoids the phobic
stimulus, which provides negative
reinforcement because avoidance
behavior is associated with relief
and prevents him or her from
experiencing fear and distress
that would otherwise occur (i.e.,
operant conditioning). However,
recent research suggests that this
theory only characterizes a minority of individuals with specific phobias, as many phobic individuals
do not recall a traumatic experience with the feared object or
situation (Poulton, Davies,
Menzies, Langley, & Silva, 1998).
Instead, they often report that
they have “always” been fearful
or that the fear gradually developed into a phobia.
Contemporary theory and
research suggests that an interplay of factors contributes to
the development of specific
phobias. Kendler, Karkowski,
and Prescott (1999) calculated
heritability estimates ranging from
46% to 59% for particular classes
of specific phobias. According to
Antony and Barlow (2002), it is likely that a predisposition to specific
fear-relevant reactions (e.g., a low
threshold for an alarm response,
a tendency to feel faint around
blood or needles) is the particular characteristic that is inherited.
But just as important to the development of specific phobias are
unique or individual-specific environmental experiences (Kendler
et al., 1999; Page & Martin, 1998).
These unique experiences might
involve a traumatic encounter with
the feared stimulus, but they also
could include observational learning (e.g., watching someone else
react fearfully in the presence of a
feared stimulus) or learning from
information (e.g., reading about
the danger of a feared stimulus)
(Rachman, 1977). All of these experiences contribute to the development of beliefs that a particular
stimulus is dangerous, that it is
imperative to be on guard for a
potential encounter with the stimulus, and that the individual does
not have the resources to deal
effectively with an encounter with
the stimulus (Beck & Emery, 1985).
The phobic individual places exaggerated importance on the aversiveness of the stimulus, which
contributes to anxious apprehension about future encounters
(Antony & Barlow, 2002; Beck &
Emery, 1985). Thus, when clinicians are asked about the etiology of specific phobias by clients,
they can explain that biological
vulnerabilities prime individuals
to have specific anxiety responses
to actual or observed encounters
with phobic stimuli or learned
information about phobic stimuli, which in turn contribute to
the development of maladaptive beliefs about the amount of
danger posed by the stimulus, the
frequency with which they will
encounter the stimulus, and their
ability to cope with the stimulus.
Diagnostics
Although the central feature of
phobias is irrational fear, it has long
been recognized that phobias
are heterogeneous with regard
to their clinical presentation and
associated features (Marks, 1970).
When the third edition of the
Diagnostic and Statistical Manual
of Mental Disorders (DSM-III)
(American Psychiatric Association
[APA], 1980) was introduced, the
category of phobic neurosis was
divided, such that agoraphobia
and social phobia were separated
from other phobias. Agoraphobia
involves fear and avoidance of
being in situations where escape
might be difficult or help may not
be available should a panic attack
occur, and social phobia involves
fear and avoidance of social and
evaluative situations due to the
possibility of embarrassment,
humiliation, or negative evaluation. These disorders are viewed
as comprising a broader range of
symptoms and as being associated
with more functional interference
than specific phobias. Thus, theory
and research about specific phobias applies to these conditions,
but clinical scientists typically
regard them as distinct diagnostic categories that have extensive
literatures of their own.
The DSM-IV (APA, 1994) specifies seven criteria, all of which
must be satisfied, for an individual to be diagnosed with specific
phobia. First, the individual must
experience fear cued by the presence or anticipation of a specific
object or situation that is marked,
persistent, and excessive or unreasonable (Criterion A). In addition,
exposure to the feared stimulus
must almost invariably provoke
an immediate anxiety response,
which may take the form of a
situation-specific panic attack
(Criterion B). The person, if an
adult, must recognize the fear
as excessive or unreasonable
(Criterion C). The feared situation or object must be avoided
or endured with extreme distress
(Criterion D). The avoidance, anxious anticipation, or distress in the
feared situation(s) must interfere
significantly with the person’s functioning, or the person must report
marked distress about having the
phobia (Criterion E). In individuals
under age 18, the duration must
be at least 6 months (Criterion F).
Finally, the symptoms cannot be
better accounted for by another
mental disorder (Criterion G).
The requirement of insight
into the unreasonableness or
excessiveness of the fear was
introduced in order to distinguish
phobias from delusional fears, for
which insight is lacking. In actuality, insight has been shown to
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tain animal phobias, but not the
other subtypes, experience disgust and repulsion in addition to
fear (Tolin, Lohr, Sawchuk, & Lee,
1997). Moreover, BII phobias differ from all of the other types in
the unique constellation of physiological symptoms. Whereas most
phobias typically are associated
with higher heart rates and primarily sympathetic activity upon
exposure to the feared stimulus
(Friedman, Thayer, Borkovec, &
Tyrrell, 1993), BII phobias are
associated with only a brief initial increase in arousal (typically
lasting a few minutes or less), followed by a sudden fall in heart
rate and blood pressure below
baseline and frequently resulting
in fainting (Thyer & Curtis, 1985).
Assessment
When screening for phobias,
clinicians may start with a question such as, “Do you experience
fear or discomfort when you
are confronted with any of the
following objects or situations:
spiders, snakes, insects, other animals, closed places such as tunnels or elevators, water, heights,
driving, flying, blood, injections,
dental treatment, or other situations or objects?” (Antony, 2001a).
Additional probing should determine the intensity and reasonableness of the fear, degree of
avoidance, and degree of distress
and functional impairment. Semistructured interviews such as the
Structured Clinical Interview for
DSM-IV (First, Spitzer, Gibbon, &
Williams, 1994) and the Anxiety
Disorders Interview Schedule for
DSM-IV (Brown, DiNardo, & Barlow,
1994; DiNardo, Brown, & Barlow,
1994) systematically and comprehensively cover diagnostic criteria and may aid in the evaluation
process. For treatment planning, a
thorough inventory of fear-related
thoughts, safety behaviors, and
Specific Phobia in children
It is important to distinguish phobias, which are excessive, persistent and maladaptive fears that cause marked distress or disruption
in functioning, from developmentally appropriate childhood fears,
which tend to dissipate within months (Bauer, 1976). Age-appropriate and relatively common fears in children include those related to
the loss of nurturing, unfamiliar people, and loud noises (infancy);
imaginary creatures, small animals, and the dark (early childhood);
school and achievement (during school years); and those related
to social life and bodily injury (later childhood and adolescence)
(Silverman & Moreno, 2005).
Although most childhood fears dissolve without intervention,
some fears may develop into phobias, particularly if the child
avoids the feared object or situation and fails to have corrective learning experiences. Epidemiological studies estimate that
approximately 5% of children and adolescents in the United
States suffer from specific phobia at any given point in time
(Ollendick, Davis, &
Muris, 2004). Animal
phobias typically develop around age 6 or 7,
and situational, blood,
and dental phobias typically develop between
ages 9 and 12 (Öst, 1987;
Kendler, Neale, Kessler,
& Heath, 1992). The
onset of social phobia,
claustrophobia, and
agoraphobia is typically in adolescence or
later (Öst, 1987). When
left untreated, specific
phobias tend to take a rather chronic course and may outlast
many other psychiatric disorders (Barlow, 2002).
As with adult treatment for specific phobias, “real life” exposure is considered an important ingredient of successful treatment. Given that children might be especially reluctant to
engage in “real life” exposure, it is important that they have a
sense of control over the frequency and duration of exposure
exercises. In addition, the use of contingency management procedures (or reinforced practice) and modeling—directly by the
therapist or indirectly using videos—may also be beneficial.
Involvement of caregivers and the consideration of family
influence and dynamics are advisable in the assessment and treatment for childhood phobias. A child’s phobia may disrupt family functioning, such as by preventing joint family activities that
involve the feared stimulus. Therefore, psychoeducation of family
members regarding the nature, maintenance, and treatment of
the disorders, as well as their assistance in exposure exercises and
contingency management plans, may be critical in breaking the
vicious phobia cycle.
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vary greatly among individuals
with phobias. For example, as recognized in the DSM-IV, insight may
be limited in children, which is why
this requirement applies only to
adults. Moreover, recent studies
indicate that a large number of
individuals who would otherwise
qualify for a diagnosis of specific
phobia may be excluded because
they do not view their fear as
excessive (Jones & Menzies, 2000).
Thus, it is important for clinicians
to understand the rationale for the
insight criterion and use their clinical judgment in assigning a diagnosis of specific phobia in cases of
excessive fear and avoidance of a
non-delusional quality.
The DSM-IV defines five categories of phobias: (1) animal type,
which includes fears of spiders,
snakes, cats, dogs, mice, birds, and
other animals; (2) natural environment type, which includes fears of
being near water, storms, and high
places; (3) blood-injection-injury
(BII) type, which includes fears
of seeing blood, medical procedures, and injuries, receiving
injections, and having blood
drawn; (4) situational type, which
includes fears of driving, flying,
and being in enclosed spaces;
and (5) other type, which includes
fears of vomiting, choking, loud
sounds and other residual fears
not belonging to any of the
other categories. The distinction among subtypes is partially
supported by statistical covariation, such that fears within subtypes generally co-occur more
frequently than fears across
subtypes (Öst, 1992). In addition,
subtypes differ along other clinically relevant dimensions such as
age of onset, severity, focus of
apprehension (i.e., interoceptive
versus external triggers), and
physiological response (Hugdahl
& Öst, 1985; Craske et al., 1996;
Marks, 1988). For instance, individuals with BII phobias and cer-
Phobias
avoidance strategies (both overt
and more subtle ones) is essential.
Not only are phobic thoughts and
behaviors targets of treatment, but
subtle avoidance behavior, such as
averting one’s gaze at the sight of
the phobic stimulus, if unrecognized, may undermine exposurebased interventions.
A number of self-report inventories assess fear and avoidance
of particular objects and situations. The 72-item Fear Survey
Schedule–III (FSS–III) (Wolpe
& Lang, 1964, 1969) and the
extended 108-item version of the
FSS-III (Wolpe & Lang, 1977) are
among the most popular screening tools for phobias in both
clinical and research settings. The
scales list a large range of specific objects and situations and
clients rate the intensity of fear
they associate with each item on
a five-point Likert scale. In addition, many clinical scientists have
developed self-report inventories to capture fearfulness and
avoidance of stimuli related to
particular specific phobias. There
are a number of inventories that
target various animal phobias (e.g.,
spider phobia, snake phobia, dog
phobia) and BII and medical phobias. In contrast, there is only one
published self-report inventory
that targets natural environment
phobias (i.e., heights) and only
a handful that target situational
phobias, most of which focus on
claustrophobia and one focuses
on the fear of flying. A comprehensive description of self-report
inventories assessing aspects of
specific phobias can be found in
Antony (2001a, b) and in McCabe
and Antony (2002).
Perhaps the most accurate way
to obtain a clear understanding
of the severity of a client’s specific phobia is to observe him or
her first-hand in the presence of
the phobic object or situation
using a Behavioral Approach Test
(BAT) (Antony & Swinson, 2000). A
Progressive BAT requires the client to gradually approach a feared
stimulus while the clinician records
variables such as the number of
steps taken toward the stimulus,
self-reported level of anxiety on
a 0-100 scale, self-reported fearrelevant cognitions, subtle avoidance behaviors (gaze aversion), and
physiological reactivity (heart rate).
A Selective BAT requires the client
to generate a list of feared situations (i.e., exposure hierarchy; see
description below), and the same
variables as in the Progressive BAT
are measured. In addition to providing clinicians with a thorough
understanding of the extent of
their client’s specific phobias, BATs are used to individually tailor treatment (such
as by establishing an exposure
hierarchy), track progress,
and evaluate the success of
treatment (Antony, 2001a;
Barlow, 2002).
Treatment Options
Most clinicians agree that some
type of exposure to the feared
stimulus is necessary for the treatment of specific phobias (Antony
& Barlow, 2002). Imaginal exposure
involves exposure to vivid images
of feared stimuli, whereas in vivo
exposure involves actual encounters with feared stimuli. An early
exposure treatment for specific
phobias, systematic desensitization, required clients to imagine a
graded hierarchy of feared stimuli
while simultaneously engaging in
muscle relaxation. This treatment
was grounded in behavioral theory, as it was reasoned that the
pairing of relaxation with images of the feared stimulus would
extinguish the fear response.
However, few clinicians currently
use systematic desensitization in
the treatment of specific phobias,
as in vivo exposure is both more
effective and more time efficient
(Marks, 1987), and some empirical research suggests that adding
relaxation to exposure protocols
does not result in increased effectiveness (Öst, Lindahl, Sterner, &
Jerramalm, 1984).
Although the central feature of in vivo exposure is that
it involves an actual encounter
with the stimulus, there is tremendous variation in its particular
implementation. For example, we
know that massed exposure (e.g.,
10 daily sessions) is more effective in reducing phobic symptoms
than spaced exposure (e.g., 10
weekly sessions) (Foa, Jameson,
Turner, & Payne, 1980). Data from
recent studies suggest that an
expanding-spaced exposure protocols (where sessions begin close
together and are gradually spaced
out throughout the course of treatment) are beneficial because they
provide optimal circumstances for
the initial reduction in fear, but also
reduce the probability of a return
of fear following treatment (Rowe
& Craske, 1998a). In addition, exposure appears to be most effective
when sessions occur in a variety
of different contexts and using a
variety of different feared stimuli
in order to ensure that reduction
in fear generalizes to multiple
settings and stimuli (Bouton,
Mineka, & Barlow, 2001; Rowe &
Craske, 1998b). Moreover, cliniciandirected exposure is significantly
more effective than self-directed
exposure (Öst, Salkovskis, &
Hellström, 1991).
What, then, is the optimal
approach to conducting in vivo
exposure with a specific phobic
client? If the clinician has an ample
chunk of time with the client, there
is evidence that a single 3-hour session is sufficient for clinically significant reductions in fear in 95%
of clients (Öst, 1996). If the clinician
has the more typical 50-minute
time slot with the client, then as
few as five sessions will achieve
clinically significant results, particularly when sessions are spaced
relatively close to one another. It is
also recommended that clinicians
facilitate exposure to a number of
different feared stimuli in order to
promote generalization. Specific
phobias can be treated either in
individual or group format (Öst,
1996); if a group format is chosen,
then it is pertinent that the clinician ensures that each client has
ample direct exposure with the
phobic stimulus (Öst, Ferebee, &
Furmark, 1997). Regardless of the
particular schedule of exposure
sessions, it is crucial that clients
continue the exposure exercise
until their fear decreases rather
than escape the situation (Antony
& Barlow, 1998).
In addition to in vivo exposure, there are other empirically
supported treatments for specific
phobias that are relevant for use
in particular circumstances. As
discussed, BII phobia is associated with a unique constellation
of physiological symptoms, such
that the majority of these clients
experience fainting due to parasympathetic activation rather than
a fight/flight response due to sympathetic activation. Applied tension is a treatment approach that
involves training clients to tense
their muscles in order to increase
their blood pressure and thereby
prevent fainting. Once clients
learn applied tension skills, they
are presented with BII stimuli and
instructed to use the skills to prevent phobic responses. Fear and
fainting associated with BII phobia
are typically reduced after one session of applied tension (Hellström,
Fellenius, & Öst, 1996), and there is
evidence that it is associated with
a greater reduction in BII phobic
symptoms than in vivo exposure
alone (Öst, Fellenius, & Sterner,
1991).
Regardless of the particular in
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quent sessions, the client undergoes systematic exposure to the
items included on the exposure
hierarchy, beginning with the easiest items and progressing through
the more difficult items. Clients are
encouraged to engage in structured exposures to feared stimuli
in between sessions.
Antony and Barlow (1998) suggest that this approach to in vivo
exposure is successful in treating
many of their clients in 1–5 ses-
sions. However, they acknowledge
that other clients benefit from
adjunctive cognitive restructuring.
Cognitive restructuring for specific
phobias involves three components. First, clients are encouraged
to learn everything they can about
the phobic stimulus in order to
develop a sense of controllability
and predictability. Second, clients
develop strategies to address
probability overestimation, which
occurs when they assign an unre-
Nico Kai/Getty Images
vivo exposure therapy protocol,
evidence is accumulating that
change in anxious cognitions is
associated with fear reduction during treatment (Shafran, Booth, &
Rachman, 1993). Thus, it is logical
that cognitive therapy would be
an effective approach in modifying distorted beliefs about phobic
stimuli, as it would directly influence the course of fear reduction.
The small number of studies that
have examined cognitive therapy in the treatment of specific
phobias suggests that it is more
effective than psychoeducation
(de Jongh et al., 1995), and that
it is equally effective as relaxation
(Craske, Mohlman, Yi, Glover, &
Valeri, 1995). One study, however,
found cognitive strategies in the
absence of behavioral experiments less effective in reducing
phobic symptoms than in vivo
exposure (Booth & Rachman,
1992). In all, cognitive therapy
appears to be an efficacious treatment for specific phobia, but that
in vivo exposure appears to be the
key ingredient for evaluating fearrelevant cognitions.
Recently, Antony and colleagues developed a combined
cognitive behavioral protocol for
the treatment of specific phobias that integrates a number of
behavioral and cognitive strategies to address the full range of
behavioral, cognitive, emotional,
and physiological phobic symptoms (see Antony & Barlow, 1998,
for a description). In the early sessions of this protocol, clients are
oriented to the treatment and are
guided in defining the parameters of their specific phobia (e.g.,
thoughts, feelings, and physiological symptoms associated with the
phobia; avoidance, safety seeking, and protective behaviors). In
addition, the client and clinician
develop a list of 10–15 feared situations in order of difficulty, called
an exposure hierarchy. In subse-
alistically high likelihood that
some predicted event will occur
(e.g., that they will have an automobile accident). For example, the
clinician assists clients in examining the evidence that supports
and refutes that prediction or in
identifying realistically the probability that the negative event
will occur. Third, clients develop
strategies to address catastrophic
thinking, which occurs when they
anticipate an excessively negative
impact of a predicted event. In
these instances, clinicians encourage clients to evaluate how bad
the predicted event really would
be; what, realistically, is the worst
thing that could happen; and how
they could cope with this event if
it were to occur.
All of the treatment strategies
discussed up to this point occur in
the context of individual psychotherapy. There is a small amount
of literature that describes the
manner in which partners and
family members may assist in
the treatment of an anxious client. Baucom, Shoham, Mueser,
Daluto, & Stickle (1998) classified
couple and family treatments for
anxiety disorders into three broad
types. Partner-assisted or family-assisted interventions (PFAIs)
involve the partner or family
member as a surrogate therapist
or coach in treating the identified
client. Disorder-specific couple
or family interventions focus on
the manner in which couple and
family interactions serve to maintain and exacerbate symptoms in
an identified client. Unlike PFAIs,
these therapeutic interventions
target relational issues, but only
those issues that directly relate to
the expression of the individual’s
disorder. General couple or family
therapy targets relationship and
family system issues that may or
may not directly relate to individual symptoms.
Rarely has the efficacy and
Phobias
effectiveness of couple and family approaches to the treatment
of anxiety disorders been examined in the empirical literature.
Research conducted 10 to 20
years ago indicates that partnerassisted exposure therapy was
equally as effective as other forms
of exposure therapy in treating
agoraphobic avoidance (Cobb,
Mathews, Childs-Clarke, & Blowers,
1984; Emmelkamp, Van Dyck,
Bitter, Heins, Onstein, & Eisen,
1992). Moreover, partner-assisted
exposure provides the additional
benefit of reducing marital distress as well as phobic avoidance
(Cobb et al., 1984). One study
found that adding a communication skills training component
to partner-assisted exposure for
agoraphobia resulted in greater
reductions in subjective anxiety
and increased unaccompanied
excursions compared to partnerassisted exposure with relaxation
(Arnow, Taylor, Agras, & Telch,
1985). These results raise the
possibility that teaching couples
to discuss and solve problems in
coping with their phobic symptoms can improve the effective-
ness of an exposure intervention.
To our knowledge, no systematic empirical investigation of
partner- or family-assisted exposure in the treatment of specific
phobias has been conducted.
However, therapists can use the
literature on PFAIs for other anxiety disorders as a guide in developing an evidence-based, partneror family-assisted intervention.
Antony and Barlow (1998) noted
that partners and family members
can provide encouragement and
model adaptive behavior during
between-session exposure homework assignments. They suggested that partners and family
members attend therapy sessions
in order to understand the rationale for exposure, the components
that make it successful (such as
clients retaining control in
behavioral exercises), and
therapist behaviors that are
helpful (guidance, coaching, and support). Eventually,
however, the goal is for phobic
clients to conduct exposure exercises on their own so that they do
not rely on their partner or family
members as a “safety signal.”
Terminology
Behavioral Approach Test (BAT). A tool used to assess a client’s
behavior and level of anxiety as he or she approaches a feared
object or situation.
In Vivo Exposure. “Real life” exposure to a feared object or situation.
Imaginal Exposure. Exposure to a feared object or situation that
occurs through vivid images.
Systematic Densensitization. A type of imaginal exposure in which
the client imagines feared objects or situations while relaxing.
Exposure Hierarchy. A list of feared situations ranging from the
easiest to most difficult that is used to guide exposures in session.
Applied Tension. A treatment for blood-injury-injection phobia in
which the client is taught to tense his or her muscles in the presence of feared stimuli in order to prevent fainting.
Partner or Family Assisted Exposure (PFAI). Inclusion of a partner or family member in exposure therapy so that he or she can
serve as a “coach” as the phobic individual attempts exposurebased homework assignments between sessions.
Antony, M. M. (Ed.). (2001b).
Summary
Phobias are a heterogeneous
group of disorders that are best
understood and conceptualized
by an interplay of biological,
cognitive, and behavioral components. Specific phobia is a common psychiatric disorder that is
very responsive to systematic
behavioral or cognitive behavioral interventions involving in vivo
exposure components. A person
might consider seeking treatment
for a phobia if he or she notices
disruption in his or her normal
routine or functioning associated
with lowered life satisfaction. The
idea of in vivo exposure might be
threatening to a phobic individual,
as it involves prolonged encounters with feared objects and situations. However, in vivo exposure
is extremely effective because
phobic clients (a) have clear
expectations for treatment and
have control over the speed with
which they approach the feared
stimuli; and (b) learn first-hand
that there is little danger associated with feared stimuli. Although in
vivo exposure has proven effective
in individual psychotherapy, marriage and family therapists might
involve partners and/or other family members to “coach” clients in
exposure exercises assigned as
homework between sessions.
Professional
Resources
Books and Workbooks
Antony, M. M. (Ed.). (2001a).
Specific phobia: A brief overview
and guide to assessment. In
M. M. Antony, S. M. Orsillo, & L.
Roemer (Eds.), Practitioner’s guide
to empirically based measures of
anxiety. AABT clinical assessment
series. (pp. 127-132). Dordrecht,
Netherlands: Kluwer Academic
Publishers.
Measures for specific phobia. In
M. M. Antony, S. M. Orsillo, & L.
Roemer (Eds.), Practitioner’s guide
to empirically based measures of
anxiety. AABT clinical assessment
series. (pp. 133-158). Dordrecht,
Netherlands: Kluwer Academic
Publishers. Provides practitioners
with a guide for an empiricallybased assessment of specific
phobia, including screening
questions.
Antony, M. M., & Barlow, D. H.
(2002). Specific phobias. In D.
H. Barlow (Ed.), Anxiety and its
disorders, second edition: The
nature and treatment of anxiety
and panic, (pp. 380-417). New
York: The Guilford Press. A comprehensive chapter on diagnostics, etiology, assessment, and
treatment of specific phobias
written by two leading experts. It
reviews the most recent empirical research and resources.
Antony, M. M., & Swinson, R. P.
(2000). Phobic disorders and panic
in adults: A guide to assessment
and treatment. Washington,
DC: American Psychological
Association. This book describes
empirical literature on the diagnostics, etiology, epidemiology,
and empirically-validated treatments of phobic disorders and
panic. It contains a chapter on
specific phobia.
Beck, A. T., Emery, G., &
Greenberg, R. L. (1985). Anxiety
disorders and phobias: A cognitive
perspective. Cambridge, MA: Basic
Books. This classic and highly
influential book (newly edited in
2005) focuses on basic concepts,
etiology and treatment of anxiety disorders from a cognitive
perspective.
Bourne, E. J. (1998) Overcoming
specific phobia—Therapist
manual: A hierarchy and exposure-based protocol for the treatment of all specific phobias (best
practices series). Oakland, CA: New
j u ly a u g u s t 2 0 0 6
41
Clinical updat e
Harbinger. Therapist guide involving specific instructions for an
empirically-validated, 10-session,
cognitive-behavioral treatment
for specific phobias. It can be
used in combination with the
Overcoming Specific Phobia Client
Manual by the same authors.
Craske, M. G., Antony, M.
M., & Barlow, D. H. (1997).
Mastery of your specific phobia:
Therapist guide. San Antonio,
TX: Psychological Corporation
Incorporated. This book contains
general and session-by-session
instructions on conducting
cognitive-behavioral therapy
for specific phobia. It is used
with the Mastery of Your Specific
Phobia Client Workbook.
School of Medicine. Part of her
research involves the investigation of cognitive biases
in anxiety disorders and the
understanding of mechanisms
that underlie change in cognitive therapy for anxiety disorders. She has published over
60 articles and book chapters
and is co-editor of Cognitive
Methods and Their Application
to Clinical Research (APA Books,
2005). Her research is currently
funded by the National Institutes
of Health, the National Alliance
for Research in Schizophrenia
and Depression, and the
American Foundation for Suicide
Prevention.
Sabine P. Schmid, PhD is a post-
Online Resources
Anxiety Disorder Association
of America (ADAA)
www.adaa.org
The ADAA is a professional organization that meets annually for
scientific exchange of the latest
research on all anxiety disorders.
National Institute of Mental
Health
www.nimh.nih.gov
Offers descriptions of symptoms
and treatments of all major
anxiety disorders including
phobias (http://www.nimh.nih.
gov/healthinformation/
anxietymenu.cfm?textSize=L)
and includes information on new
developments, statistics, and
organizations related to phobias
http://www.nlm.nih.gov/
medlineplus/phobias.html and
other anxiety disorders (http://
www.nlm.nih.gov/medlineplus/
anxiety.html), as well as links to
local resources including clinical
trials involving free treatment.
Amy Wenzel, PhD is research
assistant professor of clinical
psychology in psychiatry at
the University of Pennsylvania
42
Fa m i ly Th e r a p y m a g a z i n e
doctoral fellow at the University
of Pennsylvania School of
Medicine. She recently completed her graduate degree at
Vanderbilt University, where she
conducted research on perception biases in social anxiety, cognitive behavioral approaches to
the understanding of depression
and anxiety, and applications of
the tripartite model of anxiety
and depression to treatment
outcome research.
Aaron T. Beck, MD, university
professor of psychiatry emeritus
at the University of Pennsylvania
School of Medicine, is the
founder of cognitive therapy.
He has received numerous
awards for his work, including research awards from the
American Psychiatric Association,
the American Psychological
Association, and the Institute of
Medicine. He has also been listed
as one of the 10 Americans with
the greatest influence in the history of American psychiatry. Dr.
Beck is the author or co-author
of over 500 publications, including 17 books. His cognitive therapy, the most heavily researched
form of psychotherapy, represents a major advance in the
understanding and treatment of
a variety of psychiatric disorders
including affective disorders,
anxiety disorders, substance
abuse, personality disorders, and
schizophrenia.
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September
1–30
National Alcohol and
Drug Addiction Recovery Month
Substance Abuse and Mental Health Services
Administration Center for Substance Abuse Treatment
(800) 729-6686
[email protected]
www.recoverymonth.gov
10
World Suicide Prevention Day
International Association for Suicide Prevention
Screening for Mental Health, Inc.
(781) 239-0071
[email protected]
www.stopasuicide.org
October
1–7
Mental Illness Awareness Week
National Alliance on Mental Illness
(800) 950-NAMI
www.nami.org
1–7
Mental Illness Awareness Week (Canada)
Canadian Alliance on Mental Illness and Mental Health
[email protected]
www.miaw-ssmm.ca
5
National Depression Screening Day
Screening for Mental Health, Inc.
(781) 239-0071
[email protected]
www.mentalhealthscreening.org
10
World Mental Health Day
World Federation for Mental Health
[email protected]
www.wmhday.net
The AAMFT offers a variety of consumer brochures that can
be used in your office (with space on the back for your stamp
or business card), or used in direct mail marketing for your
practice. Please contact [email protected] to order brochures
on Alcohol Problems, AD/HD, Bipolar Disorder, Bipolar
Disorder in Children and Adolescents, Borderline Personality
Disorder, Children of Alcoholics, Depression, Mental Illness
in Children, Obsessive Compulsive Disorder, Panic Disorder,
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Intimate Relationships, Suicide Ideation and Behavior, and
Suicide in the Elderly. Over 40 titles are available.