Approach

Cognitive behavioral therapy (CBT) is the first-line treatment approach for phobias.[48][49][50][51] Short-term treatments usually suffice, and significant improvements are often attained in as few as one to five sessions.[48][51] One-session treatments involving systematic exposure are effective for phobic children and adults.[52][53] Primary goals are to reduce phobic anxiety, eliminate avoidance and safety behaviors, and improve functional capacities. When reviewing treatment options, it is important to consider patients’ past treatments, their motivation, the presence of co-occurring disorders, the availability of treatments, and any barriers to care.

Cognitive behavioral therapy

First-line treatment for all patients with frequent symptoms is CBT, a skills-based intervention.[48][49][51][54] CBT has traditionally involved a combination of education, self-monitoring, cognitive interventions such as challenging negative styles of thinking, exposure to feared stimuli, and relaxation training. The efficacy of exposure therapy in particular is backed by a substantial body of research.[50][55][56] Studies have shown exposure therapy is effective for animal, situational, natural environment, blood-injection-injury, and atypical phobias.[57][58][59][60] There is evidence that the efficacy of exposure therapy is reduced if it is combined with relaxation or the use of anxiety-reducing pharmacotherapy.[61]

Exposure therapy requires that phobic individuals voluntarily face feared stimuli without engaging in safety behaviors (e.g., distraction or reassurance-seeking). When a patient’s response to phobic stimuli involves disgust, the treatment will be more effective if not only a fear response, but also a disgust response, is elicited during exposure.[61] This can be accomplished through direct exposure (in vivo exposure) to fear- and disgust-provoking stimuli such as pictures, video clips, or actual situations; by vividly imagining feared scenarios (imaginal exposure); or through the use of virtual reality.[62] Some types of specific phobia (e.g., claustrophobia, a situational phobia involving fear of enclosed spaces) are commonly associated with fears of certain physical sensations (e.g., shortness of breath). When fears of physical sensations are present, interoceptive exposure (i.e., direct exposure to particular physical sensations – by plugging the nose and breathing through a straw to cause shortness of breath, for example) may also be indicated.[63]

Exposure therapy was initially guided by Foa and Kozak’s emotional processing theory, which posits that habituation to fearful distress within and between treatment sessions is necessary to the success of the treatment.[64] Clinicians therefore aimed to expose phobic individuals to feared stimuli in a gradual manner, allowing them to habituate to stimuli lower on their “fear hierarchy” before moving up the hierarchy. They judged the optimal length of an individual exposure session to be the length of time required to achieve habituation within that session. However, some research suggests that habituation to anxious distress within and/or between treatment sessions is neither necessary nor sufficient for the efficacy of the treatment, and that variable exposure (i.e., not following a fear hierarchy) may actually have therapeutic advantages over graduated exposure (i.e., progressing up a fear hierarchy).[65][66][67]

Although exposure therapy for specific phobias is usually conducted over several sessions spanning several weeks, single-session exposure-based interventions lasting approximately 3 hours have also been effective and efficient in specific phobias in adults and children.[52][53][68] When available, these single-session treatments can be especially useful for managing phobias that must be overcome emergently (e.g., in time for a flight or medical procedure), although one study suggests they may be slightly less effective at follow-up than multiple-session treatments.[50]

Exposure therapy can be delivered through self-help materials, internet-assisted programs, and/or referral to specialized mental health professionals.

Virtual reality therapy has also been shown to be useful for treating a number of different phobias, especially height, flying, and dental phobias, although almost all studies have been performed in adults, and studies in children are limited.[69][70][71][72][73][74][75] Treatment of specific phobias with virtual reality therapy has the potential to save patients and clinicians time and money, compared with carrying out in vivo exposures (e.g., going on multiple plane flights), and is seen as a viable treatment option for phobic anxiety, when available.[76][51][62][77][78][79] However, it may need to be supplemented with in vivo exposure therapy in certain cases, such as in spider or blood-injection-injury phobias, in order to achieve more robust results.[70][80]

Applied tension therapy

For individuals who experience a blood-injection-injury phobia that is associated with fainting, applied tension therapy has traditionally been considered standard of care.[55] This treatment aims to address the second part of the biphasic physiologic response that is typically observed in these individuals: an initial sympathetic response, with increased heart rate and blood pressure is followed shortly by a parasympathetic response, marked by an abrupt drop in blood pressure and heart rate.[81] The “tension” part of the therapy involves repetitive, brief tensing (10-15 seconds) and releasing (20-30 seconds) of arm, abdominal, and leg muscle groups to promote increases in blood pressure and circulation that theoretically help avert the fainting response. Patients then learn to “apply” tension at first signs of the parasympathetic response while undergoing exposures to fear-provoking stimuli (e.g., photographs or videos of needles or medical procedures or actual live medical procedures). Reviews of the evidence for applied tension therapy have cast doubt on its effectiveness above and beyond that of exposure therapy alone, without applied tension.[82][83] There is also research suggesting hyperventilation plays a critical role in the psychophysiologic response of people with blood-injury-injection phobias who faint in response to relevant stimuli, and that breathing re-training could potentially prove a useful addition to the treatment of such individuals.[84][85] Additional randomized trials are needed to assess the effectiveness of applied tension and breathing re-training both as individual treatments and when combined with each other and/or exposure therapy in people with blood-injection-injury phobias with and without a history of fainting.[82]

Pharmacotherapy

Short-term treatment with a benzodiazepine has been used for patients with infrequent symptoms that interfere with an important activity or urgent treatment (e.g., patients with needle phobia requiring chemotherapy, patients with claustrophobia requiring diagnostic imaging, or patients with flying phobias who need to fly for work or for an important family event); however, no studies have demonstrated efficacy of long-term treatment with benzodiazepines.

Benzodiazepines have been used as adjuncts to CBT in patients with extreme anticipatory anxiety; however, there is concern benzodiazepine use may interfere with the efficacy of exposure therapy.[86]

Other pharmacotherapeutic adjuncts to CBT include selective serotonin-reuptake inhibitors (SSRIs) for patients with concurrent depression or other anxiety disorders, such as panic disorder or generalized anxiety disorder. The use of SSRIs for specific phobias alone has not been systematically studied and is not common in clinical practice.

Self-help manuals

Self-help manuals based on CBT principles and self-guided exposure therapy have been found to be more effective than wait-list control conditions; however, written manuals may be less effective than internet-assisted treatments, which in turn may not be as effective as face-to-face CBT.[87] For this reason, a stepped-care approach is recommended.

There are few studies on the efficacy of self-help manuals for specific phobias, and those that have been conducted are heterogeneous, making meta-analysis challenging.[87] A self-help manual with evidence of efficacy is suggested.[88] Additional studies are needed.

Internet- or mobile-app-assisted treatments

Internet-assisted therapy can also deliver exposure-based treatments and is likely more effective than manual-assisted therapy.[87][89] Meta-analysis generally supports the effectiveness of internet-assisted exposure interventions over wait-list control conditions.[90][91][92][93] Mobile-app-supported treatments are a newer development, and initial studies support their effectiveness over wait-list control conditions also.[93] The available evidence suggests that therapist-assisted, internet- and mobile-based interventions are more likely to prove effective than interventions lacking therapist support, but this may change as these interventions are tested and refined to improve their efficacy.[93]

Other treatment modalities

Involving family members or friends in treatments may increase adherence with recommended interventions. Family involvement is particularly important when treating children. Although evidence suggests CBT for anxious children is effective both with and without active parental involvement, it appears active parental involvement is associated with better long-term maintenance of treatment gains.[94][95]

Studies on the efficacy of group treatment for specific phobias are limited, but group interventions for spider, height, flying, and blood-injection phobias have been found to be effective in small studies.[96][97][98]​​[99]

Referral

Inform patients with specific phobias that effective treatments are available. If they are interested in pursuing treatment, they should be referred to experts in CBT and exposure therapy, in particular. If a patient does not have access to a mental health professional with expertise in CBT or is not willing to see a mental health professional, recommend internet programs emphasizing self-directed exposure. If patients prefer bibliotherapy to internet treatment, offer an evidence-based manual.[88]

Children

First-line treatments for children are essentially the same as for adults and include one-session or multiple-session treatments with exposure therapy.[53][100] Therefore, referral to mental health professionals who specialize in CBT – especially exposure therapy – for childhood anxiety disorders is recommended.

In young children, contingency management (rewarding children for approaching feared stimuli) is often used to increase motivation. Parental involvement is helpful for implementing contingency management, coaching at-home exposures, and reducing family accommodation of avoidance behaviors.[94][101]

There is little research on the effectiveness of bibliotherapy or internet-assisted treatments in children with specific phobia. Limited data suggest these interventions are beneficial; however, further studies comparing them with therapist-directed exposure therapy are needed.[102][103] Studies on the efficacy of group treatment for specific phobias are limited, but group interventions for spider, height, flying, and blood-injection phobias have been found to be effective in small studies.[96][98]​​[97][99] In children, group treatment for anxiety disorders, including specific phobias, have been found to be as effective as individual treatments.[104][105] Group interventions are cost-effective and efficient ways to deliver treatment.

As in the adult literature, there are limited data regarding the efficacy of pharmacotherapy in the treatment of specific phobias in children and adolescents.

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