Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ONGOING

adults with subclinical symptoms and infrequent interference with usual activities

1st line – education and monitoring

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ONGOING
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adults with subclinical symptoms and infrequent interference with usual activities
1st line – 

education and monitoring

Advise patients that fear is an inevitable and normal part of life, but that avoidance behaviors can feed a particular fear to the point it interferes with everyday life and becomes a phobic disorder.

Encourage patients to face their fears, rather than avoid them.

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]

Make patients aware of self-help manuals or internet-based resources, such as the Anxiety and Depression Association of America or the Anxiety Disorders Treatment Center.[88] Anxiety and Depression Association of America Opens in new window Anxiety Disorders Treatment Center Opens in new window

Additionally, set up a return visit or a phone call to monitor progress.

Consider – cognitive behavioral therapy with exposure therapy

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ONGOING
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adults with subclinical symptoms and infrequent interference with usual activities
Consider – 

cognitive behavioral therapy with exposure therapy

Treatment recommended for SOME patients in selected patient group

This intervention involves education about the behaviors that maintain a phobia (namely, avoidance and safety behaviors); self-monitoring; and repeated, frequent, controllable, and predictable exposures to feared objects or situations in the form of words, pictures, videos, virtual reality, actual situations, imagined scenarios, or physical sensations.

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]

A single-session intervention can be effective and can be delivered by appropriately trained mental health professionals; through self-help manuals; or through internet-assisted treatment programs.

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]

Plus – applied tension

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ONGOING
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adults with subclinical symptoms and infrequent interference with usual activities
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concurrent vasovagal syncope
Plus – 

applied tension

Treatment recommended for ALL patients in selected patient group

Suitable for patients with vasovagal fainting upon exposure to blood-injection-injury stimuli.

Involves repeated tensing and releasing of large muscle groups to increase blood pressure and promote circulation during exposure to feared stimuli (e.g., blood, needles, hospitals).

Patients learn to apply this procedure at the first signs of fainting.

Refer to mental health professionals with expertise in cognitive behavioral therapy for blood-injection-injury phobia.

adults with frequent symptoms interfering with usual activities

1st line – cognitive behavioral therapy with exposure therapy

Back
ONGOING
|
adults with frequent symptoms interfering with usual activities
1st line – 

cognitive behavioral therapy with exposure therapy

This intervention involves education about the behaviors that maintain a phobia (namely, avoidance and safety behaviors); self-monitoring; and repeated, frequent, controllable, and predictable exposures to feared objects or situations in the form of words, pictures, videos, virtual reality, actual situations, imagined scenarios, or physical sensations.

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]

A single-session intervention can be effective and can be delivered by appropriately trained mental health professionals; through self-help manuals; or through internet-assisted treatment programs.

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]

2nd line – benzodiazepine

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adults with frequent symptoms interfering with usual activities
2nd line – 

benzodiazepine

Consider short-term use in emergent circumstances, including needle phobias interfering with chemotherapy; claustrophobia interfering with diagnostic imaging; and travel phobias interfering with occupations or important family events.

May negatively impact the efficacy of graduated exposure therapy. While these medications are indicated for anxiety, there are no studies exclusively focused on patients with specific phobia that show efficacy in these patients.

Caution is warranted with long-term use, given risks of dependence, withdrawal, and interference with exposure therapy.

Specialist referral may be indicated.

Primary options

alprazolam: 0.25 to 0.5 mg orally (immediate-release) every 6-8 hours until the short-term stressor has passed

OR

clonazepam: 0.25 to 0.5 mg orally every 8-12 hours until the short-term stressor has passed

OR

lorazepam: 1-2 mg orally every 8-12 hours until the short-term stressor has passed

OR

diazepam: 2-10 mg orally two to four times daily until the short-term stressor has passed

Plus – applied tension

Back
ONGOING
|
adults with frequent symptoms interfering with usual activities
|
concurrent vasovagal syncope
Plus – 

applied tension

Treatment recommended for ALL patients in selected patient group

Suitable for patients with vasovagal fainting upon exposure to blood-injection-injury stimuli.

Involves repeated tensing and releasing of large muscle groups to increase blood pressure and promote circulation during exposure to feared stimuli (e.g., blood, needles, hospitals). Patients learn to apply this procedure at the first signs of fainting.

Refer to mental health professionals with expertise in cognitive behavioral therapy for blood-injection-injury phobia.

children with ongoing symptoms interfering with usual activities

1st line – cognitive behavioral therapy

Back
ONGOING
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children with ongoing symptoms interfering with usual activities
1st line – 

cognitive behavioral therapy

This intervention involves education about the behaviors that maintain a phobia (namely, avoidance and safety behaviors); self-monitoring; and repeated, frequent, controllable, and predictable exposures to feared objects or situations in the form of words, pictures, videos, virtual reality, actual situations, imagined scenarios, or physical sensations.

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.

A single-session intervention can be effective. Treatment should be delivered by pediatric mental health professionals who are trained in exposure therapy.

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]

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.

There are limited data regarding the efficacy of pharmacotherapy in treating specific phobias in children and adolescents.

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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