Psychotherapy for specific phobia in adults

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Psychotherapy for specific phobia in adults Authors Randi E. McCabe, PhD Richard Swinson, MD Disclosures All topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: Oct 2013. | This topic last updated: Mar 26, 2013. INTRODUCTION Specific phobia is an anxiety disorder characterized by clinically significant fear of a particular object or situation that typically leads to avoidance behavior. Phobic fears include animals, insects, heights, water, enclosed places, driving, flying, seeing blood, getting an injection, and choking or vomiting. Specific phobias are among the most common mental disorders, and can be highly disabling [1,2]. However, they are also among the most treatable mental disorders [3-6]. Despite availability of efficacious treatments, the majority of individuals with specific phobias are hesitant to seek treatment [7]. This may be due to lack of knowledge that the phobia is treatable, embarrassment to disclose the phobia to a health professional, accommodation of the phobia through avoidance, or fear of increased anxiety or discomfort in the course of treatment [5]. Psychotherapy for specific phobia in adults is discussed here. The epidemiology, pathogenesis, clinical manifestations, course, and diagnosis of specific phobia in adults are discussed separately. Pharmacotherapy for specific phobia in adults is also discussed separately. Specific phobias and other manifestations of acute anxiety experienced by patients undergoing clinical procedures are also discussed separately. Specific phobia and other fears in children are also discussed separately. (See "Specific phobia in adults: Epidemiology, clinical manifestations, course and diagnosis" and "Pharmacotherapy for specific phobia in adults" and "Overview of fears and specific phobias in children".) TREATMENT OVERVIEW First-line treatment for specific phobia is cognitive-behavioral therapy (CBT) that includes exposure treatment [8]. CBT consists of cognitive and behavioral strategies designed to alter maladaptive thoughts and behaviors that serve to maintain emotional distress. Different types of exposure and different combinations of CBT interventions are used to treat differing presentations of specific phobia [9]. Pharmacotherapy has a limited role in treatment of specific phobia. Medications are used when CBT is not available or when patients prefer medication to CBT despite the lack of comparably robust supporting evidence from clinical trials. Medications (most commonly benzodiazepines) may also be used when there is insufficient time to treat with CBT (eg, patient with fear of flying presents a week or two prior to anticipated flight) and/or when exposure to the feared stimulus is expected to be a rare occurrence (eg, city-dwelling patient with fear of horses needs to travel to a ranch for a family event). (See "Pharmacotherapy for specific phobia in adults".) EXPOSURE THERAPY Exposure-based strategies involve repeated, systematic confrontation of the feared stimulus to facilitate fear reduction through extinction learning [10]. Patients are exposed to feared situations organized in an exposure hierarchy from least to most feared and avoided, based on their ratings of each situation (table 1). Over the course of treatment, exposure practice progresses up the hierarchy as anxiety reduction occurs at each step. Subjective fear level is measured based on the individuals self report, typically on a scale from 0 to 100, where 0 represents no fear/anxiety at all and 100 represents extreme fear/anxiety. In general, exposure practice on a particular step should be repeated until the fear rating is reduced by half before moving up to the next step on the hierarchy [11]. Subjective fear has been found to be a significant predictor of avoidance behavior during exposure [12]. Section Editor Murray B Stein, MD, MPH Deputy Editor Richard Hermann, MD

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Psychotherapy for specific phobia in adults

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As an example of an exposure hierarchy, a patient with a fear of snakes might begin by saying the word snake, followed by looking at a picture of a snake. A more moderate exposure would be for the patient to stand within three feet of an aquarium holding a live snake. A maximal exposure would be for the patient to hold a live snake. A table shows a 13-step exposure hierarchy developed for a patient with this fear (table 1). Types of exposure Exposure-based strategies vary by the nature of the exposure (imaginal, in vivo, or virtual) and by the addition of other treatment strategies that are provided in combination with the exposure technique, such as cognitive therapy or anxiety management. (See 'Additional interventions' below.) In vivo exposure The most effective type of exposure-based treatment is in vivo exposure [5]. The clinician assists the individual in confronting the feared stimulus in real world situations (eg, working with a live animal, experiencing an enclosed space, driving a car) in a safe and controlled manner. In vivo exposure is the most taxing emotionally because it requires the individual to tolerate increased levels of anxiety in the actual feared situation. As a consequence, it may not appeal to some individuals who may refuse the treatment or drop out prematurely. Possible avoidance of treatment may be offset by ensuring that the individual fully understands the rationale for treatment and its high rate of effectiveness, and by having the treatment pace be set by the individual so that it proceeds at a manageable level. Although the rates vary based on research methods and samples, the refusal rate for in vivo exposure has been reported to range from 14 to 27 percent [13]. Reported drop-out rates include 0 percent [14], 14 percent [15], and 44 percent [16]. It is likely that the way the rationale for exposure is presented and the quality of the clinician-patient relationship play a role in treatment acceptance and completion. Imaginal exposure Imaginal exposure involves mentally confronting the feared stimulus in imagination. It is typically guided by a script or description of the feared scenario that is repeatedly reviewed by the patient in his or her imagination until fear reduction occurs. Imaginal exposure is generally used when it would be difficult to conduct in vivo exposure due to the infrequency of a situation (eg, storm phobia) or cost (eg, flying phobia). Virtual reality exposure Virtual reality exposure (VRE, also termed in virtuo exposure) enables individuals to experience situations through computer simulation that may be difficult or expensive to produce in a live situation, such as exposure to an airplane for fear of flying [17]. It has been studied as a treatment for phobias of spiders, driving fears, flying, storms, and heights, as well as blood-injection-injury phobia. Virtual reality exposure may be used on its own or as a treatment component prior to conducting in vivo exposure. Patient access to clinicians providing virtual reality exposure is limited, primarily due to the expense of the technology [18]. Other Exposure in a flight simulator has been proposed for treating people with a fear of flying [19]. Flight simulators, used in pilot training, are motion generating platforms that simulate the effects of flight, including turbulence, gravitational force, and sounds of landing gear and flap movements. Patient access to flight simulators is likely to be very limited. Administration The duration of exposure treatment for specific phobia varies depending on the severity of the phobia and the length of each treatment session. One-session exposure treatment consists of a single two to three hour session of prolonged exposure. Multi-session treatment sessions are typically 90 minutes in length and the duration of treatment is determined by progress in fear reduction, but typically ranges from five to eight sessions. Efficacy A meta-analysis of 33 randomized trials found that exposure-based treatment was effective for reducing symptoms of specific phobia and improving functioning compared to no treatment, placebo conditions, and alternative active psychotherapeutic interventions, such as cognitive therapy and progressive muscle relaxation [5]. The response rates to exposure are high, with 70 to 85 percent of patients showing clinically significant improvement [20]. Treatment gains from exposure therapy appear to be maintained for at least one year [21-23]. There is a lack of data on longer-term outcomes. Continued self-exposure on a regular basis is important for maintaining treatment gains [15]. As an example, a person treated for a snake phobia could post a picture of a snake on the fridge to maintain daily self exposure to snakes. Ideally, continued exposure would be almost daily, and at a minimum on a weekly basis. Lack of continued exposure to feared situations has been associated with return of fear in longer term follow up [24]. A meta-analysis of seven clinical trials found in vivo exposure to be more effective in specific phobia than other

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Psychotherapy for specific phobia in adults

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types of exposure at the completion of treatment, but no difference was seen by exposure type at follow-up [5]. (See 'Exposure therapy' above.) As examples: A trial of 40 children with a water phobia (eg, fear of a swimming pool) found that children who had direct interactions with water (in vivo exposure) achieved greater improvement than children who spent a similar duration observing the therapist engage in interactions with water (vicarious exposure) [25]. A trial of 82 patients with dog phobia compared imaginal exposure, active-imaginal exposure (where the individuals engaged in imaginal exposure while acting out coping behaviors) and in vivo exposure found response rates of 51.9, 62.1, and 73.1 percent respectively, although no statistically significant differences between groups was observed [26]. Randomized trials comparing virtual reality exposure to in vivo exposure for specific phobia have had mixed findings, with some studies suggesting equivalence and other studies suggesting an advantage for in vivo exposure [5,16,27,28]. Imaginal exposure is not used routinely in clinical practice as a standalone treatment; it is most typically combined with in vivo exposure and cognitive therapy. Research suggests that one session of prolonged exposure (three hours) is roughly equivalent in efficacy to five sessions over six hours of gradual exposure for flying phobia [24]. However, a meta-analysis of clinical trials showed that multi-session treatments slightly outperformed single session treatments on measures of phobic dysfunction in specific phobia [5]. Effective exposure treatment of specific phobia of a greater phobic severity (ie, more severe fear and avoidance) has been found to require a greater number of sessions. (See 'Administration' above.) Although exposure treatment is typically administered by a trained therapist, computer programs have been used to guide patients though self-administered exposure treatment, with limited evidence of effectiveness in specific phobia [29,30]. A trial found that computer-guided self-administered exposure was associated with a high rate of drop outs among participants [29]. ADDITIONAL INTERVENTIONS Other CBT components may be used in combination with exposure, including psychoeducation, cognitive therapy, and anxiety management. Applied tension and systematic desensitization combine exposure with additional components. These interventions are described below. Psychoeducation Background information to correct misattributions or faulty beliefs regarding the feared stimulus is a key treatment component in combination with exposure. As an example, individuals with animal phobias often hold the belief that the animal wants to hurt or attack them, when in fact the animal is scared of humans and prefers to stay away from them. Numerous self help workbooks provide a detailed background on the nature of various phobias as well as treatment strategies. These resources can be used by patients in either a self-directed or clinician-assisted exposure treatment [31]. Cognitive therapy In cognitive therapy, treatment focuses on helping an individual identify maladaptive thoughts and appraisals that trigger and maintain the phobic fear, with the goal of promoting more realistic thoughts and appraisals. As an example, an individual with a specific phobia of elevators may believe that the chances of getting stuck in an elevator are very high (ie, 90 percent likelihood per elevator ride) when in fact the likelihood of getting stuck in an elevator is extremely low. In the individuals own experience he or she may have had hundreds of elevator rides but only been stuck a small handful of times, if at all. The individual may also believe that if he or she gets stuck he or she will not be able to cope or will not be able to ever get out. Addressing these cognitive distortions through therapy greatly reduces fear levels. A meta-analysis of five trials of treatment for specific phobia compared exposure treatment alone to exposure treatment plus a cognitive intervention, finding no advantage to the addition of the cognitive component [5]. Considerable heterogeneity was seen in these findings, suggesting more research on this question is needed. Virtual reality exposure (VRE) that includes a cognitive component has greater benefit than VRE alone for treatment of flying phobia [32]. A randomized trial comparing VRE, cognitive therapy, and bibliotherapy in 86

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Psychotherapy for specific phobia in adults

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patients with flying phobia found that both the VRE group and VRE plus cognitive therapy group had significantly reduced anxiety compared to the bibliotherapy group [33]. The magnitude of the effect size of improvement seen in the VRE only group was markedly smaller than other trials that examined VRE plus cognitive therapy. The addition of cognitive interventions may increase the palatability of exposure for patients who may initially refuse exposure treatment alone, but its role in patient acceptance of exposure has not been tested in clinical trials. The benefit of adding cognitive therapy to in vivo exposure therapy may also depend on the type of phobia [11]. As an example, cognitive therapy was found to enhance the effects of in vivo exposure for claustrophobia [34], but not for flying phobia [21] or spider phobia [35]. These differences may be due to ceiling effects for the effectiveness of the exposure component [36] or to the degree to which cognitive symptoms are a central component of the phobia [37]. Anxiety management Anxiety management techniques that promote arousal reduction, such as breathing retraining, progressive muscle relaxation and imaginal relaxation are sometimes used in combination with exposure for individuals who present with high levels of distress that interferes with his or her ability to engage in treatment [5]. There is a lack of data comparing exposure with or without anxiety management techniques in specific phobia but data from other anxiety disorders suggest that anxiety management is not an essential treatment component [38]. Anxiety management techniques are not generally considered to be effective treatments when delivered in the absence of exposure treatment [5]. Safety behaviors Safety behaviors are a series of strategies used by individuals with specific phobia to cope with the phobic stimulus. Safety behaviors include: Cognitive distraction Thought suppression Carrying an item that increases feelings of safety Clinical trials of the effects of safety behaviors on outcomes of exposure treatment have shown mixed findings. Some trials suggested safety behaviors may hinder therapeutic outcome [26,39], possibly by enabling avoidance of feared outcomes in anxiety-provoking situations. However, other trials have found that safety behaviors may not interfere with treatment outcome and may actually improve willingness to encounter the feared stimulus at a closer distance [40]. The effects of safety behaviors on exposure treatment may be dependent on the type of phobia. Trials of dog phobia and claustrophobia found that safety behaviors reduced treatment efficacy. A trial of spider phobia found safety behaviors to increase treatment efficacy. Applied tension First-line treatment for blood-injection-injury phobia is applied tension, in which muscle tensing is performed in addition to in vivo exposure. Patients are trained to use muscle tension to increase their blood pressure and counteract the vasovagal fainting response [41-43]. The efficacy and administration of applied tension for blood-injection-injury phobia are described separately. (See "Treatment for specific phobias of medical and dental procedures", section on 'Blood-injection-injury phobia'.) Systematic desensitization A precursor to in vivo exposure, systematic desensitization uses imaginal exposure to a hierarchy of feared scenarios in combination with progressive muscle relaxation that is postulated to inhibit the fear response [44]. Clinical trials suggest that systematic desensitization is more efficacious than a control condition, but less efficacious than in vivo exposure in specific phobia [9,45,46]. Systematic desensitization has largely been supplanted by contemporary exposure therapies [47]. Systematic desensitization provides a treatment option for individuals who refuse in vivo exposure [48]. However, it is recommended that imaginal or virtual exposure be used prior to systematic desensitization as they are simpler and do not require the additional teaching of the relaxation component. In addition, the relaxation component may serve as a safety behavior that inhibits the patient from learning that the anxiety response is not dangerous and can be tolerated. COMPARING CBT AND MEDICATION There are no clinical trials comparing the efficacy of cognitive-behavioral therapy (CBT) to benzodiazepines or serotonin reuptake inhibitors for specific phobia. However, multiple trials show

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Psychotherapy for specific phobia in adults

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CBT to be effective versus placebo, while studies of SSRIs and benzodiazepines are of insufficient number and quality to clearly demonstrate benefit over placebo. (See "Pharmacotherapy for specific phobia in adults".) COMBINING CBT AND MEDICATION There are no clinical trials comparing combinations of SSRIs or benzodiazepines with CBT in specific phobia to either medications or CBT as monotherapy. (See "Pharmacotherapy for specific phobia in adults".) SUMMARY AND RECOMMENDATIONS We recommend first-line treatment of specific phobia with a cognitive-behavioral therapy (CBT) that includes exposure treatment over other psychotherapeutic or pharmacologic interventions (Grade 1B). (See 'Comparing CBT and medication' above and 'Efficacy' above.) We suggest medication treatment of specific phobia when CBT with exposure is unavailable or when patients prefer medication to psychotherapy (Grade 2C). (See 'Treatment overview' above and "Pharmacotherapy for specific phobia in adults".) For specific phobia with a phobic stimulus that is frequently encountered and feasible to treat with in vivo exposure therapy, we suggest in vivo exposure rather than imaginal or virtual-reality exposure (Grade 2B). (See 'Types of exposure' above.) For specific phobia with a phobic stimulus that is relatively infrequent (eg, storm phobia) or that would be costly to experience (eg, flying phobia), we suggest treatment with imaginal exposure. This could be enhanced with virtual reality exposure if it is available (Grade 2C). (See 'Types of exposure' above.) Other cognitive, behavioral, and anxiety management interventions have been tested in combination with exposure treatment, but the evidence for these multi-modal treatments in specific phobia is limited. (See 'Additional interventions' above.) Exposure treatment can be provided in one prolonged two to three hour session or in several 90-minute sessions. (See 'Administration' above.) Use of UpToDate is subject to the Subscription and License Agreement. Topic 16126 Version 2.0

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Psychotherapy for specific phobia in adults

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GRAPHICS Example exposure hierarchy for snake phobia

Fear rating (0-100)
100 98 95 90 90 85 85 75 70 65 60 55 45

Step
1 2 3 4 5 6 7 8 9 10 11 12 13 Hold a live snake

Situation

Avoidance rating (0-100)

100 100 98 95 90 100 90 80 80 80 80 75 75

Touch a live snake being held by another person Stand in front of someone holding a live snake Stand 3 feet from someone holding a live snake Stand 1 foot from an aquarium holding a live snake Walk on a trail in the woods Stand 3 feet from an aquarium holding a live snake Watch a video of live snakes Hold a rubber snake Sit 3 feet away from a rubber snake Touch a picture of a snake Look at a picture of a snake Say the word snake

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