Week 2: Choy et al. (2007) – Treatment of specific phobias in adults
Specific phobia is characterized by an excessive, irrational fear of a specific object or situation, which
is avoided at all costs or endured with great distress.
Subtypes
In the DSM-5 five subtypes of specific phobias are recognized:
▪ Animal
▪ Natural environment (e.g., heights, storms, water)
▪ Blood-injection-injury (e.g., needles, invasive medical procedures)
▪ Situational (e.g., airplanes, elevators, enclosed spaces)
▪ Other (e.g., situations that may lead to choking or vomiting; in children, e.g., loud sounds or
costumed characters)
Although specific phobia is a chronic illness, it is generally considered a benign disorder since anxiety is
circumscribed and alleviated when the phobic situation is avoided. However, avoidance can interfere
with work and leisure activities and impact quality of life. Also, specific phobia is highly comorbid with
other mental disorders, particularly anxiety disorders.
Behavioral Approach test (BAT): a measure which consists of a series of behavioral tasks in which
the subject is observed approaching the feared object or situation. The strength of the BAT is that is
objective and visible. Three aspects of anxiety can be measured in a BAT:
1. Avoidance level: corresponding to a BAT score of how close the subject was able to approach
the phobic object.
2. Subjective anxiety: indicated by a visual analog scale such as a fear thermometer scale (0–10)
or a Subjective Units of Distress Scale (SUDS) (0 to 100).
3. Physiological response: such as heart rate or galvanic skin response (GSR).
Acute treatments
▪ Imaginal exposure therapy: involves exposure to the phobic stimulus through imagination
(i.e., active visualization of the phobic stimulus). The goal of treatment is to achieve habituation
and eventual extinction of the phobic reaction.
▪ Systematic desensitization: also includes exposure to the phobic stimulus through
imagination, but the goal is to supress anxiety with deep muscle relaxation.
→ Efficacy: improves subjective anxiety, however effects on avoidance are mixed.
Follow-up: initial treatment gains were maintained at the time of follow-up.
▪ In vivo exposure: the patient confronts the actual phobic stimulus, such as a live snake in
the treatment of snake phobia or standing on a rooftop in the treatment of height phobia. This is
usually conducted in a graduated fashion, starting from the least anxiety-provoking aspect to
the most anxiety-provoking aspect of the stimulus. Exposure generally lasts several hours, in
either one-long session (3 hours) or, over five 1-hour sessions.
→ Efficacy: significantly better outcomes (in both subjective anxiety and avoidance) compared
to control conditions.
Follow-up: acute treatment gains were either maintained of improved further over time for
animal, height, claustrophobia, elevators, and darkness phobia. For flight phobia and blood
phobia these long-term effects are not so prominent.
, ▪ Interoceptive exposure: A form of behavioral therapy in which internal physical sensations
(such as feelings of choking, dizziness) are reproduced and the patient is exposed to them in a
controlled setting. This is in contrast to exposure to an external stimulus as in in vivo exposure.
It is used in PD and claustrophobia.
→ Efficacy: Compared to the control group, the interoceptive group had fewer negative
cognitions and less unpleasant physical sensations. It was equal to the other two treatments
(i.e., in vivo exposure and cognitive therapy) in decreasing cognitive distortions, anxiety, and
physical sensations. All three treatments led to increased ability of the subjects to stay in closed
situations.
▪ Virtual reality exposure: A computer program generates a virtual environment that simulates
the phobic situation by integrating real-time computer graphics, visual displays, body tracking
devices and other sensory input devises.
→ Efficacy: Equally effective as in vivo exposure for flying and height phobia, and more
effective than systematic desensitization.
As an adjunctive treatment, virtual reality also enhanced the effects of cognitive therapy for
flying phobia in one study.
Virtual reality provides a much-needed alternative and convenient treatment option for
specific phobia, in particular for fear of flying. In contrast to flying phobia, the cost-effectiveness
of virtual reality treatment for spider phobia is questionable given the ease of obtaining a spider
for in vivo exposure.
▪ Applied muscle tension: a combination of muscle tension and in vivo exposure. Subjects first
learn to recognize the early signs of decrease blood pressure, and then practice muscle tension
alone-tensing and releasing the tension in the body. Then muscle tension is used in
combination with in vivo exposure in order to reverse the drop in blood pressure and prevent
fainting.
→ Efficacy: as effective as applied muscle relaxation, and more effective as in vivo exposure
alone.
Follow-up: Results at 12-month follow-up were mixed varying from 60-70% to 90-100% clinically
significant improvement.
▪ Applied muscle relaxation: Combination of in vivo exposure and muscle relaxation.
▪ Cognitive therapy: The focus of cognitive therapy is cognitive restructuring in which
distorted or irrational thoughts that are associated with the feared stimulus or situation are
modified, with a resulting decrease in anxiety and avoidance.
Example: Cognitive therapy would attempt to help a flying phobic re-evaluate the possibility of a
plane crash given actual data, or an animal phobic to reassess the realistic danger of the animal
causing harm.
→ Efficacy: Strong evidence supporting the efficacy of CT for the treatment of claustrophobia,
either alone or as an adjunct to in vivo exposure. Thus, CT may be a good alternative to in
vivo exposure for claustrophobia.
As a solo treatment, there is also some evidence that CT may benefit dental and flying phobia,
but it does not seem to add much to in vivo treatment of animal or flying phobia.
Specific phobia is characterized by an excessive, irrational fear of a specific object or situation, which
is avoided at all costs or endured with great distress.
Subtypes
In the DSM-5 five subtypes of specific phobias are recognized:
▪ Animal
▪ Natural environment (e.g., heights, storms, water)
▪ Blood-injection-injury (e.g., needles, invasive medical procedures)
▪ Situational (e.g., airplanes, elevators, enclosed spaces)
▪ Other (e.g., situations that may lead to choking or vomiting; in children, e.g., loud sounds or
costumed characters)
Although specific phobia is a chronic illness, it is generally considered a benign disorder since anxiety is
circumscribed and alleviated when the phobic situation is avoided. However, avoidance can interfere
with work and leisure activities and impact quality of life. Also, specific phobia is highly comorbid with
other mental disorders, particularly anxiety disorders.
Behavioral Approach test (BAT): a measure which consists of a series of behavioral tasks in which
the subject is observed approaching the feared object or situation. The strength of the BAT is that is
objective and visible. Three aspects of anxiety can be measured in a BAT:
1. Avoidance level: corresponding to a BAT score of how close the subject was able to approach
the phobic object.
2. Subjective anxiety: indicated by a visual analog scale such as a fear thermometer scale (0–10)
or a Subjective Units of Distress Scale (SUDS) (0 to 100).
3. Physiological response: such as heart rate or galvanic skin response (GSR).
Acute treatments
▪ Imaginal exposure therapy: involves exposure to the phobic stimulus through imagination
(i.e., active visualization of the phobic stimulus). The goal of treatment is to achieve habituation
and eventual extinction of the phobic reaction.
▪ Systematic desensitization: also includes exposure to the phobic stimulus through
imagination, but the goal is to supress anxiety with deep muscle relaxation.
→ Efficacy: improves subjective anxiety, however effects on avoidance are mixed.
Follow-up: initial treatment gains were maintained at the time of follow-up.
▪ In vivo exposure: the patient confronts the actual phobic stimulus, such as a live snake in
the treatment of snake phobia or standing on a rooftop in the treatment of height phobia. This is
usually conducted in a graduated fashion, starting from the least anxiety-provoking aspect to
the most anxiety-provoking aspect of the stimulus. Exposure generally lasts several hours, in
either one-long session (3 hours) or, over five 1-hour sessions.
→ Efficacy: significantly better outcomes (in both subjective anxiety and avoidance) compared
to control conditions.
Follow-up: acute treatment gains were either maintained of improved further over time for
animal, height, claustrophobia, elevators, and darkness phobia. For flight phobia and blood
phobia these long-term effects are not so prominent.
, ▪ Interoceptive exposure: A form of behavioral therapy in which internal physical sensations
(such as feelings of choking, dizziness) are reproduced and the patient is exposed to them in a
controlled setting. This is in contrast to exposure to an external stimulus as in in vivo exposure.
It is used in PD and claustrophobia.
→ Efficacy: Compared to the control group, the interoceptive group had fewer negative
cognitions and less unpleasant physical sensations. It was equal to the other two treatments
(i.e., in vivo exposure and cognitive therapy) in decreasing cognitive distortions, anxiety, and
physical sensations. All three treatments led to increased ability of the subjects to stay in closed
situations.
▪ Virtual reality exposure: A computer program generates a virtual environment that simulates
the phobic situation by integrating real-time computer graphics, visual displays, body tracking
devices and other sensory input devises.
→ Efficacy: Equally effective as in vivo exposure for flying and height phobia, and more
effective than systematic desensitization.
As an adjunctive treatment, virtual reality also enhanced the effects of cognitive therapy for
flying phobia in one study.
Virtual reality provides a much-needed alternative and convenient treatment option for
specific phobia, in particular for fear of flying. In contrast to flying phobia, the cost-effectiveness
of virtual reality treatment for spider phobia is questionable given the ease of obtaining a spider
for in vivo exposure.
▪ Applied muscle tension: a combination of muscle tension and in vivo exposure. Subjects first
learn to recognize the early signs of decrease blood pressure, and then practice muscle tension
alone-tensing and releasing the tension in the body. Then muscle tension is used in
combination with in vivo exposure in order to reverse the drop in blood pressure and prevent
fainting.
→ Efficacy: as effective as applied muscle relaxation, and more effective as in vivo exposure
alone.
Follow-up: Results at 12-month follow-up were mixed varying from 60-70% to 90-100% clinically
significant improvement.
▪ Applied muscle relaxation: Combination of in vivo exposure and muscle relaxation.
▪ Cognitive therapy: The focus of cognitive therapy is cognitive restructuring in which
distorted or irrational thoughts that are associated with the feared stimulus or situation are
modified, with a resulting decrease in anxiety and avoidance.
Example: Cognitive therapy would attempt to help a flying phobic re-evaluate the possibility of a
plane crash given actual data, or an animal phobic to reassess the realistic danger of the animal
causing harm.
→ Efficacy: Strong evidence supporting the efficacy of CT for the treatment of claustrophobia,
either alone or as an adjunct to in vivo exposure. Thus, CT may be a good alternative to in
vivo exposure for claustrophobia.
As a solo treatment, there is also some evidence that CT may benefit dental and flying phobia,
but it does not seem to add much to in vivo treatment of animal or flying phobia.
