Phobias
Introduction

Specific Phobia is defined in the DSM 5 as a consistent,“intense or severe”… “marked fear or anxiety” in response to a “specific object or situation” that persists for 6 months or more. The amount of fear experienced is “out of proportion to the actual danger posed by the specific object” and is usually related to the “proximity” to the phobic object or situation and can range in intensity from moderate to intense symptoms of panic. Oftentimes, in fact, the phobic object or situation presents no objective danger whatsoever. Nonetheless, the “fear and anxiety” experienced “causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.”, and consequently is avoided if possible or “endured with intense fear”. To meet criteria it is important that symptoms NOT be the product of another condition, such as the type of “fear, anxiety, and avoidance” caused by “panic-like symptoms (as in agoraphobia), or those related to obsessions (as in obsessive-compulsive disorder), “reminders of traumatic events, separation from home or attachment figures or social situations (as in social anxiety disorder).”

Types of Phobias

Phobias are generously spread across situations and themes. Some of the most common:

  • Animal (e.g., spiders, insects, dogs)
  • Natural environment (e.g., heights, storms, water)
  • Blood-injection-injury (e.g., needles, invasive medical procedures)
  • Fear of blood
  • Fear of injections and transfusions
  • Fear of other medical care fear of injury
  • Situational (airplanes, elevators, enclosed places). The clinical features of this phobia depend on the specific situation, and can be complex. More information on fear of flying and driving phobia can be found on separate pages on this site
  • Fear of choking
Fear of Vomiting (Emetophobia) - Obsession Meets Phobia
Phobia of vomiting, is more complex, and, in my opinion, is a clinical phenomenon that stands separately from other phobias. There is some data that correlates emetophobia with the contamination subtype of obsessive compulsive disorder. There are also factors of “disgust” ( as can occur with blood or needle phobia) in emetophobia. Onset is typically durning childhood, and oftentimes can persist into or even throughout adulthood. Emetophobics are ferociously avoidant and therefore can be quite resistant to treatment. Emetophobia can be mild or debilitating. Additional information about this “phobia” will be added to this page over time. The treatment methods, I have found useful with emetophobia are similar to those used with obsessive compulsive disorder, the exposure approaches described below.
Prevalence

The 12-month prevalence estimate, in the US, is approximately 7%-9%.

Treatment

Systematic desensitization is an established, effective treatment for phobias. It is important to first gather a thorough history or the person’s anxiety and co-existing conditions. It is also important to “unpack’” the specific components of the phobia which can be unique to the person. A hierarchy of exposure steps with progressive difficulty is created. Often there are irrational beliefs about the situation or object that need to be discovered and reframed. It is important to have a decastrophized path to travel when desensitizing.

For example, a phobia of elevators could be driven by fear of a life-threatening accident; or there could be a fear of suffocation in the elevator. The cognitive strategies and even the way exposures are organized would vary depending what exactly what is feared in a given situation. Thorough interviewing is the only way to reveal the specificity of meaning necessary to design a treatment plan tailored to the person’s needs.

Safety Behaviors

A key component of anxiety treatment is identifying and eliminating “safety behaviors”. In the treatment of anxiety, a safety behavior is anything a person does to avoid or minimize fear. I have nothing but respect for the creativity at work in the invention of safety behaviors. These can take the form of simple, straight ahead avoidance or elaborate mental devices such as calculating the seconds until an elevator door opens, scanning a flight attendant’s expression or the clever hunt for reassurance from a loved one.

Safety behaviors have a stealth quality, as they seem so intuitive on the surface. After all, what is wrong with lessening anxiety ? Doesn't it make sense to do something to feel better? Paradoxically, it is this "natural" impulse to "protect" and relieve anxiety that makes these responses insidious obstacles to change. The problem with safety behaviors is that if there is no real threat (just one that that is imagined) then nothing needs to be done to keep you "safe". But if you behave “as if” there were danger- praying that you don't suffocate in an elevator- then the illusion of danger is made real, reinforced and perpetuated. This is why it is important to identify and then progressively drop safety behaviors when overcoming all phobic or obsessional fears.

The choice of safety behavior often lines up with the individual's personal narrative and with the specific fear and context in question. Nonetheless, many are universal in nature and not situation-specific. A short list of common safety behaviors would include:

  • Seeking reassurance from friends or loved ones
  • Checking pulse
  • Tapping or fidgeting
  • Internet searching to reassure self
  • Praying (when there is no justified reason or context)
  • Crushing up pills
  • Staying awake to hear an intruder (when there is no plausible threat
Self soothing

Self-soothing and calming strategies, such as breathing retraining, recalled relaxation and mindfulness training are also components the treatment of phobias. Dialing down “anxious reactivity” increases the tolerance of the distress experienced during exposure. It important to first practice and master these strategies in a non-threatening environment. In basketball you develop your shot and dribble in practice. Once skill is achieved, then you move on to a game situation. Self-soothing is also a skill that must be mastered in order for it to be effective in real time.

Desensitization

Desensitization indeed presents a paradox: it is both exquisitely simple and extraordinarily difficult. It requires a high level of what I call “motivational loading” together with a certain ability to tolerate distress. However, as one progresses up the hierarchy of tasks, a motivational momentum is generated that is paid forward at the next level of challenge. This progression also undermines the foundation of the phobia itself, setting the stage for “sudden gains” in treatment.

Return of Fear - Relapse

Return of fear is well described in the literature. Hence, it is important to maintain what I call “behavioral hygiene” once desensitization has been achieved. Meticulous and well executed cognitive and behavioral goals and methods are more likely to affect global changes, and these are the best defense against relapse. Unlike conditions such as OCD, where extended interval sessions are often necessary to maintain gains, treatment of phobia often ends when goals are met.

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© 2018 Robert Safion, LMHC

Treatment of Obsessional Spectrum Anxiety

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