Pages 263-265 from the Management of Mental Disorders, published by World Health Organization, Sydney. Editions in Australia, Canada, China, Italy, New Zealand and the United Kingdom.

4.5 Specific Phobias

4.5.1 Description and diagnosis

Description
Specific phobia is characterised by a persistent and irrational fear and avoidance of a particular object or situation. The range of situations that give rise to specific phobias are remarkably small and may have once had some protective function for the young mammal. There are two groups of situations; heights, closed spaces, still water in which the danger of falling, suffocating and drowning are obvious; poisonous insects, snakes and carnivorous animals from which the possibility of harm is again obvious. Everyone is wary in such situations, but people with specific phobias become anxious in anticipation of entering such a situation and when in the situation, their fear is out of all proportion to the danger. Fears of blood or injury are a special case that again must have had a protective function. Fear of flying is different, and highlights the importance of asking the person what the ultimate risk is. Fear of flying can be a manifestation of fears of heights or closed spaces, of agoraphobia or social phobia, or a conditioned fear related to previous airline trauma, and in each disorder the ultimate risk or reason for the fear will be quite different. The focus of treatment will depend on the ultimate fear.

When people with specific phobias encounter their feared situation they may experience panic attacks (see above), or complain of symptoms like:

• Accelerated heart rate/pounding heart
• Trembling
• Faintness or light-headedness
• Difficulty with breathing
• Sweating

The severity of the anxiety usually varies according to the nature and location of the stimulus (for example, the size of the animal, whether the animal is moving, distance from the animal).

Generally, individuals with specific phobias will attempt to avoid the feared stimulus whenever possible, to the extent that the fear or avoidance interferes with the individual's life or causes marked distress. The feelings of anxiety are absent when the individual is not in contact with the feared stimulus or is not thinking about the stimulus. Specific phobias are usually recognised by individuals as being irrational or excessive.

Diagnosis
According to the World Health Organization's (WHO) International Classification of Diseases (ICD)-10th Edition, for a diagnosis of specific phobia the individual must display the following characteristics:

• Persistent and irrational fear of a particular object or situation (excluding fears due to Panic Disorder, Social Phobia, Agoraphobia, Obsessive-Compulsive Disorder, and PTSD).
• An immediate anxiety response when brought into contact with the stimulus.
• Avoidance of the stimulus or extreme anxiety during exposure.
• Fear, avoidance, or distress interfere with the individual's normal life and social activities.
• The fear is recognised as being irrational or excessive.

Differential diagnosis
In panic disorder the individual experiences sudden panic attacks although the panic attacks are unpredictable and not always in response to specific stimuli.

In social phobia, avoidance of social situations is due to fear of humiliation and negative evaluation by others. It is not the social situation itself which is feared but the consequences of being in that situation.

Agoraphobia involves fear and avoidance of certain places and activities. This fear and avoidance, however, stems from the possibility of having a panic attack and not being able to get help, or escape the situation.

In obsessive compulsive disorder individuals may fear and avoid specific activities or objects so as to avoid the feared consequences (e.g., avoiding the use of chemicals for fear of contamination, or avoiding using sharp knives in case they get the urge to stab somebody).

Similarly in post-traumatic stress disorder, the individual may avoid specific situations or objects which are associated with previous traumatic events so as to prevent the possibility of `re-living' the traumatic event.

Specific phobia should not be diagnosed if criteria for any one of these previous differential diagnoses is met.

Epidemiology
Specific phobias are very common: 8% of the population have a diagnosable specific phobia although only about 1% of the population will present for treatment of this phobia. This disorder is almost twice as common among women than among men. Phobias that begin during childhood generally disappear without treatment. Phobias that develop later in life, however, are usually more chronic. Most specific phobias do not usually cause enough impairment to warrant treatment since most phobic stimuli can generally be avoided without too much difficulty. However, even if specific phobias are severe and cause marked disruption to normal activities, treatment based on education and exposure therapy can produce very successful outcomes.

4.5.2 Management plan for specific phobias
Management strategies will always vary from one individual to the next depending on the individual's particular problems. Generally, however, the management of specific phobias usually involves:

1. Ongoing assessment of the disorder. For example, ask the individual whether or not he or she still avoids the feared situation, and obtain his or her subjective rating of anxiety when in the feared situation (scored out of 10 where 0 is no anxiety and 10 is maximum anxiety).
   
2. Education about the nature of anxiety, tailored to each individual's needs. Some basic information about anxiety is provided in Section 4.1 and includes:

• The nature of anxiety
• Management of the fight-or-flight response
• The role of hyperventilation in anxiety

Handouts on panic attacks and hyperventilation if present (Section 4.14.3 & 4.14.4) Education about phobic avoidance (Section 4.3.3)

3. Providing training in strategies to control anxiety symptoms, and encouraging the individual to practise these techniques regularly.
   • Breathing control - the slow breathing exercise (Section 4.1.2
   • Relaxation training (Section 4.1.3)
     
     
4. Graded exposure to feared situations is the principal treatment (see Section 4.3.4 for general instructions). For example, if an individual is afraid of snakes, the following hierarchy could be arranged depending on how fearful the individual finds each step: ·
   • Looking at pictures of snakes.
   • Touching pictures of snakes.
   • Looking at snakes in the zoo.
   • Touching a fake snake.
   • Touching a snake through a sheet of glass (i.e., a hand on one side of the glass and the snake on the other side).
   • Imagining how it would feel to touch a snake (scaly skin, cool, firm, etc.).
   • Touching a harmless snake.
     
     
5. Individuals should not use sedative medication to cope with the feared situations.
6. Individuals with a blood-injury phobia who faint may require additional intervention.

Blood injury phobia: a special case
The majority of individuals who fear stimuli associated with blood or injury (e.g., visiting the dentist, getting a needle, any medical procedure) will faint with exposure to these stimuli as well as becoming anxious.

These individuals experience initial sympathetic arousal (the fight-or-flight response, see Section 4.1.1) followed by a rapid switch to parasympathetic arousal (decrease in heart rate and blood pressure). This switch in arousal leads to fainting (i.e., vasovagal syncope). Therefore, in addition to graded exposure to the feared stimuli the individual will also need to learn how to prevent the fainting response.

The main method of preventing the fainting response is to train the individual to deliberately tense the major muscle groups (e.g., the legs and abdomen) in response to the first signs of fainting. This technique effectively minimises the rapid parasympathetic response that leads to the drop in blood pressure.
N.B.: Blood-injury phobia is different from illness phobia. Illness phobia is an unreasonable fear that one has a serious illness. Correctly, an illness phobia is encompassed under the classification of hypochondriacal disorder (see Section 4.12).

Edited by Gavin Andrews MD, UNSW, 2007
©2007 CRUfAD