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Case

K. was bitten by a dog as a child. Since that time, she has avoided anything to do with dogs, including looking at pictures of dogs, and being around real dogs or places where dogs might be (parks). She believes that dogs are dangerous and is afraid that she will be bit by one and be seriously injured. She insisted that her husband give away his dog before they were married, this created tension in their relationship. She is often afraid to walk around near her home and is unable to walk her children to school. Her fear of dogs often interferes with her ability to shop and run errands as she will not enter a store if there is a dog tied up outside. She has often had nightmares about dogs. She has experienced a full panic attack at least three times while being unable to get out of her car because of a dog and owner were walking by. At her last doctor's visit, there was a seeing eye dog in the waiting area, which unfortunately is now making her worried about even seeing her doctor...

Epidemiology

• Lifetime prevalence of 12.5% (CPA)
• Begin at a young age between 5 and 12 years
• Median age of onset of 7 years (CPA)
• Age of onset varies with type of specific phobia

Screening Questions

Do any of the following make you feel anxious or fearful:

• Animals (spiders, bugs, snakes, etc)?
• Heights, storms, water?
• Sight of blood, injections or blood tests?
• Driving, flying in an airplane, enclosed places?

Do these fears interfere with your life or cause marked distress?

Diagnosis

• Excessive or irrational fear of an object or a situation, leading to avoidance of the situation, or distress when faced with the situation
• Most common phobias
  • Spiders (Arachnophobia)
  • Insects/bugs (Entomophobia)
  • Mice (Musophobia)
  • Snakes (Ophidiophobia)
  • Heights (Acrophobia)
• Phobias can lead to serious life impairment and endanger a patient’s well being
  • Fear of needles can lead to avoidance of medical care
  • Fear of phobias in general can lead to avoidance of social activities, leading to impaired work or social funciton (Hood et al)

Comorbidity 

• Specific phobias commonly occur with other specific phobias and with other anxiety disorders sometimes leading to challenges in diagnosis

DSM-5 Criteria

1. Marked fear or anxiety about specific object or situation (flying, heights, animals, seeing blood)
2. The phobic object or situation almost always provokes immediate fear or anxiety
3. The phobic object or situation is actively avoided or endured with intense fear or anxiety
4. The fear or anxiety is out of proportion to the actual danger posed by the specific object or situation and to the sociocultural context
5. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more
6. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning
7. The disturbance is not better explained by the symptoms of another mental disorder, including fear, anxiety, and avoidance of situations associated with panic-like symptoms or other incapacitating symptoms (as in agoraphobia); objects or situations related to obsessions (as in OCD); reminders of traumatic events (as in PTSD); separation from home or attachment figures (as in separation anxiety disorder); or social situations (as in social anxiety disorder)

Specifiers in DSM-5 include:

• Animal, e.g. spiders, insects, dogs
• Natural environment, e.g. heights, storms, water
• Blood-injection-injury, e.g. needles, medical procedures
• Situational, e.g. airplanes, elevators, enclosed spaces

Though not necessarily in DSM-5, other types of fears have been documented as well such as:

• Fear of choking/vomiting (aka emetophobia)
• Fear of loud sounds (consider selective sound sensitivity syndrome aka. misophobia as a differential diagnosis)
• Fear of costumed characters such as clowns

Differential Diagnosis

Sensory processing problems

• Is there a sensitivity to loud noises? If yes, screen further for auditory hypersensitivity
• Is there a sensitivity to certain types of noises, such as chewing, slupring, throat clearing, breathing, sniffing? If yes, screen further for selective sound sensitivity syndrome (aka Misophonia).
• Is there a sensitivity to touch? If yes, consider tactile hypersensitivity

Other anxiety conditions

• Agoraphobia: Is there a fear of leaving the home in general?
• Social anxiety disorder: Is there significant distress in social situations? Is there a fear of embarrassment or being the centre of attention?
• Separation anxiety disorder: Are there problems with separating from an attachment figure such as a parent?
• Panic disorder: Patients with specific phobias may experience panic attacks when faced with their specific phobia. However, if a patient has panic attacks out of the blue, then consider panic disorder.
• Obsessive compulsive disorder:
  • Obsessions: Are there fears that come over and over again?

  • Compulsions: Are there habits or rituals that the person has to do repetitively?

• Trauma- and stressor- related disorders
  • Has there been a traumatic situation?
  • Since the traumatic situation, has there been symptoms such as re-experiencing the traumatic event, emotional avoidance, and increased arousal? (Hood et al, 2012)
• Eating disorders
  • Do you get anxious around food?
  • Is it because you are worried about gaining weight? 
• Schizophrenia spectrum and other psychotic disorders
  • Patients with psychosis can have various fears, such as paranoia
  • In psychosis, patients generally do not recognize that their fears are unwarranted, however patients with phobias generally do have insight 

Investigations

• Specific phobia is a clinical diagnosis; there are no pathognomonic investigations.

Physical Exam

• There are no specific physical findings in specific phobias.

Management: Overview

• Specific phobias are primarily managed through exposure based therapies

• Pharmacotherapy is of minimal usage to date in the long-term treatment of specific phobias

Management: Psychological Treatments in General

• Educate patients that whether or not they seek formal counselling, the best approach in the long run is to gradually face their fears (i.e. exposure to the feared situation), because eventually the body will habituate and get used to the fear
   
• Exposure and CBT treatments can be delivered in a variety of ways such as:
  • Self-help books (aka bibliotherapy)
  • Internet / eTherapy that are primarily through a computer without therapist intervention
  • Virtual reality exposure (computer based or artificially created environments), that can be helpful for specific fears such as heights, flying, public speaking
• Seeing a professional such as a psychologist, psychotherapist/counsellor, psychiatrist

Consider giving patients basic teaching regarding principles of anxiety and CBT

• That anxiety is the body’s normal response to dangers

• That many phobias do have an evolutionary basis (e.g. fear of spider is reasonable, given that spiders may be dangerous) however the problem is that in modern society, phobias are usually an excessive fear out of proportion

• That the good news is that there are various strategies that can help with anxiety

Basic principles

• Exposure
  • It is important to expose oneself to small amounts of the fearful situation as much as possible
  • Avoiding feared situations can lead to worsening avoidance over time
     
• Graded or progressive exposure
  • Teach patients how to gradually expose themselves to more and more of the feared situation
  • For example, with a dog phobia, an example of a hierarchy might be:
    • Look at pictures of small dogs, then large dogs
    • Go to a dog park, and from a distance, view small dogs and large dogs
    • Ask a friend who has a small dog to bring their small dog so that you can 1) look at the dog; 2) pet the dog
    • Ask a friend who has a large dog to bring their large dog so that you can 1) look at the dog; 2) pet the dog
       
• Response inhibition
  • Teach patients that after they expose themselves to the fear, they should suppress the urge to escape the situation, and try to tolerate the fear for longer and longer periods
     
• Cognitive strategies
  • Exposure and validate patient’s worry thoughts
  • Help patient come up with alternative, more adaptive thoughts
  • For example:
    • Clinician: “What types of anxiety thoughts do you get when you are in the situation? (e.g. seeing a spider)”
    • Patient: “I worry that if it bites me, I’ll die.”
    • Clinician: “So you worry that if the spider bites you, that you’ll die? I can definitely appreciate why you would be afraid of spiders then! I’d be afraid too, if I had that thought when I saw a spider!”
    • Clinician: “Is that a helpful thought?”
    • Patient: “No, I guess not really…”
    • Clinician: “You've said your goal is to overcome this anxiety, and feel more confident when you see a spider… What type of a thought would help you feel more confident when you see a spider?”
    • Patient: “Well, I guess if I tell myself that it’s not likely to be a poisonous spider in my home…”
       
• Relaxation and self-regulation skills
  • Teach patients to use deep breathing, muscle relaxation or other relaxation strategies
  • Teaching resources include yoga classes, as well as various online resources such as videos, mediation/relaxation apps

Management: Psychological Treatments for Specific Phobias

Blood-injection-injury phobias (e.g. needle phobias)

Interventions include:

• Exposure therapy plus muscle tension exercise (applied tension) to prevent fainting
• Using stress-reducing medical devices such as decorated butterfly needles and syringes

Dental phobias

Contact local dental associations, or dentists in your area to find out about which dentists specialize in helping patients with dental fears or phobias.

Some dentists for example, have more 'patient friendly' waiting areas and offices; some dentists have training in hypnosis; when  various strategies have been tried without success, there are dentists that can offer sedation. 

Mental health professionals such as psychologists can offer Cognitive behaviour therapy (CBT) to reduce dental fears. 

Fear of flying

The following is general advice for patients with fear of flying: 

• Travel with a companion that can help calm and relax you.
  • For example, you want someone who is good at listening and validating how you feel, as well as able to give you reassurance and advice when you need it. 
• Avoid alcohol / caffeine as they can worsen anxiety
• Alcohol is classically used to dampen anxiety; try to limit to one drink at most
• Do not mix alcohol with other medications as they can cause unintended effects such as disinhibition and inappropriate behaviour
• Meditation / breathing exercises
  • Consider watching / listening to meditation or breathing videos on your cell phone
• Distraction
  • During the flight, listen to music or watch a movie
• Cognitive restructuring
  • Reassure yourself with the knowledge that statistics show that air travel is safer than road travel
  • According to the Federal Aviation Administration, 109 people died in plane crashes from 2002 to 2007; compared to 196,724 people who died in car crashes, according to the National Highway Traffic Safety Administration (NHTSA), during the same time period. In other words, air travel is almost 2000 times safer than road travel!
• Private practice resources
  • There are private practice resources to help those with fear of flying such as
    • Deplour in Montreal, Quebec, Canada
    • Shift Cognitive Therapy in Oakville, Ontario, Canada.

Management: Medications

Consider benzodiazepines for acute relief on an as needed basis, e.g. dental procedures, claustrophobia associated with having an MRI done, having to take an unexpected airplane flight.

Benzodiazepines for Specific Phobia

• Alprazolam (Xanax) 0.25-2 mg bid
• Clonazepam (Rivotril) 0.5-4 mg daily
• Diazepam (Valium) 5-40 mg daily

Source: Management of Anxiety Disorders in Primary Care, Therapeutics, Feb-Apr 1997. Retrieved June 6, 2015 from http://www.ti.ubc.ca/newsletter/management-anxiety-disorders-primary-care.

Otherwise, there is little research regarding the efficacy of medication treatment for specific phobias (CPA Guidelines, 2006)

Prognosis

• Most patients do not require long-term treatment after successful treatment

When to refer

• Consider referral to mental health services if there is
• Lack of response to therapy
• Multiple co-morbid psychiatric and medical illness
• Risk of self-harm or harm to others

Clinical Practice Guidelines

Clinical Practice Guidelines: Management of Anxiety Disorders. The Canadian Journal of Psychiatry.  2006; 51(2).

References

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: Fifth Edition (DSM-5), 2013.

Anxietybc.com. Specific Phobia | Anxiety BC [Internet]. 2015 [cited 15 June 2015]. Available from: http://www.anxietybc.com/resources/specific.php

Hood H, Antony M. Evidence Based Assessment and Treatment of Specific Phobias in Adults. Intensive One-Session Treatment of Specific Phobias [Internet]. 1st ed. New York: Springer-Verlag New York; 2012 [cited 15 June 2015]. Available from: http://www.springer.com/us/book/9781461432524

About this Document

Written by Talia Abecassis (Medical Student). Reviewed by Dr. Dhiraj Aggarwal, along with members of the eMentalHealth.ca Primary Care Team, which includes Dr’s Mireille St-Jean (family physician), Eric Wooltorton (family physician), Farad Motamedi (family physician), Michael Cheng (psychiatrist).

Disclaimer

Information in this pamphlet is offered ‘as is' and is meant only to provide general information that supplements, but does not replace the information from a health professional. Always contact a qualified health professional for further information in your specific situation or circumstance.

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