Specific Phobia: Diagnosis and Treatment

Anxiety disorders are the most common mental illnesses in the United States, including a category of anxiety called specific phobias. Experts estimate that as many as 40 million adults – more than 19% of the U.S. population age 18 and above – currently have an anxiety disorder.

Given the prevalence of anxiety disorders, you might expect that they are also among the most thoroughly studied. While some disorders within this category have a long history of detailed research, others do not. Somewhat surprisingly, the under-researched category includes the most common of all the anxiety disorders: specific phobias.

As recent studies shed new light on a disorder that experts estimate will affect 12.5% of all adults over the course of their lifetime, this under-researched status is slowly changing.

What Is Specific Phobia?

The anxiety disorders section of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) contains entries for several distinct conditions, including:

• Generalized anxiety disorder (GAD)
• Social anxiety disorder (social phobia)
• Agoraphobia
• Specific phobia
• Selective mutism
• Separation anxiety disorder
• Panic disorder (PD)

One category of symptoms unites these disorders: excessive worry and extreme, disproportionate fear. The primary differentiators are the types of circumstances that trigger the onset of symptoms.

In the case of specific phobia, the DSM-5 criteria include “marked fear or anxiety about a specific object or situation (e.g., flying, heights, animals, receiving an injection, seeing blood).”

Specific Phobia: Diagnostic Criteria

• The object or situation that causes the response prompts immediate anxiety and/or fear.
• The individual experiences negative emotions whenever they see or think about the object or situation. It’s not a one-time thing.
• This fear or anxiety is not proportionate to any actual threat or danger that the object or situation poses.
• The individual either changes their behavior to actively avoid the object or situation, or they endure its presence while experiencing intense anxiety and/or fear.
• Persistent fear and anxiety undermine their ability to function in one or more important areas of life.

The DSM-5 definition of specific phobia also includes the following distinctions based on the type of object or experience that prompts the onset of symptoms.

Specific Phobia: Types

• Animals, including spiders, insects, and dogs.
• Nature, including bodies of water or heights.
• Blood-injection-injury, which can include donating blood, undergoing an invasive medical procedure, or simply seeing a needle in a medical context.
• Situational, such as being on a plane, in an elevator, or otherwise confined.
• Other, which is a catchall sub-category that can include fear of loud noises, costumed performers, and other stimuli.

The intensity of the fear and the resultant functional impact are essential for an accurate diagnosis of specific phobia. For example:

• Preferring cats to dogs doesn’t indicate a phobia of dogs.
• Even if you don’t like dogs and have no desire to ever interact with one, that doesn’t indicate a specific phobia of dogs.
• If being in the presence of a dog causes intense emotional (and possibly physical) distress that leads you to make lifestyle alterations in order to avoid dogs, then that may indicate specific phobia of dogs.

If you suspect that you have specific phobia, the best way to confirm this suspicion to arrange an assessment with a qualified mental health professional. In addition to providing you with an accurate diagnosis, a mental health professional can recommend appropriate treatment options.

The good news about specific phobia is that it’s a treatable condition. The even better news is that recent research efforts and more effective neuroimaging techniques have improved our understanding of this common yet complex mental health concern.

Neurobiology and Specific Phobia

René Garcia, PhD, addressed the neurobiological underpinnings of fear and specific phobia in a September 2017 article in the journal Learning & Memory.

Fears and phobias, Garcia noted, fall into two general categories:

Experiential:

These result from events that you were involved in. For example, if you were attacked by a large dog when you were a small child, you might develop an intense fear of dogs based on that experience.

Nonexperiential:

These are innate. If you’re terrified of spiders, even though you have never been directly harmed by one, that’s a nonexperiential phobia.

Both experiential and nonexperiential phobias are real. However, specific phobias with an experiential cause are easier to understand and treat. Nonexperiential specific phobias may have more complex causes, such as abnormal functioning in the amygdala, the area of the brain associated with fear and other emotions.

Garcia reported studies involving animals and neuroimaging tests on humans support the involvement of the amygdala in the development of fear and specific phobia. He also discusses research documenting a possible link between abnormal production and functioning of neurotransmitters such as γ-aminobutyric acid (GABA), serotonin, dopamine, and norepinephrine with specific phobia.

It’s important to understand that neurobiology plays a role in the development of both experiential and nonexperiential specific phobias. Not everyone with an unpleasant experience with a dog, spider, or other creature develops a specific phobia. This means the experience alone is not enough to account for the phobia.

This combination of experiential and internal factors is similar to what occurs when someone develops posttraumatic stress disorder (PTSD). Living through one or more traumatic events is a necessary precursor to developing PTSD – but many people who have a history of trauma never develop this disorder.

As with specific phobia, this points to the presence of other causes and risk factors.

Risk Factors for Specific Phobia

Garcia’s article notes that individual experiences and individual variations within the brain can increase risk for developing specific phobia. Unfortunately, it’s virtually impossible to detect brain variations before a person develops a specific phobia.

Does this mean it is impossible to identify who is at greatest risk for this type of anxiety disorder?

According to researchers Carlos M. Coelho, Daniela Gonçalves-Bradley, and Andras N. Zsido, the answer is simple:

“No.”

This research team conducted a population-based study on risk factors for worrying about and developing specific phobia. They published the results in the July 2020 edition of the Journal of Psychiatric Research.

The three researchers studied data collected by the Australian Bureau of Statistics (ABS) in 2007. This included information from 8,461 adults aged 18 and above. Their conclusions include, but aren’t limited to the following:

• Two factors most strongly associated with specific phobia:
  • Female gender
  • Presence of major depressive disorder (MDD).
• Other influential factors:
  • History of substance use
  • Multiple chronic conditions
  • Witnessing a traumatic experience involving a loved one
• Specific phobia is associated with an increased risk of alcohol use disorder (alcoholism).
• People with specific phobias involving animals, heights, or closed spaces are at increased risk of depression.
• Marijuana use is higher among people who have blood-injection-injury specific phobia, as compared to people who have other types of specific phobias.

Though the researchers reviewed information from more than 8,000 individuals of various genders and ages, they acknowledged the relatively limited scope of their study may have affect the accuracy of their findings.

“Although there is evidence that risk factors are universal across countries, we based our assumptions on an Australian sample, thus future cross-cultural validation is necessary,” they wrote. “Results might be biased due to the due to the fact that Australia is a high-income country, which was previously found to be associated with higher prevalence of specific phobias.”

Treatment Options for Specific Phobia

Treatment options for specific phobia include prescription medication and therapy. Continued research into the neurobiology of this condition, other risk factors, and common co-occurring disorders will hopefully lead to improvements in both these elements of care.

For example, as researchers gain greater insights into which neurotransmitters contribute to specific phobia, psychiatrists and other prescribing professionals may be able to use this information to select more effective medications for their patients.

Previous research shows selective serotonin reuptake inhibitors (SSRIs) and monoamine oxidase inhibitors (MAOIs) – which are typically used to treat depression – are effective at reducing symptoms of specific phobia. In addition, the medication tiagabine, an anticonvulsant that precludes the reuptake of GABA, can be helpful.

From a therapeutic perspective, exposure therapy and cognitive behavioral therapy (CBT) have long been regarded as optimal services. However, as with the pharmacological approach to treatment, recent research into therapy for specific phobia may lead to expanded options.

New Research on Treatment for Specific Phobia

In March 2020, the open access journal F1000 Research published a review of 33 prior studies on this topic. The team that conducted this review reported the following findings:

• Several studies determined CBT is the “superior intervention” for specific phobia, either on its own or as an adjunctive service.
• In vivo exposure therapy – which involves supervised direct interaction with the subject of the specific phobia – yields results similar to CBT.
• Virtual reality exposure therapy (VRET) is “efficacious and seemingly non-inferior” to traditional exposure therapy.
• Very brief exposure (VBE) therapy, which involves the extremely rapid display of images, may eliminate some avoidance behaviors among people who have spider phobia.
• Cognitive bias modification (CBM) demonstrated promise during initial research efforts.
• Applied muscle tension (AMT), which involves the intentional tensing and relaxing of muscles to boost the delivery of oxygen to the brain, may ease the impact of needle phobia.
• Group psychoeducation and haptotherapy (a touch-based approach) help people overcome extreme fear of giving birth.

Determining which medications and therapies are right for you – or for someone in your life with specific phobia – is an individualized choice that requires input from the patient and the provide. In some cases, input from family and loved ones helps, as well.

This underscores the value of receiving care from a comprehensive treatment center with experienced staff members who can identify and address the full scope of your needs.

The causes, effects, and optimal treatment options for specific phobia can vary considerably from one person to the next. When you choose a center that offers an array of services across a full continuum of care, you increase the likelihood of receiving customized treatment that can help you make sustained progress toward improved health.