1. Treatment of specific phobia in adults (Choy et al., 2007)
Definition: excessive, irrational fear of a specific object or situation, which is avoided at all cost
or endured with great distress.
Subtypes:
1. animals
2. natural environment
3. situational
4. blood-injection-injury
5. other
Lifetime prevalence: 12.5%, twice as common in women, childhood onset, chronic.
benign (when phobic stimuli can be avoided) but debilitating when avoidance interferes with
everyday life or has significant medical consequences + when comorbid illnesses are present.
Since advent of behavioral therapy, specific phobia has been considered one of the success stories
in psychiatric treatment, however, there are few RCTs in clinical samples.
Treatment modalities for specific phobias:
1. behavior therapy
2. cognitive therapy
3. other less well-accepted treatments (supportive therapy, hypnotherapy, pharmacotherapy)
Outcome measures
BAT (behavioral approach test) consists of series of behavioral tasks in which the subject is
observed approaching the feared object or situation objective and visible.
1. avoidance level
2. subjective anxiety
3. physiological response
Self-report measures complement BATs because they reflect real life gains more.
1. Systematic desensitization and imaginal exposure
Imaginal exposure = active visualization of the phobic stimulus in order to achieve habituation
and eventual extinction of the phobic reaction.
Systematic desensitization = exposure to the phobic stimulus through imagination with the goal
to suppress anxiety with deep muscle relaxation.
o consistently improved subjective anxiety
o effects on avoidance were mixed
o Systematic desensitization resulted in a greater proportion of subjects who recovered
compared to the control treatment one month after acute treatment.
o Initial treatment gains were maintained at the time of follow-up (from 6 months to 3 years).
70% of the 32 patients reported minimal or no anxiety (flying, 2 years)
60% of initial responders continued to fly after 3.5 years of treatment
,2. In vivo exposure
The patient confronts the actual phobic stimulus in a graduated fashion.
Results of the in vivo studies were consistently positive compared to control conditions (8
studies).
o greater decrease in subjective anxiety
o greater decrease in avoidance in animal, water, heigh, flying, claustrophobia, and driving
phobia.
o 80% to 90% of treatment completers were able to perform the terminal task in the BAT.
In vivo exposure was significantly more effective than systematic desensitization (92 vs 25%
were able to touch a snake with bare hands).
Not significantly different compared to imaginal exposure . The amount of time in the exposure
in the in vivo treatment (30 min) might not have been sufficient to produce the maximum
therapeutic effect.
In vivo exposure resulted in a significantly better outcome (75%) compared to direct
observation (7%) and indirect observation (31%).
The number of participants able to complete a test-flight decreased from 93% immediately post-
study to 64% at follow-up.
But in vivo exposure may not have much long-term efficacy for blood phobia.
In vivo exposure results in good treatment outcome for most types of specific phobias, provided a
sufficient length of exposure time.
3. Interoceptive exposure
Form of behavioral therapy in which internal physical sensations are reproduced and the patient is
exposed to them in a controlled setting (vs in vivo exposure to external stimuli).
Usually used in panic disorder.
Compared to control, interoceptive group had fewer negative cognitions and less unpleasant
physical sensations.
All three treatments (intero, in vivo, cognitive therapy) led to increased ability of the subjects to
stay in closed situations.
Interoceptive exposure appears to be a promising treatment for claustrophobia.
4. Virtual reality therapy
A computer program generates a virtual environment that simulates the phobic situation.
The two studies found virtual reality and in vivo exposure to be equally effective. There was
no difference between the two treatments. Virtual reality and in vivo exposure group improved
significantly on all dependent measures.
Virtual reality was equal to desensitization in alleviating subjective anxiety but more effective in
increasing flying activity.
In the adjunctive treatment study, virtual reality enhanced the effects of cognitive therapy in flying
phobia.
Virtual reality treatment may be as effective as in vivo exposure for flying and height phobia, and
more effective than systematic desensitization. Virtual reality also enhanced the effects of
cognitive therapy for flying phobia.
, Treatment gains were maintained, with virtual reality doing as well as in vivo exposure. The
addition of virtual reality to cognitive therapy did not affect long-term outcome.
5. Applied muscle tension
Applied tension is a combination of muscle tension and in vivo exposure.
Applied muscle tension was as effective as applied muscle relaxation and required fewer sessions
for treatment response.
Muscle tension alone is as effective as applied muscle tension, both of which were more effective
than in vivo exposure alone. Subjects treated with applied muscle tension, muscle tension or in
vivo exposure had a response rate of 90%, 80% and 40%, respectively.
Subjects treated with muscle tension only or applied muscle tension remained well over time (90%
to 100% clinically significant improvement).
6. 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, resulting in a decrease in
anxiety and avoidance.
Five studies found cognitive therapy to be an effective solo treatment.
o Less subjective anxiety, physical symptoms and negative cognitions.
o There was no group difference between in vivo exposure and cognitive therapy.
o Cognitive therapy was ineffective in decreasing avoidance in subjects with a fear of heights,
elevators or darkness. For flying phobia, cognitive therapy produced a better outcome than no-
treatment controls.
o As a solo treatment, cognitive therapy appears to be long-lasting in claustrophobia, but less so
in flying or dental phobia.
As an adjunctive treatment, findings are mixed but overall promising in the use of cognitive
therapy.
o As an adjunctive treatment, cognitive therapy enhanced the effects of in vivo exposure therapy
of claustrophobia.
There is strong evidence supporting the efficacy of cognitive therapy for the treatment of
claustrophobia, either alone or as an adjunct to in vivo exposure. Cognitive therapy may be a good
alternative to in vivo exposure for claustrophobia.
Supportive psychotherapy
Supportive therapy was as effective as adjunctive behavioral therapy.
45% of those who had completely recovered eventually relapsed during the follow-up period and
63% of the subjects followed were symptomatic at follow up.
