Specific Phobia

A specific phobia is an extreme fear or anxiety over an actual or anticipated specific situation or object — out of proportion to the real threat, and not reasoned away. Patients avoid the object/situation, become anxious anticipating having to encounter it, and endure it (if unavoidable) with intense distress. Phobic disorders as a group also include Agoraphobia and Social Anxiety Disorder, which are managed differently (see their own pages).

Specific phobias fall into 5 subgroups:

• Animal (e.g. dogs, spiders, birds)
• Natural environment (e.g. heights, storms, water, lightning)
• Blood-injection-injury (e.g. blood, needles, hospitals)
• Situational (e.g. flying, lifts, enclosed spaces)
• Other (e.g. situations that may lead to choking or vomiting)

Common examples: spiders, social situations, flying, open or confined spaces, heights, thunderstorms, and illness-related fears (cancer, heart disease). The problem is seldom encountered as a primary presentation in general practice.

Management

Psychological therapy is first-line — behavioural therapy with a graded-exposure component, sometimes combined with relaxation strategies, to gradually reduce the autonomic response to the feared stimulus. Virtual-reality exposure is an emerging, convenient alternative to real-world exposure, though not yet shown to be superior.

Drug therapy is rarely the mainstay. Where a phobia needs managing for a specific event or time — the classic example being claustrophobia before an MRI — or psychological therapy alone is insufficient, adjunctive single-dose diazepam 2–5 mg, 30 minutes before the event (repeat after 2 hours if needed) can help. Use the usual benzodiazepine caution: falls, memory problems, motor vehicle accidents, daytime sedation, and dependence — particular concerns in older people, where harms may outweigh benefits.

In children: fear of animals and blood-injection-injury phobias tend to emerge in childhood, while other situational phobias (driving, claustrophobia) more often appear in adolescence. Prevalence in children is roughly 10–35%, with a mean age of onset of 5–12. Management is the same graded-exposure-first approach, adapted to be age-appropriate (cognitive reframing of specific worries/fears can also help); pharmacotherapy is rarely indicated, and if considered necessary should go through a child psychiatrist or age-appropriate mental health service.