Specific Phobia: Nature, Diagnosis, and Treatment

Common phobias include fear of heights (acrophobia), aerophobia (flying), arachnophobia (spiders), claustrophobia (closed in spaces), and hydrophobia (water). Fear of needles and injections, fear of thunder and lightning, and fear of snakes are also common. There are hundreds of phobias, and some of quite obscure. Arithmophobia is a fear of arithmetic. Plutophobia is a fear of money. Giving the various phobias sophisticated sounding Latin or Greek names makes them appear to be discrete diseases or conditions. In fact, all phobias represent an exaggerated, irrational fear of a discrete event, object, place, or situation.


Fear is a basic emotional response to a specific object or situation that involves threat. The word “specific” in the diagnosis of “specific phobia” is intended to convey the discrete nature of the emotional response, being mostly limited to the event, object, place, or situation that evokes the fear. Fear thus suggests an immediate present-moment concrete threat. Fear is right now.

Anxiety versus Fear

Anxiety, in contrast, is more nebulous and indirect and complex than fear. Whereas fear is present-moment, anxiety is framed in the future. Anxiety is not about what is happening, but about what could possibly happen, a future where you cannot control or predict the outcome if the feared object or situation becomes real. As such, anxiety is about anticipation, about detecting signals that we might soon be confronted with the feared object or situation. Fear is more stimulus-response. You see a snake, you run away. Anxiety is about what might happen, based on the information currently available. If you think you hear slithering in the grass, your anxiety escalates. You imagine that a snake might be present, but don’t actually know.


As you can see, anxiety is based on “what-if thinking.” What if I fail my exam, will I still be able to finish college? What if I feel a panic attack coming on, will I be able to hide or escape? What if I choke up when speaking and people notice? What if I really have a heart issue? The mind goes directly to those possible futures where threat is maximized. As such, anxiety always involves a perceived loss of control: Something terrible is going to happen, and you don’t know how to cope. So you experience various levels of dread until the threat passes.

Treatment

Specific phobias are one of the most easily treated disorders. The most common treatment approach is exposure. Assume that a man presents for therapy with a fear of snakes. We can talk about snakes all day long, but that’s probably not going to cure his fear. That’s because he’s being exposed to the idea of a snake, not to an actual snake. Since exposure to an actual snake probably provokes extreme anxiety, we can take a more gradual approach. He can view pictures of a snake until his anxiety settles down. Then he can move on to videos of a snake, then imagine seeing a snake on the sidewalk in front of him, then be exposed to a snake in an aquarium, and so on. Each time, he experiences anxiety and stays in the situation long enough for his anxiety to mostly dissipate.

Diagnostic Criteria for Specific Phobia

Below are the diagnostic criteria for Specific Phobia from DSM-5. Diagnostic criteria are characteristics your clinician is looking for in order to assign a diagnosis. The diagnostic critieria below are paraphrased, to avoid copyright issues. Consult the DSM-5 for exact phrasing. Terms in capital letters have been added by the author as a means of suggesting the domain to which the symptom might belong, and to facilitate understanding. Such terms do not appear in DSM-5.


The DSM-5 lists the following diagnostic criteria for Specific Phobia (paraphrased).

A. Fear or anxiety is evoked by something specific. Heights, storms, water, animals, airplanes, elevators, enclosed spaces, injections, medical procedures, and blood phobias are common examples. This is called the “phobic object.”

B. IMMEDIACY: Fear or anxiety almost always follows presentation of the phobic object.

C. AVOIDANCE: The fear or anxiety results in avoidance of the phobic object. If not avoided, the phobic object is endured only with intense fear or anxiety.

D. PROPORTIONALITY: The fear or anxiety evoked goes far beyond the actual danger represented by the phobic object.

E. PERSISTENCE: Fear, anxiety, or avoidance lasts six or more months.

F. DISTRESS OR IMPAIRMENT: Fear, anxiety, or avoidance results in distress or impairment that is clinically significant.

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