Specific phobia and graded exposure therapy
A specific phobia is an overwhelming fear of one particular object, place, situation or animal, and the central treatment is gradual, repeated exposure, meaning meeting it in small steps.
Remember
A specific phobia is kept going by avoidance (staying away from the feared thing), so it is treated with gradual, repeated exposure, either as supported self-help (such as a guided workbook) or with a therapist; medicines have only a limited, secondary place.
Memory aid
A fear ladder climbed one rung at a time
Picture each exposure step as one rung of the ladder, with avoidance keeping you on the bottom rung.
The anxiety of a specific phobia comes on only near the source of the phobia or, in severe cases, it may be set off by just thinking about it. What keeps the fear going is avoidance. Keeping away gives quick relief, but it stops the brain learning that the feared thing is safe.
In gradual exposure (also called graded exposure or exposure therapy) the person meets the feared thing in small, repeated steps, beginning with the least frightening. This goes on until the anxiety rises, peaks and settles, and this settling is called habituation. Because exposure breaks the avoidance cycle, it is the central treatment.
Exposure can be delivered as supported self-help, for example a guided workbook or an online programme, or by a therapist as part of cognitive behavioural therapy (CBT, a talking therapy that looks at how thoughts, feelings and behaviour link up). The approach is chosen according to the person's preference, the impact of the phobia on daily life and the response so far, meaning whether treatment has worked or not. When the fear is not severely disabling and the person wants to start by themselves, supported self-help is a sensible first step, with therapist-delivered CBT available if it is not enough.
Medicines have only a limited, secondary place. A beta-blocker (a drug that slows the heart and lowers blood pressure) is sometimes used for a short time when the feared situation cannot be avoided, such as before a flight.
Key facts
- Why it persists
- avoidance (staying away) gives quick relief but stops the fear from being unlearned.
- Central treatment
- gradual, repeated exposure, either as supported self-help or with a therapist.
- Habituation
- the settling of anxiety after it rises and peaks during exposure.
- Choosing
- the approach is chosen according to the person's preference, the impact of the phobia on daily life and the response so far, meaning whether treatment has worked or not.
- Medicines
- they have only a limited, secondary place, with a beta-blocker sometimes used short term when the feared situation cannot be avoided.
Exam traps
- An SSRI (selective serotonin reuptake inhibitor, an antidepressant that raises serotonin in the brain) is used for depression and for several anxiety disorders, but it does not tackle the avoidance that keeps the phobia going, and in specific phobia medicines have only a limited, secondary place.
- Immediate referral for therapist-delivered CBT is not wrong in itself, because it includes exposure, but the approach is chosen according to preference, impact and response. When a phobia is not severely disabling and the person would like to start with self-help, self-help comes first. CBT with a therapist becomes the right choice if self-help does not work, and also if the person would prefer to work with a therapist.
- Taking a benzodiazepine (a sedative that calms anxiety quickly) regularly does nothing to reverse avoidance, so the fear returns as the tablet wears off, and it is also more likely to cause physical dependence (the body comes to rely on it) than other anxiety drugs.
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