Specific Phobia
Specific phobia is an intense, persistent fear of a specific object or situation that is out of proportion to the actual risk. This can develop from an exaggerated or unrealistic sense of danger about a situation or object (1). Common categories can include, but are not limited to, phobia of aeroplanes, enclosed spaces, heights, going to school, nature (e.g., thunderstorms), animals or insects, blood, medical procedures, choking, vomiting, loud noises, or clowns. It is not unusual to experience specific phobia about more than one object or situation and there can be cooccurrence with other anxiety disorders (1). Phobias are more pronounced than fears, may cause severe anxiety and depression, and can restrict day-to-day life as people with phobias attempt to organise their life around avoiding the thing that is causing them anxiety (1). Symptoms of specific phobias can persist for at least several months, with the potential of more severe symptoms resulting in significant distress or significant impairment in personal, family, social, educational, occupational, or other key areas of functioning (1).
Specific phobia is one of the earlier anxiety disorders to appear in children. Developmentally normal appearance of specific fears at certain stages in childhood provides information about the typical onset of specific phobia, with animal and environmental (natural disasters, weather etc.) phobias most often triggered during toddlerhood (2-3 years) and other specific phobias during primary school years (2). Animal and environmental phobias are the most common subtypes of specific phobia in children (3). Prevalence is estimated at 2.3-9.2% (4). Comorbidity is high, with almost half (47.2%) experiencing an additional anxiety disorder, a third with depression (36.1%) and a third (33.3%) with somatoform disorders. Specific phobias have been found in 17-42% of children with a primary anxiety disorder diagnosis. Among children seeking treatment for anxiety disorders, specific phobias appear in 42-75% of cases (4).
This information is for commissioners, managers, trainers, and health care practitioners to consider the evidence base for the delivery of psychological interventions for people with specific phobia. This information is also for people diagnosed with specific phobia their families, and carers.
This topic introduction page covers evidence-based psychological interventions used to treat specific phobia in children, young people, and adults, and the psychological practice/settings in which these interventions can be delivered.
Exclusions for topic: This topic covers specific phobia exclusively and does not cover other anxiety disorders (see other Matrix anxiety topics for more information). This topic does not cover pharmacological interventions or interventions which are not informed by psychological theory. There are a wider range of non-psychological interventions and supports for anxiety that are beyond the scope of this topic and full guidance on best practice can be found in the NICE guidance on Common mental health problems: identification and pathways to care. NICE guideline CG123 and Anxiety Disorders: NICE QS53 Quality standards.
There are a range of interventions that could be included in the treatment tables for specific phobia. However, in order to be consistent with our focus on interventions with the highest levels of efficacy and the strongest levels of evidence where these exist, psychological interventions for the treatment of specific with low strength evidence and low levels of efficacy have not been included.
Overview of Evidence for CYP
Available evidence for psychological interventions for the treatment of specific phobias in CYP populations is limited compared to those in adult populations. However, high level evidence supports CBT (6) in the treatment of with specific phobias. Effect sizes vary between studies, and this is reflected in low-high efficacy indications. CBT for specific phobia in children can be delivered as intensive or single session interventions with equivalent efficacy (7) and can be used where there are co-occurring other anxiety difficulties (such as Generalised Anxiety or Social Anxiety) (8). Current evidence indicates that supplementing intensive phobia sessions with parental involvement does not necessarily result in additional benefit (9) so this is not included in the recommendations. There is emerging evidence for virtual reality augmentation and internet delivered packages for some phobias (10,11).
Treatment for specific phobias in CYP should be considered in the context of the wider evidence for anxiety disorder presentations in children and young people given that co-occurrence of anxiety disorders is common and differential diagnosis can be difficult to establish in young children (12). Treatment options will be influenced by developmental stage and often include involving families, carers, schools and other systems. Further information on managing anxiety presentations in children can be found in the Matrix Generalised Anxiety guidance.
Overview of Evidence for Adults
For adult populations (where most research is available), there is quality evidence (A) that Exposure Therapy and CBT can have medium to high impact on symptoms (medium to large efficacy). Exposure is an effective technique for phobias and can be delivered within CBT treatment or as a standalone approach. Exposure to the phobic stimuli can be supported in-vivo, through virtual reality, and other digitally enabled packages (10,13-16). It can also be delivered in a one session format (OST) (14,17). NICE has evaluated evidence for some specific computerised packages (18) through an early value assessment and services are encouraged to review the evidence as this develops. High level evidence of medium-high efficacy supports the recommendation of CBT (14,19) for the treatment of specific phobias in adults, although more trials are recommended to investigate long term outcomes (20). Assistance with differentiating between the cognitive and behavioural (exposure) components of CBT for specific phobia can be found in the competence framework for CBT which specifies the problem-specific competencies for specific phobia (21).
A small number of clinical trials have been conducted investigating Eye Movement Desensitisation and Reprocessing (EMDR) as an alternative approach for the treatment of specific phobias in adults, however the evidence is not established enough to make a recommendation due to the small number of studies and high risk of bias (22).
Overview of Evidence for Older People
A review covering a range of anxiety presentations, including phobias, confirms the effectiveness of CBT for anxiety for older people, but is suggestive of lower efficacy than with working age people (23). Clinicians are advised that there are differences in presentation of psychological problems in later life and to consult Delivering Effective Psychological Therapies and Interventions to Older People for further information on factors relevant to practice.
Overview of Evidence for People with Learning Disabilities
The evidence for treatment of specific phobia in CYP and adults with Learning Disabilities is limited to small studies and single case studies (24) with a non-randomised trial for specific phobias in children with learning disabilities ongoing (25). It suggests that the existing treatments for specific phobia listed in the tables below (CBT and exposure) may be used with appropriate adaptation (26). Further information on the evidence for anxiety disorders in people with learning disabilities is available in the Matrix GAD topic.
Overview of Evidence for Harms and Adverse Events
Psychological therapies have the potential to have adverse effects. Until recently, information on potential harms and rates of adverse effects have not been gathered systematically. A systematic review comparing the effectiveness and safety of Cognitive Behavioural Therapy and pharmacotherapy in children with anxiety disorders (6) (including specific phobia) indicated that adverse events were common with medications but not with CBT and were not severe. However, more research trial should include and gather this information to improve the information on adverse effects associated with psychological interventions in this area.
|
Recommendation |
Who for? |
List of Interventions |
Type of Psychological Practice |
Level of Evidence |
Level of Efficacy |
|
First line intervention |
CYP with specific phobias |
Cognitive Behaviour Therapy (CBT) with exposure (6-8)
Delivered in an intensive/one session format (7,27) With co-occurring other anxiety disorders (8) Supplemented by internet package or virtual reality (10,11) |
Enhanced/Specialist |
A
A |
Low-high
N/A |
|
Recommendation |
Who for? |
List of Interventions? |
Type of Psychological practice |
Level of Evidence |
Level of Efficacy |
|
First line intervention |
Adults with specific phobia |
Exposure Therapy In-vivo exposure in sessions or supported by a digitally enabled or computerised package or by Virtual Reality (10,13-16)
One-session treatment (OST) (14,17)
|
Enhanced/specialist |
A |
Medium-high
|
|
First line intervention |
Specific phobia where cognitive focus is required or in comorbid presentations |
Cognitive behavioural therapy for specific phobia (14,19)
|
Specialist |
A |
Medium-high
|
1. ICD-11 for Mortality and Morbidity Statistics 6B03 Specific phobia. Available at: https://icd.who.int/browse11/l-m/en#/http%3a%2f%2fid.who.int%2ficd%2fentity%2f239513569. Accessed Aug 30, 2023.
2. Beesdo K, Knappe S, Pine DS. Anxiety and Anxiety Disorders in Children and Adolescents: Developmental Issues and Implications for DSM-V. Psychiatr Clin North Am 2009;32(3):483–524.
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5. NHS England. Adult Psychiatric Morbidity Survey: Survey of Mental Health and Wellbeing, England, 2014. 2016; Available at: https://digital.nhs.uk/data-and-information/publications/statistical/adult-psychiatric-morbidity-survey/adult-psychiatric-morbidity-survey-survey-of-mental-health-and-wellbeing-england-2014. Accessed Aug 30, 2023.
6. Wang Z, Whiteside SPH, Sim L, Farah W, Morrow AS, Alsawas M, et al. Comparative effectiveness and safety of cognitive behavioral therapy and pharmacotherapy for childhood anxiety disorders: A systematic review and meta-analysis. JAMA Pediatrics 2017;171(11):1049–1056.
7. Stoll RD, Pina AA, Schleider J. Brief, Non-Pharmacological, Interventions for Pediatric Anxiety: Meta-Analysis and Evidence Base Status. Journal of clinical child and adolescent psychology : the official journal for the Society of Clinical Child and Adolescent Psychology, American Psychological Association, Division 53 2020;49(4):435–459.
8. Ryan SM, Strege MV, Oar EL, Ollendick TH. One session treatment for specific phobias in children: Comorbid anxiety disorders and treatment outcome. J Behav Ther Exp Psychiatry 2017;54:128–134.
9. Ollendick TH, Halldorsdottir T, Fraire MG, Austin KE, Noguchi RJP, Lewis KM, et al. Specific Phobias in Youth: A Randomized Controlled Trial Comparing One-Session Treatment to a Parent-Augmented One-Session Treatment. Behavior Therapy 2015;46(2):141–155.
10. Mor S, Grimaldos J, Tur C, Miguel C, Cuijpers P, Botella C, et al. Internet- and mobile-based interventions for the treatment of specific phobia: A systematic review and preliminary meta-analysis. Internet Interventions 2021;26.
11. Gujjar KR, van Wijk A, Kumar R, de Jongh A. Are Technology-Based Interventions Effective in Reducing Dental Anxiety in Children and Adults? A Systematic Review. The journal of evidence-based dental practice 2019;19(2):140–155.
12. Gale CK, Millichamp J. Generalised anxiety disorder in children and adolescents. BMJ clinical evidence 2016;2016(pagination):ate of Pubaton: 13 Jan 2016.
13. Krzystanek M, Surma S, Stokrocka M, Romanczyk M, Przybylo J, Krzystanek N, et al. Tips for Effective Implementation of Virtual Reality Exposure Therapy in Phobias-A Systematic Review. Frontiers in Psychiatry 2021;12.
14. WolitzkyTaylor KB, Horowitz JD, Powers MB, Telch MJ. Psychological approaches in the treatment of specific phobias: A meta-analysis. Clin Psychol Rev 2008;28(6):1021–1037.
15. Carl E, Stein AT, LevihnCoon A, Pogue JR, Rothbaum B, Emmelkamp P, et al. Virtual reality exposure therapy for anxiety and related disorders: A meta-analysis of randomized controlled trials. J Anxiety Disord 2019;61:27–36.
16. Wechsler TF, Kumpers F, Muhlberger A. Inferiority or Even Superiority of Virtual Reality Exposure Therapy in Phobias?-A Systematic Review and Quantitative Meta-Analysis on Randomized Controlled Trials Specifically Comparing the Efficacy of Virtual Reality Exposure to Gold Standard in vivo Exposure in Agoraphobia, Specific Phobia, and Social Phobia. Frontiers in Psychology 2019;10:1758.
17. Ost LG, Alm T, Brandberg M, Breitholtz E. One vs five sessions of exposure and five sessions of cognitive therapy in the treatment of claustrophobia. Behav Res Ther 2001;39(2):167–183.
18. NICE. 1 Recommendations | Digitally enabled therapies for adults with anxiety disorders: early value assessment | Guidance | NICE. 2023; Available at: https://www.nice.org.uk/guidance/hte9/chapter/1-Recommendations. Accessed Aug 30, 2023.
19. Kaczkurkin AN, Foa EB. Cognitive-behavioral therapy for anxiety disorders: An update on the empirical evidence. Dialogues in Clinical Neuroscience 2015;17(3):337–346.
20. Van Dis EAM, Van Veen SC, Hagenaars MA, Batelaan NM, Bockting CLH, Van Den Heuvel RM, et al. Long-term Outcomes of Cognitive Behavioral Therapy for Anxiety-Related Disorders: A Systematic Review and Meta-analysis. JAMA Psychiatry 2020;77(3):265–273.
21. Roth, AD, Pilling, S. The Competences Required to Deliver Effective Cognitive and Behavioural Therapy for People with Depression and with Anxiety Disorders (Specific Phobia). 2007; Available at: https://www.ucl.ac.uk/clinical-psychology/competency-maps/cbt/Problem%20specific%20competences/Specific%20phobia.pdf. Accessed Aug 30, 2023.
22. Cuijpers P, Veen SCV, Sijbrandij M, Yoder W, Cristea IA. Eye movement desensitization and reprocessing for mental health problems: a systematic review and meta-analysis. Cognitive behaviour therapy 2020;49(3):165–180.
23. Gould RL, Coulson MC, Howard RJ. Efficacy of cognitive behavioral therapy for anxiety disorders in older people: a meta-analysis and meta-regression of randomized controlled trials. J Am Geriatr Soc 2012 -02;60(2):218–229.
24. Dagnan D, Jackson I, Eastlake L. A systematic review of cognitive behavioural therapy for anxiety in adults with intellectual disabilities. J Intellect Disabil Res 2018 -11;62(11):974–991.
25. Apanasionok M. Specific phobias in children with learning disabilities (SPIRIT). 2021; Available at: https://www.isrctn.com/ISRCTN34766613.
26. Burton P, Palicka A, Williams TI. Treating specific phobias in young people with autism and severe learning difficulties. the Cognitive Behaviour Therapist 2017;10:Art e21.
27. Wright B, Tindall L, Scott AJ, Lee E, Cooper C, Biggs K, et al. One session treatment (OST) is equivalent to multi-session cognitive behavioral therapy (CBT) in children with specific phobias (ASPECT): results from a national non-inferiority randomized controlled trial. J Child Psychol Psychiatry 2023;64(1):39–49.
With thanks to Alice Loyal and Louise Waddington from NHS Wales who participated in the advisory and technical groups.
Advisory group: Ishbel Begg, Marita Brack, Lauren Corlett, Gemma Brown, David Gillanders, Anne Joice, Fhionna Moore, Suzy O’Connor, Alia Ul-Hassan, Naomi Whyte, Naomi Harding.
Technical group: Gemma Brown, Sandra Ferguson, Anne Joice, Leeanne Nicklas, Marie Claire Shankland.