A landmark event in the development of treatment for
phobias occurred with the publication of a book in 1958. In the book, Joseph
Wolpe, a learning theorist, reported excellent results from treating adult
phobic patients with a procedure called “systematic desensitization,” which he
had adapted from a technique developed in the 1920’s for helping children
overcome animal phobias. Systematic desensitization requires the client to
learn formal, deep-muscle relaxation. It is up to the client also to rank
situations related to the phobia that cause anxiety. An individual who fears
snakes, for example, might place “holding a snake” at the top of the list of
things that make him anxious and “viewing a caged snake from across the room” at
the bottom of the list.
The client is then asked to imagine, in as much detail as
possible, the least fear-provoking scene from his list. At the same time he is
asked to relax as previously taught. By remaining comfortable while imagining
the feared situation, the client may weaken the association between the
situation and feelings of anxiety. Once the client has become comfortable
imagining the least threatening situation, he moves up the list and masters
each in turn.
Proponents of this method have claimed that facing a
feared situation in imagination is as effective as confronting it in reality.
But most therapists have found that there is a gap between fantasy and reality.
In other words, once the client has completed desensitization treatment and undertakes
to face the real object or situation, he is likely to have to move part of the
way back down his list. For example, while holding an imaginary snake, he may
at first be able to touch, but not to hold, a real snake. By practicing further
in the real situation, however, he may eventually be able to fully master his
Systematic desensitization was the first form of behavior
therapy used to treat phobias. The late 1960’s witnessed development of
another, named “implosion,” which soon came to be widely used in a modified
form termed “imaginal flooding.”
Flooding, like desensitization, involves the client’s
experiencing fear-provoking situations in his imagination. In other ways,
flooding and desensitization are quite different. In flooding, the therapist,
rather than the client, controls the timing and content of the scenes to be
imagined. He describes the scenes with great vividness, in a deliberate effort
to make them as disturbing as possible. Also, the client is not instructed to
relax; rather, the aim is for him to experience his fears and anxieties with
maximum intensity, in the hope that by surviving “the worst,” he can loosen the
phobia’s grip on him. The prolonged experience with these feared images is
thought to help the client get used to them, so that they gradually lose their
power to cause anxiety.
In the early days of implosive therapy and flooding,
therapists included scenes referring to guessed-at unconscious conflicts
believed to underlie the patient’s phobias. But studies showed that not only
were the horrifying scenes of implosion very disturbing to patients (sometimes
causing nightmares), but also they did not make treatment any more effective
than flooding alone. Thus, implosive techniques are no longer used.
A number of researchers have compared desensitization and
flooding. They have found that the two forms of treatment are about equally
effective: Both reduce phobic anxiety and behavior in people with simple
phobias, but desensitization is not as effective as flooding for agoraphobia.
Although not well studied, neither method appears to be very effective for
When behavior therapists observed that the exposure to the
feared situation was the common ingredient in desensitization and flooding,
they began to develop other techniques they hoped would be even more effective.
While earlier methods were aimed at reducing anxiety so that clients could
change their behavior (e.g. enter feared situations), the new techniques
focused instead on altering behavior. Once behavior changed, the reasoning
went, anxiety would diminish.
The underlying assumption is that phobic anxiety is
maintained - it continues and may get more intense - when the person repeatedly
avoids the object or situation that elicits the anxiety. Avoidance prevents him
from “unlearning” the association between an object or situation and anxiety.
Exposure to such situations, by contrast, gradually habituates the person to it
- that is, he learns that no real danger is present. Gradually, the anxiety is
extinguished. Some therapists believe that the more rapidly such exposure takes
place, the more rapidly the phobia will be eliminated.
In treatment, the therapist explains this rationale to the
client, outlines the procedure that will be followed, and helps him anticipate
what his reactions are likely to be. The therapist assures the client that he
will always be available to help the client cope with the sense of danger, and
will be ready to stop the procedure at any time the client seems unable to
tolerate the danger.
The client is then exposed to the object or situation he
fears. Techniques differ on how gradually the person is made to encounter
fearful objects and how long the exposure continues. In general, clients are
asked to stay in the situation until their anxiety begins to diminish. With
each session, they tolerate closer and longer confrontations with the
threatening object or circumstance.
Such in vivo (in life) exposure has replaced methods that
rely upon imagined danger. It is considered the treatment of choice for simple
phobias. Most investigators also believe that it is the best available
treatment for agoraphobia when accompanied by drug treatment (see below). Some
therapists use exposure in imagination as a means of helping their clients
confront feared situations in real life. There is some evidence that the
effects of treatment may be more long-lasting when imagination-based exposure
is used along with in vivo exposure, although not everyone needs both. Programs
using in vivo exposure techniques have become the mainstay in the treatment of
simple phobias and agoraphobia. Exposure does not seem to be as effective in
treating social phobias, unless it is accompanied by training in specific
Several recently developed techniques that try to change
the phobic’s thought patterns may be used along with exposure. Most of these
techniques have grown out of behavioral therapists’ attempts to account for and
change the persistent habits of thought that seem to bind people to their
fears. One form of cognitive-behavioral treatment - “self-statement training” -
teaches clients to become aware of such negative thought statements as, “I’ll
faint if I touch that,” or “I can’t do it,” and to replace them with positive
coping statements like, “Of course, I can do it.” Once the client has become
familiar with this approach, he can use it to help himself progress through a
behavioral treatment program.
Taking a completely different tack, therapists using “paradoxical
intention” encourage clients to try to feel as anxious and panicky as possible.
Clients are urged to exaggerate their symptoms, often with a note of humor
injected. For example, a woman who is afraid she may faint or fall down might
be instructed to “faint” on purpose and to warn those around her: “Stay out of
my way. When I fall, I fall hard. I bet I’m the best fainter you’ve ever seen.”
Frequently, taking charge of symptoms in this way diminishes their force. In
fact, a client who is “trying” to faint, sweat, or tremble may find himself
unable to do so.
Over the years, many drugs have been tried by phobic
patients. Barbituates provided little benefit. The newer class of drugs used to
treat generalized anxiety, the benzodiazepines (such as Valium or Librium), do
lessen the anticipatory anxiety that accompanies phobias, but do not generally
block panic attacks. The exception is alprazolam, a modified benzodiazepine,
which appears to be effective in moderate to high doses, although dependency is
often an unavoidable side effect when the drug is taken for long periods of time.
Beginning in the early 1960s, however, it was discovered
that certain antidepressants could prevent the unpredictable panic attacks
characteristic of agoraphobia. The assumption is that once panic attacks no
longer threaten the patient, the anxiety that accompanies anticipation of
future panic attacks and the avoidance of future panic attacks and the
avoidance of behavior will also diminish. The two types of drugs that have been
most extensively tested and shown to be effective are the MAO inhibitors (for
example, phenelzine) and tricyclic antidepressants (for example, imipramine).
Although usually used to relieve depression, these drugs also produce
antianxiety actions that are independent of their antidepressant effects.
Anticipatory anxiety sometimes diminishes once panic attacks have stopped. Some
patients respond at low dosages, but most appear to require amounts equal to
that needed to reduce depression.
MAO inhibitors and tricyclic antidepressants do produce
some unwanted side effects. Most of these side effects, such as drowsiness,
gradually subside after the drug is taken for several weeks. MAO inhibitors
require special caution, however. Patients taking these drugs must restrict
their intake of certain foods, such as aged cheese, red wine, and other
medications. Reactions between these substances and the MAO inhibitors can
produce high blood pressure, severe headaches, and other side effects that in
rare cases can be life-threatening. Despite these possible complications, the
MAO inhibitors, when used judiciously, can produce remarkable improvements in
patients subject to panic attacks.
Drug therapy for panic attacks is generally given for
periods of 6 months to 1 year. Many patients can then manage well without
drugs, although relapses requiring resumption of medication are common. The
relative duration of success of various therapies is still a matter of controversy.
As noted, most antianxiety drugs are not thought to be
effective in stopping panic attacks, although recent research suggests that in
very high amounts they may be. The common tranquilizers, such as Valium and
Librium, are sometimes also used to treat the generalized anxiety that
As noted earlier, a relatively new drug, alprazolam
(Xanax), a type of benzodiazepine, has been found to block panic attacks quite
dramatically within days after patients start taking it. This rapid response,
along with many other positive features, may make alprazolam a useful drug for
treating panic, although this use has not yet been approved by the U.S. Food
and Drug Administration. Alprazolam has the disadvantage, however, of producing
physical dependence and drowsiness in some patients. Seizures have also been
reported when the drug is abruptly discontinued.
Another class of drugs, beta adrenergic blockers, has been
found useful in treating some phobias, especially specific types of social
phobias, such as public speaking phobia. These drugs, usually used to treat
high blood pressure, may be used in patients who do not respond to other forms
of treatment. There is some suggestion that they may be especially appropriate
for patients who have such physical symptoms as trembling and heart palpitations.
MAO inhibitors have also been demonstrated to be effective in the treatment of
Solutions to the problem of phobias have also been sought
in the realm of nutrition. Certainly, severely malnourished individuals are
less able than others to cope with stress. And, patients who are subject to
panic attacks have been found to be unusually sensitive to caffeine and may
wish to gradually eliminate it from their diets. Otherwise, there is no
reliable evidence that any special diet is likely to benefit most phobic patients.
Phobia treatment programs now exist in many parts of the
United States. These programs use a variety of behavioral therapy techniques to
help clients confront and overcome their fears. In addition, through these
programs drugs may be recommended and prescribed for individuals likely to
benefit from them.
In a typical program, phobic individuals work together in
groups with a trained group leader. In some programs, family members and friends
are also invited to attend the weekly meetings. Group sessions are used to
teach attitudes and skills that are helpful in overcoming phobias. The client
also has weekly practice sessions, either alone or in a group, with a therapist
who is a mental health professional or a recovered phobic. During these
sessions, the client uses his new coping skills in situations he would
previously have avoided. With the therapist at his side, he gradually takes
progressively more difficult steps toward his final goal. Setbacks are expected
and viewed as opportunities for further practice and gain. Agoraphobic clients
who are housebound sometimes begin their treatment in their own homes.
Although organized phobia treatment programs offer many
advantages, they do not exist in all areas. Many individual therapists are
experienced at working with phobic patients, and some will accompany their
patients in fear-producing situations.
Referrals to treatment programs and therapists can be
obtained by calling or writing to the local, regional, or State chapters of the
American Psychological Association, the American Psychiatric Association, the
National Association of Social Workers, the American Nurses Association, the
National Mental Health Association, the American Association for Counseling and
Development, and the Phobia Society of America. In addition, several books and
tape cassettes offer self-treatment programs. Since the effectiveness of these
programs has not been evaluated, referral to them in this pamphlet does not imply
an endorsement by the National Institute of Mental Health.
A word of caution: Not every form of treatment is
appropriate for every patient or client. Nor does every therapist or phobia
program offer all forms of treatment - psychotherapy, behavior therapy, and
medications. Often, a combination of these treatments is necessary. If you feel
that you are not being helped by one clinic, program, or therapist, you may
wish to seek help elsewhere.
The outlook for people with phobias has improved greatly
in the last two decades. People with simple phobias can often be relieved of
their fears in a matter of weeks. People subject to panic attacks can usually
find relief with antidepressant medication. Through the use of these drugs and exposure
treatment, people with agoraphobia can be helped to venture out and face the
threatening situations they have been avoiding. People with social phobias can
be taught social skills and helped somewhat with exposure therapy and
medication. All can learn to understand their fears, and possibly solidify
their progress, with the help of other therapies - group or individual
psychotherapy or family therapy.
If you or someone you know has a phobia, don’t bypass the
chance for help. Because physical diseases sometimes mimic phobias, it is a
good idea to consult a physician to make certain that symptoms don’t mask a
serious physical illness. Then find someone who is skilled in treating phobias.
The odds are three to one that the treatment will succeed.
Technophobia - Fear of technology Sciophobia - Fear of
shadows Decidophobia - Fear of making decisions Nyctophobia - Fear of night
Electrophobia - Fear of electricity Topophobia - Fear of performing (Stage
Fright) Tropophobia - Fear of moving or making changes Triskaidekaphobia - Fear
of the number 13 Gephyrophobia - Fear of crossing bridges Ophidiophobia - Fear
of snakes Gatophobia - Fear of cats Hydrophobia - Fear of water Batrachophobia
- Fear of reptiles Pyrophobia - Fear of fire Astrapophobia - Fear of lightning
Spermophobia - Fear of germs Pnigerophobia - Fear of smothering Cynophobia -
Fear of dogs Aerophobia - Fear of flying Ochlophobia - Fear of crowds
Blennophobia - Fear of slime Katagelophobia - Fear of ridicule Spheksophobia -
Fear of wasps Thalassophobia - Fear of the ocean Kakorraphiaphobia - Fear of
failure Gynophobia - Fear of women Agoraphobia - Fear of open spaces
Claustrophobia - Fear of enclosed spaces Eremophobia - Fear of being alone
Acrophobia - Fear of heights Musophobia - Fear of mice Apiphobia - Fear of bees
Gamophobia - Fear of marriageScholionophobia - Fear of school Odynephobia -
Fear of pain Keraunophobia - Fear of thunder Amathophobia - Fear of dust
Beck, A.T.; Emery, G.; and Greenberg, R.L. ANXIETY
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DuPont, R.L., ed. PHOBIA: A COMPREHENSIVE SUMMARY OF
MODERN TREATMENTS, New York: Brunner/Mazel, 1982.
Ferber L. Phobias and their vicissitudes. JOURNAL OF THE
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Klein, D.F., and Rabkin, J.G., eds. ANXIETY: NEW RESEARCH
AND CHANGING CONCEPTS. New York: Raven Press, 1981.
Marks, I.M. CURE AND CARE OF NEUROSES. New York: Wiley,
Mavissakalian, M., and Barlow, D.H., eds. PHOBIA:
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Sheehan, D.V. THE ANXIETY DISEASE. New York: Charles
Scribner’s Sons, 1983.
Tuma, A.H., and Maser, J., eds. ANXIETY AND THE ANXIETY
DISORDERS. Hillsdale, N.J.: Erlbaum, 1985.
Uhde, T.W., and Nemiah, J.C. Panic and generalized anxiety
disorders. IN COMPREHENSIVE TEXTBOOK OF PSYCHIATRY, 5th ed. eds.
H.I. Kaplan and B.J. Sadock, Baltimore: Williams and Wilkins 1988.
Van Praag, H.M., ed. RESEARCH IN NEUROSIS. New York: SP Medical
and Scientific Books, 1978.
Weiss, E., ed. AGORAPHOBIA IN THE LIGHT OF EGO PSYCHOLOGY.
New York: Grune and Stratton, 1964.
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ARCHIVES OF GENERAL PSYCHIATRY, 40:125, 1983.
This booklet was written by Bette Runck, science writer in
the Science Communication Branch. Office of Scientific Information, National
Institute of Mental Health (NIMH). An earlier version was done on contract for
NIMH by Washington, D.C. science writer Elaine Blume. Drafts were reviewed,
sometimes repeatedly, by many experts on phobia. The assistance of the
following is gratefully acknowledged: Jack D. Maser, Ph.D., Barry Wolfe, Ph.D.,
Jack Blaine, M.D., Robert Prien, Ph.D., Barbara Scupi, M.S., Thomas W. Uhde,
M.D., Robert M. Post, M.D., Jack D. Burke Jr., M.D., and Jeffrey H. Boyd, M.D.,
all NIMH staff members; Donald F. Klein, M.D., and Michael R. Liebowitz, M.D.,
New York State Psychiatric Institute, New York City; Robert Michels, M.D., AND
Katherine Shear, M.D., the New York Hospital-Cornell University Medical Center,
New York City; Peter A. Di Nardo, Ph.D., State University of New York, Oneonta,
N.Y.; Michael J. Kozak, Ph.D., Temple University School of Medicine,
Philadelphia; and Bruce N. Cuthbert, Ph.D., Temple University School of
Medicine, Philadelphia; and Bruce N. Cuthbert, Ph.D., University of Florida,
Gainesville. Editorial assistance was provided by NIMH staff members Anne
Cooley, Marilyn Sargent, Myrle Kahn, and Sherry Prestwich.
Department of Health & Human Services Public Health
Service Alcohol, Drug Abuse, and Mental Health Administration Rockville, MD
DHHS Publication No. (ADM)
88-1472 Printed 1986 Reprinted 1988