Specific Phobias
Treatment for Specific Phobias
Surveys have shown time and time again that only a small minority of people with specific phobias ever seek professional help. Meanwhile, the prospects for treating this condition are extremely good. Exposure in vivo is the treatment of choice for specific phobias. Exposure treatment involves graded and prolonged confrontation with the phobic object. Meanwhile the therapist encourages the patient to approach the phobic object and to refrain from avoidance behaviour. Exposure is often combined with other techniques such as modelling by the therapist in the case of animal phobias, applied tension to prevent fainting in the case of blood-injection-injury phobias , and cognitive interventions to correct catastrophic misinterpretations of bodily symptoms in the case of claustrophobia.
Exposure treatments yield good results in that success percentages of 90% are not exceptional. Furthermore, controlled studies show that the efficacy of exposure is maintained at long-term follow-up. Recently,O ¨ st summarised the results of some 25 randomised clinical trials involving rapid (i.e., one-session) exposure treatment for different subtypes of specific phobias. This author concluded that‘‘across the different specific phobias the rapid treatment methods yield 74–94% clinically improved patients after 2–3 hours of treatment’’. The precise mechanism underlying the beneficial effects of exposure is a matter of some debate. Some authors have favoured an ‘‘extinction’’ or ‘‘habituation’’ interpretation of exposure effects.
According to these authors, exposure is the extinction or habituation of a fear CR to a CS that is no longer followed by an UCS. Others have argued that exposure effects are linked to cognitive changes rather than response habituation. These authors emphasise that during exposure, the patient learns that the phobic object is not associated with catastrophic events. This will eventually lead to a correction of the phobic fear. Note, in passing, that this formulation is compatible with the S-S view of phobic fear , but also with cognitive theories about phobic fear. There is preliminary evidence that interpretations of exposure that emphasise cognitive change are closer to the truth than extinction/ habituation accounts. For example, Shafran et al. recently showed that treatment of claustrophobia is successful to the degree that it corrects certain essential cognitions (e.g., ‘‘I will suffocate’’). Similarly, in their study of one-session exposure treatment of spider phobia,O ¨ st and colleagues remark that [T]he clinical impression from treating these patients is that the most important factor in the one-session treatment is making explicit the patients’ catastrophic thoughts concerning the phobic situation and devising the exposure situation in such a way that these can be tested out.
Despite the superiority of in vivo exposure treatment for specific phobias, some clinicians have promoted alternative therapies for this condition. One of them is eye movement desensitisation and reprocessing (EMDR). EMDR is a relatively new technique that was originally proposed as a treatment method for post-traumatic stress disorder. During EMDR, patients imaginably expose themselves to a traumatic or aversive memory, while simultaneously engaging in lateral eye movements that are induced by the therapist. The idea is that through eye movements, negative memories are emotionally processed and assimilated. The therapist-induced eye movements would simulate the inhibitory function of Rapid Eye Movement (REM) sleep. Some authors have claimed that EMDR treatment is not only effective in PTSD, but also in specific phobias.
However, this claim rests largely on miraculous case studies. Controlled outcome studies designed to compare the effectivity of EMDR and exposure in vivo in the treatment of specific phobias clearly indicate that exposure yields superior results. It is not stretching the point too far to say that EMDR is effective insofar as it contains an element of exposur. So far, laboratory studies have found no evidence for the claim that the lateral eye movements during an EMDR procedure possess the potential to inhibit negative emotions. With these findings in mind, it is disturbing to see that in the past five years or so, EMDR has gained great popularity among psychotherapists. Its rapid proliferation follows the dissemination pattern of what some have called‘‘Power Therapies’’, that is therapies that promise rapid cures for an ever widening array of disorders in the total absence of empirical justifications. Needless to say that ‘‘well established cognitive and behavioural principles are more likely to serve patients’ needs’.
There is abundant evidence showing that benzodiazepines have anxiolytic effects. Furthermore, animal research indicates that benzodiazepines inhibit conditioned fear responses.
Consequently, one would predict that benzodiazepines could be useful in the treatment of specific phobias. However, studies designed to evaluate the effect of benzodiazepines on phobic avoidance have generally yielded disappointing results. Although benzodiazepines might inhibit subjective fear during phobic confrontation, they do not increase approach behaviour has gone one step further and suggested that benzodiazepines might even be harmful in that they create state dependency effects. That is, phobics learn to approach the phobic stimulus when drugged, but this learning is not transferred to a non-rugged state.