Therapy of Phobia
Dr Jonathan Haverkampf
A phobia is a fear of an object or a situation. It belongs in general to the anxiety disorders, and underlying the phobia is a feeling of anxiety, which surfaces once it is triggered by the object or situation in the context of certain psychodynamic processes and one’s life experiences. The most common fears are of spiders, snakes, and heights. 
For it to be a phobia there has to be avoidance and the efforts to avoid the object or situation must be unrelated to the danger it actually. If one is exposed to the object or situation strong feelings of anxiety occur. There is a strong feeling of distress.
Usually the phobia covers a number of objects and situations. Often the situations and objects can be interchangeable, while the underlying feeling that surfaces when facing them remains the same. However, there are some general patterns. Agoraphobia usually goes with panic attacks and a fear of blood or injections can lead to fainting.
Social phobia is when the situation is feared as the person is worried about others judging them. Agoraphobia is when fear of a situation occurs because it is felt that escape would not be possible.  I discuss these fears further in another article, but a common division is:
- specific phobias
- Social phobia
How we experience phobia is rooted in the biology of the brain. There are brain centers and pathways in the brain that seem to play important roles in the emotions and particularly in anxiety and fear, such as the hippocampus and the amygdala.
The amygdala plays an important role in fear. It induces the secretion of hormones to put our body into an “alert” state, which can then lead to the somatic symptoms we also experience in phobia and anxieties, such as heart palpitations, sweating and the general sense to either run away or fight.  One important hormone is cortisol which makes sugars available on short notice and depresses the immune system.
Different regions of the brain can regulate these circuits, ultimately also the higher brain functions that allow us to think rationally and consciously. The reason why we cannot just think ourselves into not being afraid has to do with the fact that the phylogenetically older centers of the brains, where also the ‘fight or flight’ reaction is located, have been deemed as too important for such a manual override to work. However, in the long run our conscious thoughts can bring about significant changes, especially when it comes to conditions that hinder rather than help us.
The brain is a complex system of checks and balances, which is also necessary because it largely regulates itself. The ventromedial prefrontal cortex and the basolateral nuclei of the amygdala can affect the region’s ability to not only become conditioned to fearful stimuli, but to eventually extinguish them. The basolateral nuclei receive the information about the stimuli, but their neuroplasticity allows for learned responses. Lesions in this area seem to disrupt the acquisition of learned responses to fear.  The ventromedial prefrontal cortex is responsible for monitoring the amygdala. Lesions have been shown to slow down the speed of extinguishing a learned fear response and how effective or strong the extinction is. The underlying message is that even dedicated centers in our brain adapt to the information from our environment, and thus changes in one’s social environment, whether on the job or in the relationship. We do not have enough genes to code for the entire neural circuitry in our brains. This means that we have to learn as we grow up and that we can make changes in a highly plastic (adaptable) system.
An Anxiety is an emotion characterized by an unpleasant state of inner turmoil, often accompanied by nervous behavior, such as pacing back and forth, somatic complaints, and rumination. It is the subjectively unpleasant feelings of dread over anticipated events. While fear is the response to an immediate threat, anxiety is the expectation of a future threat. Humans have a capacity to plan for, think about and evaluate the future. This seems to make them more prone to anxiety than other animals. Thus anxiety is related to the society and the social interactions we live in.
Specific phobias can be treated with exposure therapy where the person is introduced to the situation or object in question, if this can be done safely, until the fear resolves. Medication has not been of much help in the case of specific phobia, although it can reduce longer lasting feelings of anxiety.  Social phobia and agoraphobia are often treated with some combination of counselling and medication. 
There are various methods used to treat phobias. These methods include:
- systematic desensitization
- progressive relaxation
- virtual reality
Medications used include antidepressants, benzodiazepines, or beta-blockers.
Cognitive behavioral therapy (CBT) allows the patient to challenge dysfunctional thoughts or beliefs by being mindful of their own feelings with the aim that the patient will realize their fear is irrational. CBT may be conducted in a group setting. Gradual desensitization treatment and CBT are often successful, provided the patient is willing to endure some discomfort. In one clinical trial, 90% of patients were observed to no longer have a phobic reaction after successful CBT treatment.
A CBT program was developed by Ann Marie Albano to treat social phobia in adolescents. This program has five stages:
- Skill Building
- Problem Solving
- Generalization and Maintenance
Eye movement desensitization and reprocessing (EMDR) may be used to ease phobia symptoms following a specific trauma, such as a fear of dogs following a dog bite.  Exposure can be used when the person with the phobia is exposed to the object of their fear over a long period of time.
Systematic desensitization means controlled exposure to an object or a situation for a certain amount of time. It is a form of habituation, where the brain downregulates its responses if the stimulus persists. Progressive muscle relaxation can help in the process.
Another approach is to imagine scenarios that induce fear and anxiety. Since our brain has to actively hold apart information that comes from inside it and that which comes in from the outside world, it often does not distinguish clearly between the two. Basically, an image created in the brain and an image of a dangerous animal transmitted by the eyes to the brain can have the same effect, if we allow the brain to ‘relax’, as we do when we are sleeping. This means that we can imagine objects and situations and use this with systematic desensitization and relaxation techniques.
Medications can help regulate the apprehension and fear that comes from thinking about or being exposed to a particular fearful object or situation. Antidepressant medications such as SSRIs may be helpful in some cases of phobia. Benzodiazepines s tranquilizers are frequently used in the short run, which can help patients relax by reducing the amount of anxiety they feel. Their addiction potential seems at least to a certain degree dependent on other negative behaviors, such as alcohol abuse. They should still be used with caution, but quite often it helps the patient to have a tablet with them to actually avoid the feeling of fear and distress. After all, the whole condition is also about anxiety about these anxious feelings or losing control over one’s self-regulatory mechanisms.
Beta blockers can reduce the symptoms of sweating, increased heart rate, elevated blood pressure, tremors, and the feeling of a pounding heart, which signal the mind that one is afraid or anxious. By reducing these phenomena one feels less frightened.
The best way to deal with phobias permanently is probably through an extended meaningful interaction with an empathic therapist in which the underlying emotions and reasons for the phobias can be uncovered and explored. This seems to work in many clients who suffer from phobias without medical explanations. In this process the therapist asks the client questions and interacts in a way that help the client to get to the core of the problem. This works in most cases. Medication to help in the short-run can be useful to facilitate the therapeutic process.
© Dr Christian Jonathan Haverkampf
This paper is solely a basis for academic discussion and no medical advice is given. Always consult a professional if you believe you might suffer from a medical condition. The lists of drugs have not been checked for accuracy.
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 Mark F. Bear; Barry W. Connors; Michael A. Paradiso, eds. (2007). Neuroscience: Exploring the Brain (3rd ed.). Lippincott Williams & Wilkins. ISBN 9780781760034.
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