Phobia

Defining Specific Phobia

Specific phobia can be defined as a continual fear that is constrained to a circumscribed stimulus either item or scenario (American Psychiatric Association, 2013). Without delay on exposure, the stimulus is prevented each time feasible or is persevered only with extreme anxiety happening. Besides, the intensity of fear commonly is extreme enough to exhibit interference in individuals functioning educationally, socially including family activities. Usually, the most normal reaction towards specific phobia would be flight or avoidance in terms of motor or known as behavioral system (Silverman & Moreno, 2005).

According to DSM-V, there are five subtypes that classifies specific phobia which are living animals like dogs or reptiles, blood-infection-injury, natural environment such as storms, situational, for example in a lift and others such as fear of clowns and choking. These fears are excessive or unreasonable towards adults who experienced this disorder.

Prevalence

Presence rate in Asian, African, and Latin American countries are lower than European and United States with approximately 2% to 4% and 6% (American Psychiatric Association, 2013). In Malaysia itself, the exact prevalence is unknown. Besides, women are said to have a higher possibility to have specific phobias compare to men. Women often experience it than men at about the rate of 2:1 (Fleming, n.d.). Is was also mentioned that animal phobia has the highest presence followed by natural environment among all the subtypes of specific phobias (Costello, 1982).

Causes of specific phobia

Until this day, specific phobias do not have the actual factor and there are a lot still remains unknown or unclear. However, the occurrence of specific phobias may due to an individual's negative experiences (Fleming, n.d.). In line with this, individuals who had sufficient negative experiences or anxiety related to a specific object or situation such as trapped in the lift.

Besides, the influences of genetics and environment could be discussed as well. An extreme fear or anxiety of a child's parents may eventually creates a link between their own specific phobia and their parents'. It is heritably due to the genes or may caused by their learned behavior when they were young surrounded by their growth environment. Evidence from twin studies eventually found out that genetic factors contribute on developing fear or specific phobia (Van Houtem et al., 2013). In addition, the most prevalence mean heritability among the subtypes was animal phobia.

Risk factors

There are several factors that may increase the risk of an individual's specific phobias. Firstly, age would be one of the risk factors as specific phobias can first happened during childhood, but then, it could occur later in life (Essau, 2000; Kessler et al., 2005; Last et al., 1992). Secondly, first-degree relatives who experienced specific phobia may as well contribute as risk factor (American Psychiatric Association, 2013). This could be explained by the inherited tendency as if someone in the family has specific phobia or anxiety towards an object or situation, individual is more likely to have it as well. Besides, an individual's temperament shows that the risk may increase if the individual is increasingly sensitive, more obstruct than the society norms (American Psychiatric Association, 2013). Learning about negative experiences may be the risk when an individuals heard about the experiences from others, such as plane crashes that happened in Malaysia year 2014. Thus, learning from this information could affect the development of specific phobias.

Possible Functional Consequences of Specific Phobias

According to American Psychiatric Association, individuals with specific phobia may have lower quality of life including interpersonal impairment functioning. Generally, people takes specific phobia as a silly matters. In fact, individuals who experienced specific phobias may affect different perspectives of life and could be devastating to them. According to Mayo Clinic, individual who have specific phobias probably will have social isolation. They prevent objects and situations that they are fear of which can affect their daily lifestyle such as academics and relationship. Individuals with specific phobias will be more poor with social skills. Individuals will received home support informally or formally due to their specific phobia which reduced their physical and social functioning(American Psychiatric Association, 2013). Besides, depression and severe anxiety disorders may comorbid with individuals with specific phobias.

Treatment for Specific Phobias

In reducing or coping with specific phobias, psychoeducational group intervention is an effective approach. It is one of a common element in treatment plans for various phobias. It is a group therapy that mainly prioritize on educating individuals about specific phobias and ways of adapt and coping with it (Fritscher, 2017).

There is also evidences supported on using exposure-based treatments over other treatments in adults with specific phobia. Besides, in-vivo exposure treatment eventually confront with the fear of objects or situations at the post-treatment. Furthermore, active treatment condition in several studies were based on cognitive-behavioral principles. There was a statistic that 90.5% of studies used a combination of different exposure techniques (In-Albon & Schneider, 2007).

Self-Help Techniques

Exposure Therapy

Exposure therapy is the most widely studied treatment for specific phobias (Hood & Antony, 2012). Exposure therapy is a treatment based under Cognitive Behavioral Therapy (CBT) that involves the participant direct confront to the feared objects or situations (Wolitzky-Taylor, Horowitz, Powers & Telch, 2008). This process involves the person to perform a progressive exposure along the “steps for a fear hierarchy”. Participant provides an opportunity to experience the fear from the least to the most feared subjects or situation or combination of both. Along with the hierarchy, participant enable to reduce the feared subjects or situation and gain confidence in the presence of feared stimulus as the participant able to complete each stage of the hierarchy (Silverman & Morena, 2005). However, some of the people find it hard to adapt to the hierarchy of fear especially for the children or the youth group. The treatment can be construct through individual ability. For instance, breaking the exercises into smaller part through the hierarchy of fear as to simply for the participant to complete the tasks in every stage in an easier manner (Silverman & Morena, 2005).The goal of exposure therapy is to let the participant to tolerate the fear and the anxiety of the phobias. It provides a sufficient period in the stage for the participant to learn about the consequences of the feared subjects or situations do not occur and abolish the phobias by using step-by-step in hierarchy of fear.

Exposure therapy is listed as the most effective and efficient treatment for specific phobias (Hood & Antony, 2012) as well as strongest research evidence (Silverman & Morena, 2005). According to Wolitzky et al. (2008), many studies that are available to examine the comparison of the efficacy of the treatment with no treatment, placebo control and other psychotherapies. The findings show the participants who received exposure therapy shows 75% better than participants who received placebo treatment. Moreover, the studies mentioned that exposure therapy have significantly outperform by approximately 64% than non-exposure treatment. Furthermore, the meta-analysis shows a better of around 85% in exposure treatment participants than non-treated participants (Wolitzky et al., 2008). Most of the studies evaluated that exposure therapy work effectively under therapist. According to Öst, Salkovskis, & Hellström (1991), therapist-directed exposure shows more effective then self-directed exposure, and shows maintain in follow-up after a year of the treatment. Although self-directed exposure shows significant change in the post-test, however, it shows only a less improvements compare to therapist-directed exposure. However, in the study of Obrien & Kelley (1980), self-directed is as good as therapist-directed and it is more cost effective and practical treatment as it requires less direct therapist time. According to Öst et al. (1991), the reason that show inferior of self-directed exposure is that the exposure does not carry out any impact on the person’s life. Nevertheless, it occurs only 1 out of 17 cases that failed to do self-exposure while 16 of the cases shows a mean of 3.4 exposure session after committed in 2 sessions of self-directed exposure. Furthermore, studies show that self-directed exposure can be done with optimal therapist-directed, that is, go through one session of exposure therapy with therapist and continue with self-directed exposure after the week (Öst et al., 1991). Therefore, self-directed exposure therapy can be suggest as self-help techniques. Refer to Appendix 1 for exposure therapy techniques.

Mindfulness

Mindfulness is a term translated from Pali to English. It was a language of Buddhist psychology 2500 years ago. At that time, mindfulness was the core teaching and it signifies attention, remembering and awareness.

A study in 2010 assigned participants into both mindfulness treatment and cognitive-behavioral therapy (CBT) (Piet, Hougaard, Hecksher, & Rosenberg, 2010). The outcome shows mindfulness treatment achieved moderate-high effect size of d= 0.78 while CBT effect size d= 1.15. The participants has further improved through the 6 months follow up sessions into higher effect size mindfulness treatment (d= 1.42) and CBT (d=1.62). Therefore the researchers has concluded that mindfulness treatment might be a useful yet low cost treatment for specific phobia despite the smaller gap of effect from CBT.

While in 2011, researchers have proven mindfulness effective against specific phobia (Hooper, Davies, Davies, & Mchugh, 2011) they tested mindfulness on spider phobia. Participants were measured with a behavioural approach test (BAT) on how close they are willing to get towards a spider and the result of this study shows that participants that received unfocused attention induction has significantly decrease the tendency of getting closer to a spider than those participants that received mindful induction. The examination of the mean BAT scores shows that the mindful induction group (M = 7.4) moved through significantly more steps of the BAT than the unfocused attention group (M = 6) and the control group (M = 4.85).

The practice of mindfulness can helps in distinguishing a true and false threat that are required to be acted upon. Mindfulness strategies is most effective when it comes to fears that are generated in the own minds, the creation of our rich imagination. Our mind often overthinks and may it affects negatively (Gladding, 2011) especially for people with specific phobias. Thus, mindfulness strategies will be a useful self-help techniques that can reduce the anxiety that specific phobia patients are facing (Tlalka, 2014).

Mindfulness meditation is a technique that is used by Piet and colleagues in his research in 2010. It is a simple technique that can be done in an empty place more commonly home that is comfortable. Practicing mindfulness meditation are useful against annoying repetitive thoughts, lost in worry, feeling tightness and sensation of nervousness were found in oneself. These techniques helps may help shifting attention away from the complicating and messy thoughts, and drives the mind into the actual experience and the atmospheres of breathing. Helping the individual to transport out of the sophisticated mode into a sensation mode. Refer to Appendix 2 for mindfulness techniques.

Yoga exercise (Warrior pose – Virabhadrasana)

When you heard about exercise, it is probably for us to relate think about sport activity such as basketball, football and badminton. In fact, exercise can be differentiate to 4 main categories which are endurance, strength, balance and flexibility (Rogers & National Institute on Aging, 2013). Through these exercise, it is possible to help them reduce their anxiety, fear and improve in their own well-being and emotion regulation.

As specific phobia’s patient are often suffer from irrational fear and extreme anxiety, one of the self-help technique which is exercise might help them fight against this disorder. These exercise might include physical activity of outdoor, aerobic exercise, yoga. As in findings, exercise might help improve in one’s mental health, physical health and well-being (Penedo & Dahn, 2005). One of the study that involve participant in physical exercise and attend weekly class at public gym. The participants able to elicit the anxiety reaction by evaluate their body differently. Further, it’s assist in enhance one’s kindness towards one-self and decrease in negative judgement (Goldin, Gross, Jazaieri, Werner & Ziv, 2012).

Despite on reduce their anxiety, it is important to help those patient regulate their emotion to prevent them continue suffer from this disease. In a meta-analysis review, it was show that specific phobia can cause hyperactivity in amygdala and insula (Etkin & Wager, 2007). Thus, it caused them to have exaggerated fear response and emotional dysregulation (Etkin & Wager, 2007). To overcome with it, a very good strategy is exercise which it able to enhance people’s emotional regulation. According to Bernstein & McNally (2016), people whom did exercise will perceive less difficulties with emotion regulation and sadness in the study. Additionally, it also benefit in helping peoples less susceptible to experience negative mood state.

Further, physical activity and exercise can bring a positive effects on mood and anxiety (Strohle, 2008). In clinical use, exercise are always used as alternative treatment for those approach such as psychotherapy and pharmacotherapy (Strohle, 2008). So, it’s possible for us to use exercise as a self-help technique in the absence of mental health professional. This can be a proven when regular physical activity can lead to lower prevalence of specific phobia, social phobia and agoraphobia (Goodwin, 2003). While people with physical inactivity might had poorer mental health status and lead them with condition of worsen mood and increase anxiety (Benton & Thirlaway, 1992).

Lastly, one of the possible exercise that can be done step by step is yoga .As yoga might help us to enhance mood, decrease mood and depression (Uebelacker & Broughton, 2016).. Study had been proved to state yoga can direct people’s attention to their present thoughts and feeling (Uebelacker & Broughton, 2016). So it might be helpful that we put this practice into our daily life. Therefore, peoples with specific phobia can try to shift their attention from the fear. So, it is advised to do this exercise weekly. Refer to Appendix 3 for self-help yoga exercise techniques.

Referral Information

In Malaysia, there are also numerous of Mental health professionals (MHP) such as clinical psychologist, counsellors, therapists, and social workers, who can give a hand in dealing with the specific phobia. Each of them have provide different approaches or services toward the clients, and the clients are requested to get the advice from the professionals to identify the most suitable treatment plans and methods for them due to there were various type of therapies and different therapies perform different impacts to each people. Clients are encouraged to put in some efforts in performing self-help techniques too as the complementary method for them to deal with the specific phobia instead of ongoing dependent on therapists or medication.

The use of pharmacology in treating specific phobia has a result of constant throughout the decade as can be spot in the previous studies from different decades that pharmacology treatment tends to be used together with the other treatments sure as exposure therapy and Cognitive Behavior therapy. Pharmacology treatment can be in short term or long term progress depends on the clients’ needed (Koen, & Stein, 2012). However, the best choice to treat the specific phobias starts with exposure-based therapy followed by cognitive therapy, relaxation exercises and short-term pharmacotherapy. While the application of long-term pharmacotherapy is associated with reactions from adverse drug and substance abuse (Singh, &Singh, 2016). The modest amount of benzodiazepines can help the individual advances the approach to the phobic stimuli during the progress of treatment specific phobia. In the study conducted by Straube, Glauer, Dilger, Mentzel, and Miltner (2006), has shown that Cognitive Behaviour Therapy (CBT) can help in reduction of activation in thalamus and dorsomedial prefrontal cortex (DMPFC) in the treated which indicated that the reduction of fear is occur simultaneously.

References

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Appendix 1

Exposure therapy

1) Write down what is the subjects or situations you afraid of.

2) Set a goal. What has your phobia prevent you from doing? What would you like to be able to do?

3) Rating your fear. Range the fear from nothing to the worse anxiety imaginable, from a number between 0 to 100, 0 represents no dear at all, 100 represents the worst anxiety imaginable.

4) Creating a hierarchy of the feared subjects or situations. Make a list of the feared subjects or situations, starting with the situations that don’t cause much fear at all to the subjects or situation that find the most frightening.

5) Start slowly. Start with the feared subjects or situations that rated mildly fearful.

• 3 tips:

i. Start small. Begin with the less fearful and slowly work up to the more fearful.

ii. Do each exposure more than once until comfortable with it.

iii. Stay in the scary situation longer to decrease the anxiety level.

Note: You can ask supports from friends or family members to make things easier.

6) Practice record. Record down the date, target subjects or situations, expected anxiety, actual anxiety and outcome whenever facing a new feared subjects or situations.

Note:

• Gradually attempt to face the situation that are more anxiety provoking

• Keep progressing through the hierarchy. If the anxiety level did not come down, try to start again from the bottom of the hierarchy of fear. Insert relaxation techniques if necessary.

• Evaluate the performance and the goal.

Appendix 2

Mindfulness

1) Take your seat. Whatever you’re sitting on a chair, a meditation cushion or a park bench. Most importantly find a spot that gives you a stable, solid seat, not perching or hanging back.

2) Notice what your legs are doing. If on a cushion on the floor, cross your legs comfortably in front of you. (If you already do some kind of seated yoga posture, go ahead.) If on a chair, it’s good if the bottoms of your feet are touching the floor.

3) Straighten but don’t stiffen your upper body. The spine has natural curvature. Let it be there. Your head and shoulders can comfortably rest on top of your vertebrae.

4) Place your upper arms parallel to your upper body. Then let your hands drop onto the tops of your legs. With your upper arms at your sides, your hands will land in the right spot. Too far forward will make you hunch. Too far back will make you stiff. You’re tuning the strings of your body—not too tight and not too loose.

5) Drop your chin a little and let your gaze fall gently downward. You may let your eyelids lower. If you feel the need, you may lower them completely, but it’s not necessary to close your eyes when meditating. You can simply let what appears before your eyes be there without focusing on it.

6) Stay at the position for a few moments until you are relax, and bring your attention to your breath or the sensations in your body.

7) Feel or follow your breath as it goes out and as it goes in. Draw your attention to the physical sensation of breathing: the air moving through your nose or mouth, the rising and falling of your belly, or your chest. Choose your focal point, and with each breath, you can mentally note “breathing in” and “breathing out.”

8) Inevitably, your attention will leave the breath and wander to other places. Don’t worry. There’s no need to block or eliminate thinking. When you get around to noticing your mind wandering in a few seconds, a minute, and five minutes—just gently return your attention to the breath.

9) Practice pausing before making any physical adjustments, such as moving your body or scratching an itch. With intention, shift at a moment you choose, allowing space between what you experience and what you choose to do.

10) You may find your mind wandering constantly—that’s normal, too. Instead of wrestling with or engaging with those thoughts as much, practice observing without needing to react. Just sit and pay attention. As hard as it is to maintain, that’s all there is. Come back over and over again without judgment or expectation.

11) When you’re ready, gently lift your gaze (if your eyes are closed, open them). Take a moment and notice any sounds in the environment. Notice how your body feels right now. Notice your thoughts and emotions. Pausing for a moment, decide how you’d like to continue on with your day.

Appendix 3

Yoga exercise (Warrior pose – Virabhadrasana)

1) Stand straight with your legs by keeping distance 3-4 feet between each other.

2) Inhale and raise both hands parallel to the ground and turn your head to the right.

3) While exhaling slowly turn your right foot at 90 degrees to the right.

4) Slowly bend your right knee as shown in the above image. And hold this position for some time.

5) Repeat this for, cycle for 4-5 times.