Diagnostic features

• Marked fear or anxiety about a specific object or situation.
• Immediate fear response on exposure, which is out of proportion to actual danger.
• Persistent (typically ≥6 months) and causes significant distress or impairment.
• Fear/avoidance not better explained by another mental disorder (e.g., OCD, PTSD).

Common types

• Animal (dogs, spiders)
• Natural environment (heights, storms, water)
• Blood‑injection‑injury: unique vasovagal response with fainting risk
• Situational (flying, elevators, enclosed spaces)
• Other (choking, vomiting, loud noises)

Assessment checklist

1. Detailed history: onset, course, triggers, avoidance behaviours and functional impact.
2. Assess fear severity and avoidance using measures (e.g., Fear Survey Schedule, SPIN for social phobia when relevant).
3. Medical history: especially for blood‑injection‑injury phobia (syncope) and cardiovascular status.
4. Comorbidity screen: other anxiety disorders, mood disorders, substance use, and neurodevelopmental conditions.
5. Collaboratively set treatment goals and willingness for exposure work—obtain informed consent and explain rationale.

Evidence‑based treatment

• Exposure therapy: first‑line—graded in vivo exposure or imaginal exposure when in vivo not feasible. Key elements: habituation/learning, response prevention, repeated and prolonged exposure, and behavioural experiments.
• Virtual reality exposure (VRET): effective for specific situational fears (flying, heights) where real exposure is difficult.
• Applied tension: for blood‑injection‑injury phobia to prevent fainting—tensing muscles to raise blood pressure during exposure.
• CBT components: cognitive restructuring for catastrophic beliefs, psychoeducation, and relapse prevention planning.
• Brief, single‑session treatments: highly effective for specific phobia in many cases—intensive, therapist‑led sessions of several hours with graded exposure.

Practical exposure steps (brief guide)

1. Develop a fear hierarchy with the client (0–100 SUDS) listing situations from least to most distressing.
2. Start with low‑SUDS item; use psychoeducation and breathing/grounding; prevent safety behaviours that reduce learning.
3. Prolonged exposure until SUDS reduces by ~50% or for a predetermined time; record SUDS and behavioural response.
4. Repeat exposures across sessions and in different contexts; schedule homework for in‑vivo practice.
5. Use imaginal exposure or VR if in vivo impractical; combine cognitive experiments to test catastrophic predictions.

Pharmacotherapy

• Medication is not first‑line for specific phobia. Short‑term benzodiazepines may reduce acute anxiety but can interfere with exposure learning and carry dependence risk.
• SSRI/SNRI may be used when comorbid anxiety/depression present but do not replace exposure for phobia-specific improvement.
• Pre‑session beta‑blockers can reduce autonomic symptoms for performance‑type fears, but use cautiously and do not substitute for exposure.

Practical tips for clinicians

• Set clear expectations: explain exposure rationale and normalise initial anxiety increase as part of learning.
• Collaboratively create the hierarchy and use measurable SUDS—track progress objectively.
• Encourage frequent, short homework exposures rather than rare long exposures; vary contexts to promote generalisation.
• Document consent and ensure safety measures for B‑I‑I phobia and medical comorbidity.

Key takeaways

• Specific phobia is common and highly treatable—exposure therapy is the gold standard and can be delivered in brief, intensive formats.
• Assess comorbidity and medical risks (especially for blood‑injection‑injury phobia) before exposure work.
• Use collaborative hierarchies, plan repeated in‑vivo practice and support generalisation with homework and context variation.