Evidence Based Practices for Mental Health Professionals
By Jim Messina, Ph.D., CCMHC, NCC, DCMHS-T
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LEARNING OBJECTIVES FOR PHOBIAS
After reading this section you will learn the answers to the following questions:
- What are the ICD-10-CM Codes for Phobias?
- What are the clinical descriptors for Phobias?
- What are the symptoms common for Phobias?
- What are the common populations which are treated for Phobias?
- What are the common treatment settings for Phobias?
- What are the Evidence Based Practices for treating Phobias?
- What are the common psychopharmacological treatments for Phobias?
- What are some common manuals, guideline books and client workbooks for treating Phobias?
- What are some good references you can use to learn more in-depth information about Phobias?
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ICD-10-CM Codes for Phobia in DSM-5
F40.218 Specific Phobia to Animal
F40.228 Specific Phobia to Natural Environment
F40.23 Specific Phobia With Fear of Blood
F40.231 Specific Phobia With Fear of injections and transfusions
F40.232 Specific Phobia With Fear of other medical care
F40.233 Specific Phobia With Fear of injury
F40.248 Specific Phobia Situational
F40.298 Specific Phobia Other
F40.10 Social Anxiety Disorder (Social Phobia) Specify if Performance Only
F41.0 Panic Disorder
F40.00 Agoraphobia
American Psychiatric Association (APA). (2013). Diagnostic and statistical manual of mental disorders (5th ed.) (DSM-5). Washington, DC: Author.
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Kathy: Phobia-Fear of Flying
Kathy was excited in that she was just given a promotion as regional manager of her company. The problem was that with this new position she would be expected to visit all of the offices in the region a minimum of once a month which would mean she would need to fly to a minimum of three different cities each month. Problem was that Kathy had an extreme fear of flying and was frightened by heights. She tells you this story when she arrives for her first visit. You tell her you will be involving her in evidenced based treatment for her phobia so that she will be able to handle her new job with as little fear, anxiety or stress about the need to fly to her destinations.
You tell her the treatment over the next six months will entail about 12 sessions involving:
1) Initially the use of video exposure similar to video games to expose her to the stimuli of getting on a plane and flying
2) Training in relaxation training so as to keep her relaxed and breathing as she experiences this exposure process
3) Training in “thought stopping” so that she can immediately stop and dismiss her internal thoughts and self-talk which raises her fear of entering an airport, plane, taking off and landing in a plane.
4) Finally “in vivo” exposure in which she along with you will enter an airport, go through security check, and go to a departure gate, and if possible go on a flight with you or a coach to get her through the flight with no fear
5) By the end of six months you inform her she will be able to get on a plane and arrive at her destination with little or no fear since she will be using the tools she has learned in her therapeutic process.
Kathy seems skeptical but says to you: “since there is research to prove this model is effective, I am willing to give it a try.” And you begin immediately to train her in how to do systematic relaxation training and give her a homework assignment to do this model daily until her next appointment in two day when you will introduce her to the video game airplane entering experience. You give her first homework assignment to begin training herself in “thought stopping” which is to be brought in for her next appointment.
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The different types of Phobia are:
1) Social Phobia (Abbott and Rapee, 2004; Curtis, Kimball and Stroup, 2004; Hofmann, Schulz, Meuret, Moscovitch and Suvak, 2006: Hertel, Brozovich, Joormann and Gotlib, 2008; Olivares-Olivares, Rosa-Alcr and Olivares-Rodriguez, 2008).
2) Agoraphobia (Hahlweg, Fiegenbaum, Frank, Schroeder and von Witzleben, 2001; Porter, Prceri, Koch, Fons and Spates, 2006; Penate, 2012).
3) Specific Phobias and Fears:
- Fear of Spiders: (Arntz, Merckelbach and de Jong, 1993; Lange, Tierney, Reinhardt-Rutland and Vivekananda-Schmidt, 2004);
- Fear of Flying: (Bornas, Tortella-Feliu and Llabres, 2006; Tortella-Feliu, Botella, Llabres, Brenton-Lopez; del Amo, Banos and Gelabert, 2011; Lakes, 2012);
- Fear of Heights: (Wilhelm, Pfaltz, Gross, Mauss, Kim and Wiederhold, 2005);
- Fear of School: (Pina, Zerr, Gonzales and Ortiz, 2009);
- Dental Phobia: (Thom, Sartory and Johren, 2000; Vika, Skaret, Raadal, Ost, and Kvale, 2009).
- Driving Phobia (Townsend and Grant, 2006).
Populations treated for Phobias include:
1) Children and adolescents (Ollendick, King and Muris, 2002; Curtis, Kimball and Stroup, 2004; King, Heyne and Ollendick, 2006; Mendez, Santacruz and Sanchez-Meca, 2006; Olivares-Olivares, Rosa-Alcr and Olivares-Rodriguez, 2008; Silverman, Pina and Viswevaran, 2008, Pina, Zerr, Gonzales and Ortiz, 2009).
2) Adults (Abbott and Rapee, 2004; Hertel, Brozovich, Joormann and Gotlib, 2008).
3) Elderly adults (Pagoto, Kozak, Spates and Spring, 2006).
EBP treatments for Phobias include:
1) Cognitive Behavioral Therapy (CBT) (Gaston, Abbott, Rapee and Neary, 2006; King, Heyne and Ollendick, 2006; Silverman, Pina and Viswevaran, 2008).
2) In vivo Exposure (Arntz, Merckelbach and de Jong, 1993; Hahlweg, Fiegenbaum, Frank, Schroeder and von Witzleben, 2001; Porter, Prceri, Koch, Fons and Spates, 2006).
3) Virtual Exposure: (Riva, 2003; Robillard, Bouchard, Fournier. and Renaud, 2003; Lange, Tierney, Reinhardt-Rutland and Vivekananda-Schmidt, 2004; Bornas, Tortella-Feliu and Llabres, 2006; Botella, C., Quero, S., Barios, R.M., Garcia-Palacios, A, Brenton-Lopes, J., Alcaniz, M. and Fabregat, S., 2006; Penate, 2012).
4) Combination of CBT and Exposure (Rowa and Antony, 2005; Hofmann, Schulz, Meuret, Moscovitch and Suvak, 2006; Olivares-Olivares, Rosa-Alcr and Olivares-Rodriguez, 2008).
5) Eye Movement Desensitization and Reprocessing (EMDR) (Shapiro, 2002; Lakes, 2012).
6) Pharmacotherapy only (Van Amerigen, Mancini, Oakman and Farvolden, 1999; Thom, Sartory and Johren, 2000; Andrews, Oakley-Browne, Castle, Judd and Baille, 2003).
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First Assignment given to Kathy as she begins to work on her Fear of Flying
Directions for Thought Stopping
Step 1: Use relaxation training and breathing exercises to get yourself relaxed. It is important that you be relaxed as you proceed with this process.
Step 2: Record the word "stop" in alternating 1, 2, and 3‑minute intervals on a 30‑minute recording session. Using the stop recording in a relaxed state, think your unwanted thought and every time you hear stop, discontinue the thought. Go back to the thought again and cease the thought only when you hear stop. Do this for 30 minutes every night for two weeks or until you can consistently discontinue the thought when you hear stop.
Step 3: After you are trained to arrest your thought using the stop recording, you are ready to try arresting your thought by yelling stop out loud. Think of your unwanted thought for 30 minutes and yell stop to discontinue the thought. Once you arrest the thought, go back to thinking about it for a while, then yellstop again. Do this for 30 minutes each night for two weeks or until you are able to consistently discontinue the thought by yelling stop.
Step 4: After you have trained yourself to stop thoughts by yelling stop, you are ready to train your thoughts to end by whispering stop. For thirty minutes, repeat the process of dwelling on your unwanted thoughts but this time whisper stop to halt them. Do this 30 minutes nightly for two weeks or until you are able to consistently discontinue the thought by whispering stop.
Step 5: After you have trained yourself to discontinue unwanted thoughts by whispering stop, you are ready to train your thoughts to discontinue by thinking the word stop. Repeat the process of dwelling on your thought for 30 minutes, but this time simply think stop to discontinue unwanted thoughts. Do this for 30 minutes nightly for two weeks or until you are able to consistently discontinue unwanted thoughts by thinking the word stop.
NOTE: The technique of either recording, yelling, whispering, or thinking stop can be effective in discontinuing unwanted thoughts. Ideally you could get to the point where simply thinking stop would work; however, use whichever mode works best for you and keep practicing. Remember to start the process in a relaxed state.
After reading these instructions on Thought Stopping I am committed on using thought stopping to stop myself from falling into my fear of flying and to regain serenity in my life.
Signed: Dated:
Adapted from: Section 3, Chapter 8: Thought Stopping in Recovery in: Messina, J.J. (2013). Self-Esteem Seekers Anonymous-The SEA’s Program of Recovery, retrieved at www.coping.us
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Medications used for Phobias
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Classificaton
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Drug name (Generic Name)
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New Benzodiazepines
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Ativan (Lorazepam)
Xanax (Alprazolam)
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Old Benzodiazepines
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Valium (Diazepam)
Librium (Chlordiazeproxide)
Klonopine (Clonazepam)
Restoril (Temazepam)
Halcion (Triazolam)
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Buspirone
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Buspar (Buspirone)
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Non-Benzodiazepines
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Ambien (Zolpidem)
Sonata (Zaleplon)
Lunesta (Eszopiclone)
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SNRI
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Effexor XR (Venlafaxine)
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SSRI’s
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Lexapro (Escitalopram)
Paxil (Paroxetine)
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Exposure therapies involve both in-vivo which requires the client to work up to going into the feared environment and succeed in engaging with it. Virtual exposure gives the client an active engagement without having to leave the office setting. Typically, the clinician uses 1) video segments (Riva, 2003) 2) segments derived from video games (Robillard, Bouchard, Fournier. and Renaud, 2003) or 3) Internet programs (Bornas, Tortella-Feliu and Llabres, 2006; Botella, C., Quero, S., Barios, R.M., Garcia-Palacios, A, Brenton-Lopes, J., Alcaniz, M. and Fabregat, S., 2006; Titov, Gibson, Andrews and McEvoy, 2009).
Treatment with children who have a phobia typically involve up to 12 sessions in which the clinician gives them: 1) psychoeducation on phobias, causes and treatments; 2) social skills training with a focus on assertiveness, maintaining interpersonal conversation, making and keeping friends and public speaking; 3) exposure either in-vivo real life or simulated; and 4) cognitive restructuring by identifying negative automatic thoughts and applying new meanings to the negative thoughts (Olivares-Olivares, Rosa-Alcr and Olivares-Rodriguez, 2008).
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Handouts for Kathy to better explain the elements involved in her treatment
- TEA System
- ALERT System
- ANGER System
- LET GO System
- CHILD System
- RELAPSE System
All available online at: www. coping.us at: http://coping.us/seastoolsforrecovery.html
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Treatment Workbooks for Phobias
Antony, M.M., Craske, M.G. and Barlow, D.H. (2006). Mastering your fears and phobias: Therapist guide. Second edition. New York: Oxford University Press
Antony, M.M., Craske, M.G. and Barlow, D.H. (2006). Mastering your fears and phobias: Workbook. Second edition. New York: Oxford University Press
Antony, M.M. and Rowa, K. (2008). Social phobia. Gottingen, Germany: Hagrefe and Huber Publishers.
Antony, M.M. and Swinson, R.P. (2000). Phobic disorders and panic in adults: A guide to assessment and treatment. Washington, DC: American Psychological Association.
Beck, A.T., Emery, G. and Greenberg, R.L. (1990). Anxiety disorders and phobias: A cognitive perspective. New York: Basic Books.
Bourne, E. (2005). The anxiety and phobia workbook. Oakland, CA: New Harbinger
Heimberg, R. G. and Becker, R.E. (2002). Cognitive-behavioral group therapy for social phobia: Basic mechanisms and clinical strategies. New York: Guilford.
Messina, J.J. (2013). Tools for coping series: (1) Self-esteem seekers anonymous-The SEA’s program manual; (2) Laying the foundation: Personality traits of low self-esteem; (3) Tools for handling loss; (4) Tools for personal growth; (5) Tools for relationships; (6) Tools for communications; (7) Tools for anger work-out; (8) Tools for handling control issue; (9) Growing down:Tools for healing the inner child; (11) Tools for a balanced lifestyle, retrieved at www.coping.us
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References for Phobias
Abbott, M.J. and Rapee, R. M. (2004). Post-event rumination and negative self-appraisal in
social phobia before and after treatment. Journal of Abnormal Psychology, 113(1), 136-144. DOI: 10.1037/0021-843X.113.1.136
Andrews, G., Oakley-Browne, M., Castle, D., Judd, F. and Baille, A. (2003). Summary of
guideline for the treatment of panic disorder and agoraphobia. Australian Psychiatry, 11(1), 29-33.
Arntz, A., Merckelbach, H. and de Jong, P. (1993). Opiod antagonist effects of exposure in vivo.
Journal of Consulting and Clinical Psychology, 61(5), 865-870.
Bornas, X., Tortella-Feliu, M. and Llabres, J. (2006). Do all treatments work for flight phobia?
Computer-assisted versus brief multicomponent nonexposure treatment. Psychotherapy Research, 16(1), 41-50. DOI: 10.1080/10503300500091058
Botella, C., Quero, S., Barios, R.M., Garcia-Palacios, A, Brenton-Lopes, J., Alcaniz, M. and
Fabregat, S. (2006). Telepsychology and self-help: The treatment of phobias using the internet. CyberPsychology and Behavior, 11(6), 659-664. DOI: 10.1089/cpb.2008.0012
Curtis, R.C., Kimball, A. and Stroup, E.L. (2004). Understanding and treating social phobia.
Journal of Counseling and Development, 82 (Winter), 3-9)
Gaston, J., Abbott, M., Rapee, R., and Neary, S. (2006). Do empirically supported treatments
generalize to private practice? A benchmark study of a cognitive-behavioural group treatment programme for social phobia. British Journal of Clinical Psychology,45, 33-48. doi:10.1348/014466505X35146
Hahlweg, K., Fiegenbaum, W., Frank, M., Schroeder, B., and von Witzleben, I. (2001). Short-
and long-term effectiveness of an empirically supported treatment for agoraphobia. Journal of Consulting and Clinical Psychology, 69(3), 375-382. doi: 10.1037//0022-006X.69.3.375
Hertel, P., Brozovich, F., Joormann, J., and Gotlib, I. (2008). Biases in interpretation and
memory in generalized social phobia. Journal of Abnormal Psychology, 117 (2), 278-288. doi: 10.1037/0021-843X.117.2.278
Hofmann, S. G., Schulz, S. M., Meuret, A. E., Moscovitch, D. A. and Suvak, M. (2006). Sudden gains during therapy of social phobia. Journal of Consulting and Clinical Psychology,74(4), 687-697. doi: 10.1037/0022-006X.74.4.687
King, N.J., Heyne, D. and Ollendick, T.H. (2006). Cognitive-behavioral treatments for anxiety
and phobic disorders in children and adolescents: A review. Behavioral Disorders, 30(3), 241-257.
Lakes, M. (2012). Specific phobia: Flight. Activitas Nervosa Superior, 54(3-4), 108-117.
Lange, W.G.T., Tierney, K.J., Reinhardt-Rutland, A.H. and Vivekananda-Schmidt, P., (2004).
Viewing behavior of spider phobics and non-phobics in the presence of threat and safety stimuli. British Journal of Clinical Psychology, 43, 235-243.
Mendez, F., Santacruz, I. and Sanchez-Meca, J. (2006). Play therapy applied by parents for
children with darkness phobia: A comparison of two programmes. Child and Family Behavior Therapy, 28(1), 19-34. doi:10.1300/J019v28n01_02
Olivares-Olivares, P., Rosa-Alcr, A. and Olivares-Rodriguez, A. (2008). Does individual
attention improve the effect of group treatment of adolescents with social phobia? International Journal of Clinical Health and Psychology, 8(2), 465-481.
Ollendick, T.H., King, N.J. and Muris, P. (2002). Fears and phobias in children: Penomenology,
epidemiology, and aetiology. Child and Adolescent Mental Heatlh, 7(3), 98-106.
Pagoto, S.L., Kozak, A.T., Spates, C.R. and Spring, B. (2006). Systematic desensitization for an
older woman with a severe phobia: An application of evidenced-based practice. Clinical Gerontologist, 30(1), 89-98. doi:10.1300/J018v30n01_07.
Penate, W. (2012). About the effectiveness of telehealth procedures in psychological treatments.
International Journal of Clinical and Health Psychology, 12(3). 475-487.
Pina, A.A., Zerr, A.A., Gonzales, N.A. and Ortiz, C.D. (2009). Psychsocial interventions for
school refusal behavior in children and adolescents. Child Development Perspectives, 3(1), 11-20.
Porter, K., Prceri, C., Koch, E.I., Fons, C. and Spates, C.R. (2006). In vivo exposure treatment
for agoraphobia. The Behavior Analyst Today, 7(3), 434-441.
Riva, G. (2003).Virtual environments in clinical psychology. Psychotherapy: Theory, Research,
Practice, Training, 40(1/2), 68-76. doi:10.1037/0033-3204.40.1/2.68
Robillard, G., Bouchard, S., Fournier, T. and Renaud, P. (2003). Anxiety and presence during
VR immersion: A comparative study of the reactions of phobic and non-phobic participants in therapeutic virtual environments derived from computer games. CyperPsychology and Behavior, 6(5), 467-475.
Rowa, K. and Antony, M. (2005). Psychological treatment for social phobia. The Canadian
Journal of Psychiatry, 50(6), 308-316.
Shapiro, F. (2002). EMDR and the role of the clinician in psychotherapy evaluation: Towards a
more comprehensive integration of science and practice. Journal of Clinical Psychology, 58(12), 1453-1463. DOI: 10.1002/jclp.10104.
Silverman, W.K., Pina, A.A. and Viswesvaran, C. (2008). Evidence-based psychosocial
treatments for phobic and anxiety disorders in children and adolescents. Journal of Clinical Child and Adolescent Psychology, 37(1), 105-130. doi: 10.1080/15374410701817907
Thom, A., Sartory, G. and Johren, P. (2000). Comparison between one-session psychological
treatment and benzodiazepine in dental phobia. Journal of Consulting and Clinical Psychology, 58(3), 378-387. DOI: 10.I037//0022-006X.68.3.378
Titov, N., Gibson, M., Andrews, G., and McEvoy, P. (2009). Internet treatment for social phobia
reduces comorbidity. Australian and New Zealand Journal of Psychiatry, 43(8), 754-759. doi:10.1080/00048670903001992
Tortella-Feliu, M., Botella, C., Llabres, J., Brenton-Lopez, J.M., del Amo, A.R., Banos, R.M.
and Gelabert, J.M. (2011). Vitural reality versus computer-aided exposure treatments for fear of flying. Behavioral Modification, 35(1), 3-30. DOI: 10.1177/0145445510390801
Townsend, M. and Grant, A. (2006). Integrating science, practice and reflexivity-cognitive
therapy with driving phobia. Journal of Psychiatry and Mental Health Nursing, 13, 554-561.
Van Amerigen, M., Mancini, C., Oakman, J.M. and Farvolden, P. (1999). Selective serotonin
reuptake inhibitors in the treatment of social phobia-The emerging gold standard. CNS Drugs, 11(4), 307-315.
Vika, M., Skaret, E., Raadal, M., Ost, L-G, and Kvale, G. (2009). One- vs. five-session treatment
for intra-oral injection phobia: a randomized clinical study. European Journal of Oral Sciences, 117, 279-285.
Wilhelm, F.H., Pfaltz, M.C., Gross, J.J., Mauss, I.B., Kim, S.I. and Wiederhold, B.K. (2005).
Mechanisms of virtual reality exposure therapy: The role of the behavioral activation and behavioral inhibition systems. Applied Psychophysiology and Biofeedback, 30(3), 271-284. DOI: 10.1007/s10484-005-6383-1
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WHERE DO I GO FROM HERE?
CONCERNING PHOBIAS
Now that you have read this section, in “My Mental Health Professional Practitioner Journal” record your answers and reactions to the following questions:
- How will this information help me as a Mental Health Professional?
- How interested am I in implementing Evidence Based Practices concerning Phobias in my clinical practice?
- Why is it important that I learn more about Phobias?
- What more do I need to know about Phobias?
- Where can I go to obtain more information about Phobias?
- Where can I go to obtain the journal articles, manuals, workbooks or guidebooks on Phobias?
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