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While specific phobias are common in the general population, they are relatively rarely encountered in clinical settings. One way of interpreting this discrepancy is to assume that specific phobias represent a minor form of psychopathology, because most sufferers can apparently live without seeking help for it. The other interpretation is that people with specific phobias may feel embarrassed to seek help or that there are other impediments to their treatment. Regardless of the interpretation, there is a need to change the conceptualization of specific phobias.

One task here is to ''legitimize'' specific phobias by tightening the boundary with normal fears. Perhaps this can be done by using a diagnostic designation only for cases with severe phobic fear, extensive avoidance, and evidence of substantial distress or impairment caused by fear and/or avoidance.

The other task is making an effort toward eliminating trivialization of the suffering and impaired functioning of people with specific phobias. A successful completion of these tasks would make it possible for both the sufferers and clinicians to take specific phobias seriously. And if they are taken seriously, they will no longer be relatively neglected by researchers.

Addressing the heterogeneity within specific phobias should receive priority because various types of phobias differ too much to be classified together. Understanding better the psychopathology and pathogenesis of various phobias would illuminate the relationships between them. Efforts to do this are already under way, for example, through research aimed at elucidating the role of disgust in some types of phobias. The putative dichotomy between disgust-driven and fear-driven phobias is not the only one; all distinctions that seem conceptually and clinically meaningful should be considered.

Exposure-based treatments for specific phobias are generally effective, but they need to become more accessible to sufferers. This implies greater use of the computer, Internet, and other modern technology. Treatments should also be adapted with the goal of improving compliance and minimizing dropout rates. Tendencies to shorten the therapy and pressure for treatments to be more cost-effective need to be balanced against evidence of efficacy of ultra brief treatments and needs of many patients for a slower pace and greater attention to detail throughout treatment. Maintaining treatment gains is particularly important for phobias that are not likely to abate without treatment, and in these cases greater emphasis should be placed on ensuring the long-term benefit of exposure therapy and preventing relapse. Finally, exposure therapy needs to be modified for phobias that are more resistant to treatment; it remains to be ascertained whether adding cognitive or other techniques or pharmacotherapy in these situations would result in greater improvement.

References:

1. Purdon C, Clark DA. 1994. Perceived control and appraisal of obsession intrusive thoughts: A replication and extension. Behavioral and Cognitive Psychotherapy, 22: 269--285.

2. Quitkin FM, Harrison W, Stewart JW, et al. 1991. Response to phenelzine and imipramine in placebo nonresponders with atypical depression: A new application of the crossover design. Archives of General Psychiatry, 48: 319--323.

3. Rabinowitz I, Baruch Y, Barak Y. 2008. High-dose escitalopram for the treatment of obsessive-compulsive disorder. International Clinical Psychopharmacology, 23: 49--53.

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