Specific phobia — assessment and exposure-first management (MEQ)

(i) Assessment priorities. Structure risk, medical/syncope, phobia inventory, differential anxiety map, MSE, function and prior treatment. Risk: expand passive death wishes and cancer-care fear into full suicide assessment (ideation, intent, plan, means, protective factors); depression criteria review (PHQ-9 11). BII: faint/near-faint history, injury to self during collapse, prior investigations for cardiac/neuro causes of syncope if atypical. Flying fear details and other situational cues. Multi-phobia screen (animals, heights, vomiting). Duration (≥6 months typical threshold), almost-always immediate fear, avoidance/endurance, impairment. Safety behaviours (looking away, alcohol, insistence on general anaesthetic for minor procedures). Substances, medical history, medications. Scales: SUDs for hierarchy building; dental fear tools if relevant. Collateral if available. Capacity regarding refused investigations.^[1][2][5][6]

(ii) Working diagnoses and differentials. Working diagnoses: specific phobia, blood-injection-injury type (needles/blood/medical procedures with faint response and long avoidance) and specific phobia, situational type (flying) — both with clinically significant impairment; depressive symptoms with passive suicidal ideation needing full MDD review. Differentials: agoraphobia (not multi-domain escape fear; ground travel OK); panic disorder (no unexpected attacks described); social anxiety (works as teacher; not scrutiny-primary); PTSD (single turbulent flight without trauma cluster described — still screen); medical syncope syndromes if red flags. Normal fear does not explain multi-year healthcare refusal and career-limiting flight avoidance.^[1][5]

(iii) Psychological plan. Psychoeducation on fear maintenance and BII physiology. Build separate hierarchies for BII cues and flying with SUDs. For BII: teach applied tension (tense major muscles ~10–15 s cycles) then graded in vivo exposure (images → videos → sitting near clinic → watching blood draw → finger prick → supervised venepuncture) with medical support as needed; drop safety behaviours that block learning.^[2][3] For flying: graded exposure (education videos → airport → seated aircraft without takeoff if available → short flight) with possible VR adjunct; OST-style massed session can be considered for discrete animal-type phobias and may be adapted in specialist services for other discrete cues — explain Öst principles (therapist-guided massed practice, modelling, overlearning) even if multi-session graded work is used here because two phobias and BII safety need sequencing.^[2][4] Homework, booster planning, medical/dental liaison for essential procedures.

(iv) Medication limits. Exposure first; drugs not disease-modifying first-line for pure specific phobia. If a single unavoidable exposure requires a bridge, a short-term plan such as lorazepam 0.5–1 mg orally with strict indication, dose, non-repeat default, and discussion of sedation, dependence and blocked extinction — not daily long-term monotherapy. Treat comorbid depression on its own merits (SSRI with activation review) rather than as a substitute for BII exposure.^[2][5]

(v) Healthcare avoidance and depression. Frame delayed cancer-relevant investigations as high-stakes functional harm; coordinate with GP/specialists for staged procedures during exposure work; safety plan for passive suicidal ideation; increase follow-up frequency; do not discharge to empty care; monitor PHQ-9 and risk after any antidepressant start.^[5][6]