Phobias

What are phobias?

Fear is a normal human response to a situation or object. Normal fear serves to protect us: it activates our 'fight or flight' response, primes us to be ready for action and allows us to act quickly to protect ourselves.

A phobia is when someone experiences a disproportionate or unrealistic sense of danger. For example, a normal fear may be feeling nervous when you see a dog on the street, whereas a phobia would be avoiding walking through a park in case you see a dog.

A phobia is classified as a type of anxiety disorder. It is estimated that around 10% of the general population may experience a phobia during their lifetime. ^{[1 ]}

Phobias are a common mental health condition and can be severely debilitating if left untreated. ^[1] The severity of phobias can vary widely between people. The more severe forms of phobias may lead to crippling anxiety, and lead a person to reorganise their life in order to avoid the object or situation that causes their anxiety.

People can potentially develop phobias to anything, with some of the more common phobias being a fear of driving on a freeway, heights, public speaking, needles and spiders.

Phobias can be classified into five main categories:

• Animals - e.g., spiders, dogs or snakes;
• Natural environment - such as heights, storms or water;
• Blood-injection-injury - such as needles, invasive medical procedures;
• Situational - e.g., airplanes, elevators, closed-in spaces, and;
• Other - e.g. vomiting, costumed characters.

It is not necessary to be in the situation that is the source of the fear in order to experience the symptoms, as the brain is able to react to a frightening situation without needing to actually be in the situation. However, when actually exposed to the frightening situation, the fear is automatic and overwhelming.

Phobias tend to first appear during childhood, but some people may not develop them until they are adults. Children in particular tend to develop strong fears at certain ages, but they are fears they will usually grow out of and are not classified as phobias.

Common fears that children develop between the ages of:

• 0-2 years - separation anxiety, a fear of strangers and loud noises;
• 3-6 years - a fear of ghosts, monsters, the dark and sleeping alone, and;
• 7-16 years - a fear of illness, school performance, injury and death.

Causes

There is no single factor that causes phobias to develop. Instead, it is thought that they are caused by a complex interaction between genetics and environment. Children who have parents or siblings with an anxiety disorder are more likely to develop a phobia, while other children with a phobia may have learned this maladaptive response through a parent with an anxiety disorder.

Traumatic or distressing events can also trigger a phobia, such as nearly drowning, being attacked by an animal or being trapped in a confined space.

Current research has indicated that serotonin levels may be abnormal in people with phobias. Serotonin is a neurotransmitter that is involved in mood stabilisation - abnormal levels are associated with anxiety or depression.

Types

Phobias can be either simple/specific or complex.

Specific phobias

A specific phobia centres on a specific object, situation, animal or activity. It often develops during childhood or in adolescence, but may ease with increasing age.

Common examples include:

• Animal phobias;
• Environmental phobias - including heights or deep water;
• Situational phobias, such as going to the dentist or flying;
• Bodily phobias, such as vomiting or bleeding, and;
• Sexual phobias, such as performance anxiety or anxiety of contracting a sexually-transmitted disease.

Complex phobias

Complex phobias are generally more severe and disabling than specific phobias. They typically develop in adults and usually involve a crippling fear of a specific circumstance or situation.

Common examples are agoraphobia and social phobia.

Agoraphobia

People with agoraphobia experience anxiety that is brought on by being in a place where it may be too difficult to escape if they experience a panic attack. Their anxiety is so severe that it often results in them totally avoiding the situation. Common situations may include travelling on public transport, flying, crowded places or, conversely, being alone.

Social phobia

Someone with social phobia, or social anxiety disorder, suffers from severe anxiety when they encounter a social situation. A social phobia makes someone exceedingly embarrassed to speak in front of others, as they are fearful of humiliation. The phobia may be so severe that they find it too difficult to carry out seemingly simple activities such as meeting up with friends or dining out.

Signs and symptoms

The severity of symptoms may vary widely between people. There can be either physical and psychological symptoms, or a mixture of the two.

Some of the more typical physical symptoms include:

• Trembling;
• Rapid heartbeat;
• Panic;
• Fear;
• Dizziness;
• Hot flushes;
• Dry mouth;
• Ringing in the ears;
• A need to go the toilet;
• Headache;
• Upset stomach;
• Sweating;
• Nausea;
• Choking sensation, and;
• Shortness of breath.

Some of the more typical psychological symptoms include the fear of:

• Losing control;
• Fainting, and;
• Dying.

There may also be a feeling of impending dread and an intense need to escape.

For most phobias, there is typically a fear of fainting. However, fainting does not generally happen. The exception are people who experience blood-injection-injury phobia. When someone with this phobia is confronted by the sight of blood or a needle, they may experience disgust and fear and their initial response is anxiety accompanied by a racing heart rate. This sudden increase in heart rate is followed by a quick drop in blood pressure that results in nausea, dizziness and fainting.

Methods for diagnosis

There are no specific laboratory tests used to diagnose a phobia. Instead, diagnosis is based on taking a detailed history and following clinical guidelines.

Some of the criteria of phobias include:

• A marked and persistent fear that is excessive and unreasonable, triggered by a confronting object or situation;
• An immediate anxiety response when exposed to the stimulus;
• Avoiding the situation/object;
• Avoiding the stimulus to a degree that it causes interference with normal routine, function, social activities, relationships;
• In adults, realising that the fear is excessive, and;
• In adults, experiencing these symptoms for at least six months.

Types of treatment

The goal of treatment is to diminish the anxiety and help to manage reactions to the stimulus.

Simple phobias can be readily treated with exposure therapy: progressive exposure to the object, place, animal or situation that trigger your fear. Complex phobias may take longer and involve cognitive behaviour therapy, counselling and in some cases, medication.

Cognitive behaviour therapy

Cognitive behavioural therapy (CBT) forms a core component of treatment of phobias and includes exposure treatment. A therapist will guide you through developing strategies for thinking and behaving in ways that will help you cope with the phobia and reduce your emotional distress.

There can be different combinations of exposure therapy and behavioural therapy to treat specific phobias.

Exposure therapy

Exposure therapy involves facing your fears, gradually and repeatedly. During the exposure, you ride out the anxiety and fear until it all passes. Over repeated exposures, you gradually internalise the fact that the worst-case scenario is not actually going to happen, nor will you die or fail to cope. With each exposure comes increased confidence and control over the phobia and it loses its power.

As an example, to treat a phobia of dogs, the following stages may be worked through during exposure therapy:

• Looking at pictures of a dog;
• Watching a video clip with a dog in it;
• Looking at a dog through a window;
• Standing across the street from a dog on a leash;
• Standing on the same side of the road as a dog on a leash;
• Standing close to a dog on a leash;
• Patting a small dog that is being held by someone else;
• Patting a larger dog on a leash, and finally;
• Patting a larger dog off a leash.

Relaxation techniques

To ease anxiety, panic and fear, relaxation techniques may be used before and during exposure to a stimulus. These techniques may include deep breathing, meditation and muscle relaxation. With regular practice, these techniques can help to improve your control over physical symptoms and enable more effective anxiety control.

Medication

Medication is not typically used for treatment of phobias, but some people with severe forms of anxiety may be prescribed medication to help them cope with their condition.

Typical medications may include:

• Beta-blockers - these block the stimulating effect of adrenaline on the body. Their short-term use can be effective in decreasing symptoms when taken prior to exposure to the stimulus;
• Antidepressants such as selective serotonin reuptake inhibitors (SSRIs) can decrease the level of anxiety, and;
• Sedatives - these can induce relaxation by decreasing the level of anxiety, but need to be used with caution, as they can be habit-forming. They are only used for short periods of time until other therapies start to work.

Potential complications

Potential complications of living with phobias include:

• Social isolation;
• Depression;
• Substance abuse, and;
• In extreme circumstances, suicide.

Prognosis

If left untreated, phobias tend to be lifelong. When treated, phobias have an excellent prognosis, especially with exposure-based treatment.

Prevention

Although there is no known prevention, children typically learn coping skills from their parents. As a parent, you may reduce the likelihood of passing these fears on to your children by dealing with your own fears.

References

1. Kessler, R. C., Berglund, P., Demler, O. et. al., (2005) Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National comorbidity survey replication.” Archives of General Psychiatry 62:593–602. doi:10.1001/archpsyc.62.6.593.

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