What is Phobia?
Harvard Medical School defines phobia as “a persistent, excessive, unrealistic fear of an object, person, animal, activity or situation.” It is a type of anxiety disorder. The fear is out of proportion to the objective threat and is recognized as such by the person experiencing it. A person with a phobia either tries to avoid the thing that triggers the fear or puts up with it with great anxiety and distress. The phobia, by rule, lasts longer than 6 months.
Almost everyone has an irrational fear or two—for example, the annual dental checkup. For most people, these fears are minor. For the fear to qualify as a phobia, the fear and avoidance must significantly interfere with the person’s social or occupational functioning or the person must experience marked distress about the fears.
Although the range of phobic situations is potentially quite broad, the four general types of phobias are:
- Animal phobias, such as the fear of snakes, spiders, insects, rodents, and dogs.
- Natural environment phobias, such as a fear of heights, storms, water, and of the dark.
- Situational phobias (fears triggered by a specific situation), such as the fear of enclosed spaces (claustrophobia), flying, driving, tunnels, and bridges.
- Blood or Injury phobias, such as the fear of blood, injury, illness, needles, or other medical procedures.
Some phobias can be specific and limited. For example, one may fear only cats (ailurophobia) or spiders (arachnophobia). Here, one can avoid anxiety by avoiding the thing one fears. Some phobias trouble one in a wider variety of situations or places. For instance, symptoms of fear of heights (acrophobia) can be brought one by looking out the window of a tall building or by driving over a high bridge, and symptoms of fear of enclosed spaces (claustrophobia) can be brought one by using an elevator or even a smaller restroom. Such people may not need to drastically alter their lives. In severe cases, the phobia may influence the person’s employment, work location, the driving route, home environment, and recreational and social activities (Harvard Medical School, 2018).
In ICD-10 and DSM-5, phobic disorders are divided into specific phobia, social phobia (social anxiety disorder), and agoraphobia. Phobias are one of the most common mental illnesses in the United States. Among adults, the lifetime prevalence of specific phobias has been estimated to be around 7% in men and 17% in women. The age of onset of most specific phobias is in childhood. The onset of phobias of animals occurs at an average age of 7 years, blood phobia at around 8 years, and most situational phobias develop in the early twenties (Harrison, et al., 2018).
Symptoms of Phobia
Phobias are characterized by exaggerated anxiety responses that occur reliably during exposure to relatively harmless stimuli or situations. Typically, the symptoms of phobias could include:
- Avoidance of the feared object or event
- Great anxiety and distress upon encountering the feared object or event
- Trembling or shaking
- Rapid heart rate
- Dizziness or lightheadedness
- Excess sweating
- Shortness of breath
- A choking sensation
- Loss of bladder or bowel control
- Feelings of unreality
- Preoccupation with the feared object.
Causes of Phobia (Harrison, et al., 2018)
Genetic factors. Most specific phobias in adulthood are a continuation of childhood phobias. Around 30% of first-degree relatives of people with specific phobia also have the condition. The genetic vulnerability may involve differences in the strength of fear conditioning, which has a heritability of around 40%.
Psychoanalytical theories. These theories suggest that phobias are not related to the obvious external stimulus, but to an internal source of anxiety. The internal source is excluded from consciousness by repression and attached to the external object by displacement. These theories are not borne out by objective evidence.
Conditioning and cognitive theories. Conditioning theory suggests that specific phobias arise through association learning. They may arise in relation to a highly stressful experience. For example, a phobia of horses may begin after a dangerous encounter with a bolting horse. Some specific phobias may be acquired by observational learning, as the child observes another person’s fear responses and learns to fear the same stimuli.
Cognitive factors are also involved in the maintenance of the fear, especially fearful anticipation of and selective attention to the phobic stimuli.
Prepared learning. This refers to an innate predisposition to develop persistent fear responses to certain stimuli. Some young primates seem to be prepared to develop fears of snakes.
Neural mechanisms. Functional imaging studies have revealed hyperactivity of the brain region known as amygdala upon presentation of the feared stimulus, which diminishes with treatment. Anticipation of a phobic stimulus activates certain parts of the cortical brain. Generally, imaging studies indicate that specific phobias are characterized by increased activation in the regions of the brain linked to emotional appraisal and fear (amygdala, insula, anterior cingulate), with a concomitant failure to recruit regions of the brain that regulate those regions (prefrontal regions).
Diagnosis of Phobia
DSM-5 lists the following diagnostic criteria for specific phobia (American Psychiatric Association, 2013):
- Intense fear or anxiety about a particular object or situation (e.g., heights, flying, animals, seeing blood, receiving an injection). Note: Children may express the fear or anxiety by crying, tantrums, freezing, or clinging.
- The phobic object or situation provokes immediate fear or anxiety.
- The phobic object or situation is actively avoided or endured with intense fear or anxiety.
- The fear or anxiety is out of proportion to the actual danger posed by the specific object or situation and to the sociocultural context.
- The fear, anxiety, or avoidance lasts for 6 months or more.
- The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other areas of functioning.
- The disturbance is not better explained by the symptoms of another mental disorder, including agoraphobia; obsessive-compulsive disorder; posttraumatic stress disorder; separation anxiety disorder; or social anxiety disorder.
Treatment (Sadock, et al., 2017) (Harrison, et al., 2018)
The main treatment is desensitization or exposure form of behavior therapy. With this treatment, there is a considerable reduction in intensity and social disability. For this to happen, repeated and prolonged exposure is needed. But, up to 25% of phobic patients decline exposure-based therapies. Exposure usually takes place over several 1-hour sessions, but it can be carried out in a single very long and intensive session lasting for several hours. Virtual reality exposure may also be of benefit. Exposure-based treatments are generally superior to other kinds of therapy; for example, relaxation therapy.
Cognitive behavioral therapy (CBT) is beneficial by letting the person challenge dysfunctional beliefs or thoughts by being mindful of their own feelings so that the person will realize that his or her fear is irrational. CBT can be conducted in a group setting. In one clinical trial, 90% of people were observed to no longer have a phobic reaction after successful CBT treatment.
In the case of phobias where there is a clear traumatic cause (e.g., fear of driving after a car accident), imaginal exposure is used to help the patient confront his or her memory of the traumatic event. Here again, the procedure promotes habituation to the memory and helps the patient to distinguish between the actual traumatic event, which was dangerous, and the current memory of the event, which, although distressing, is not harmful.
Virtual Reality Graded Exposure Therapy (VRGET) is used for the management of severe phobias that are difficult to treat using conventional therapies. VRGET desensitizes the patient to a situation or object that would normally cause anxiety or panic. VRGET combines advanced computer graphics, 3D visual displays, and body-tracking technologies to create realistic virtual environments with the goal of simulating feared situations or objects through visual, auditory, tactile, vibratory, vestibular, and olfactory stimuli to patients in highly controlled settings. During a virtual exposure session, the therapist closely tracks the patient’s state of arousal by monitoring physiological indicators of stress, including heart rate and respiration. Patients are ready to practice in vivo exposure to the feared object or situation after they have been desensitized to a virtual environment. VRGET is more effective than conventional imaginal exposure therapy and has comparable efficacy to in vivo exposure therapy for the treatment of specific phobias, agoraphobia, panic disorder, and PTSD.
Psychodynamic therapy involves exploring the unconscious meaning of the phobic stimulus to the individual as revealed by associated feelings, memories, dreams, and fantasies. Then, there is an opportunity to engage them and to work through the resistances, and the associated issues and conflicts.
Although pharmacotherapy has not been regarded as useful in the treatment of specific phobias, there is some evidence that D-cycloserine may be helpful in augmenting the effectiveness of exposure treatment of phobias. In animals, D-cycloserine facilitates fear extinction, and it is possible that a similar mechanism may be involved when D-cycloserine is combined with behavior therapy in humans. SSRI antidepressants (escitalopram and paroxetine) and antipsychotics may be useful as second-line treatments in phobias if patients do not respond to psychotherapy.
Some patients seek help soon before an important engagement that will be made difficult by the phobia. In such cases, a benzodiazepine may be prescribed to relieve phobic anxiety until a proper treatment can be arranged.
The presence of comorbid depression and other anxiety disorders, which are frequently found, would necessitate treatment with appropriate first-line pharmacological agents.