People with Specific Phobia suffer intense fear and sometimes panic attacks in the presence or anticipation of certain triggers. These triggers can come from a wide variety of categories, and the resulting anxiety far exceeds any real danger. Some of the most well known phobias are snakes, spiders, and heights, but people can also fear numbers, cell phones, or even bad breath. People are aware that their fear is unwarranted but are unable to control it.
To observers, people with Specific Phobia appear to avoid, without reason, seemingly innocuous situations, like walking several flights of stairs to circumvent taking the elevator. They may even base major life choices around avoiding their phobias, such as turning down a promotion if it requires flying or refusing to move to a new home in a high-rise building because of fear of heights.
With a phobic trigger in their immediate presence, they will keep their distance and appear visibly anxious, sweating, breathing quickly, or trembling. Full panic attacks may follow, and they suffer rapid-onset episodes of chest tightness, intense anxiety, rapid breathing, and nausea.
Relative to other anxiety disorders, Specific Phobia is very treatable and has a generally very good prognosis. Although this is, of course, dependent on previous level of functioning, support system, and ability to engage in treatment. Left untreated, however, functional impairments are similar to those from other anxiety disorders as well as substance use disorders, and the degree of impairment is directly proportional to the number of different phobias.
Causes and Risk Factors
The average age of onset is young, just 10 years old, and many start to experience symptoms as early as age 5. As a result, the diagnosis is most prevalent in teenagers, at 16%.
Heritability of Specific Phobia is about 50% across the various types. Genetic vulnerabilities are specific to the subtypes of phobias, even down to the exact phobic stimulus, with parents and children being more likely to share a fear of the same animal, for example.
About 9.4% of people will be diagnosed with Specific Phobia at some point in their lives, and women have twice the risk of men. People with Specific Phobia are over twice as likely as the general population to have drug, alcohol, and nicotine use disorders. They are over five times as likely to have any other anxiety disorder. Additionally, they are especially at risk – almost twenty times greater than average – for Agoraphobia.
Learned versus innate fear
Over 90% of people with Specific Phobia either remember a specific traumatic event as the start of their phobia or have no memory of a source. The rest have some memory of seeing someone else afraid of the trigger or learning the fear by watching others’ reactions. Regardless of memory of a traumatic event or the type of phobic trigger, they do not differ in baseline levels of neuroticism (a risk factor for phobias). This means that specific fearful experiences are not always necessary for the creation of a phobia.
Since these assessments are based on memories, it is difficult to tell whether the traumatic experiences are the source of fear or are only memorable because of an already innate fear. In fact, when comparing otherwise similar phobic and non-phobic groups, researchers find similar rates of similar traumatic events that, for the phobic group, are seen as the source of the fear. What sets this group apart is their significant tendency to expect negative experiences associated with their phobic focus.
Diagnosing Specific Phobia
Making the diagnosis
People with Specific Phobia experience overwhelming fear and anxiety when confronted with any of a great variety of possible types of settings or objects. Children will cry, freeze, or hold tightly to their caregivers as a source of security. The subject of fear almost always induces this reaction, but the severity of the reaction can change depending on the intensity of the exposure. For example, experiencing the feared object in person would evoke a much more intense response than seeing a picture of it.
The reaction is greatly out of proportion from what other people would normally have. A lot of people do not like spiders, but someone with a true phobia of spiders will have a much more intense reaction. They understand that their fear is much greater than necessary, but they are unable to recognize this or control their reaction in the moment.
People will go to great lengths to avoid the subjects of their phobias, even altering daily routines, moving their homes, or changing jobs. These symptoms last for at least 6 months, and they significantly interfere with functioning in work and everyday life.
Focus of fear
Roughly three quarters of people with Specific Phobia have more than one feared subject. In fact, the average is three. Subjects usually fall into a few common categories: animals, situations, environment/forces of nature (think heights or water), and blood/injection/injury.
People with Specific Phobia who fear animals, situations, or the natural environment usually experience an activated fight-or-flight response: a cold sweat, increased heart rate, and rapid breathing. However, those who fear the sight of blood or needles usually react with nausea, dizziness, and even fainting due to a rapid rise and subsequent fall of both heart rate and blood pressure.
Fear can also occur even in expectation of the subject, and the reaction often takes the form of a panic attack. However, these panic attacks are distinguishable from those of Panic Disorder because the person can tell when the attacks are going to happen, whereas those of Panic Disorder come out of the blue.
Treating Specific Phobia
Exposure therapy is the primary and most effective treatment for Specific Phobia. The exposure occurs in three forms. It can be imagined, where the therapist guides the person through visualization of the phobia subject, or in person. Technology provides a third, intermediate option, where the person will use a computer or virtual reality to experience the focus of fear. Exposure lasts for several hours, either in one long session or broken up over several 1-hour sessions.
Muscle tension and relaxation
Systematic desensitization involves combining muscle relaxation techniques with exposure. This works by creating in the person’s mind new, non-fearful associations surrounding the previously feared stimuli. With practice, these new connections overpower the older, anxiety-provoking ones. In fact, in-person exposure is the most effective form, with most studies showing that immediate treatment responses were either maintained or even improved several months later.
Where in person exposure therapy alone falls short (blood/injection/injury phobia), combination with applied muscle tension successfully addresses the unique issues related to this phobia, such as dizziness and fainting. People learn that, when they begin to feel dizzy in the presence of their phobic trigger, they use conscious, body-wide muscle tension to increase blood pressure and avoid fainting.
Cognitive Therapy can be used either as an additional or stand alone treatment by training people to confront their irrational fears with logical, fact-based reassessments. Available studies best support its use in claustrophobia, where it is at least as effective as in person exposure.
Although these therapies have high rates of success, a few situations call for the kind of rapid response that can only be provided by medication, specifically benzodiazepines. Claustrophobic patients who need to get an MRI (which requires lying still in an enclosed space) or people with Specific Phobia who fear airplanes but need to fly somewhere benefit from one-time doses of these muscle relaxants.
Managing Specific Phobia
Late to get help
Contrary to the beliefs of many people, Specific Phobia is highly treatable. However, fewer than a third seek treatment for their affliction. The ones who do get treatment usually delay many years, and the average age at the start of treatment is over 31 years old, more than 20 years after the average age of onset. Many have become so accustomed to avoiding the source of their anxiety that they see no need to bother with treatment.
Fear of treatment
A quarter of those who do seek treatment do not want exposure therapy because they either fear confronting their phobic trigger or think that it will not work for them. A subset of people with Specific Phobia, those who fear blood/injection/injury, have an especially hard time getting treatment because of their aversion to those parts of the medical system. The fear is so severe that they often avoid getting help even if they are gravely ill.
Specific Phobia versus Agoraphobia
The key to differentiating Agoraphobia from the situational type of Specific Phobia is the number of different situations that are feared. Agoraphobia requires at least two of five different categories of situations. However, if the person only fears situations that fit into one of those categories, the diagnosis of Specific Phobia, Situational Type, is more appropriate.
Substances to avoid
As with other anxiety disorders, intake of caffeine and alcohol can exacerbate symptoms and should be minimized if possible.
Phobias in the elderly
Elderly people with Specific Phobia face characteristic issues that their families and caretakers should look out for. Their phobias often center around pre-existing medical issues, and patients often have a phobia of falling. This enhanced fear of falling can decrease the amount of exercise they are willing to engage in, thus lowering physical mobility and increasing potential need for in-home assistance.