Fear is one of the most rational human reactions in the face of danger. Traditionally, fear causes flight or fight mode activation, essentially an attempt in the preservation of life. Some fears, however, occur not necessarily due to the danger presented by an object rather out of internal fear of the object or situation. Such levels of fear are known as phobias. Phobias are debilitating fears that require expedited care and treatment for the well-being of the individual.
By definition, a phobia is a fear of a specific object(s) or situation triggered by an actual or expected contact with the phobic stimuli (Huberman, 2019). Classification of a fear as a phobia requires that the onset of the fear lasts more than six months. According to the American Psychiatric Association (APA) (2013) individuals with phobias usually present avoidance of the situation or object to a level greater than the danger posed. Instances where the situation or object is unavoidable cause great distress to the individual.
Historically, phobia dates back to the Greeks. Hippocrates, a Greek physician, described it as shyness. Later, however, Casper was among the first to research erotophobia, terming it as grave social anxiety affecting a young man. Later developments in the 20th century saw fronting of the theory of fear, characterized by the development of persistent fear (Coelho & Purkis, 2009). The current definition of phobia on the 5th edition of DSM came into use in 2013 describing it as “extreme or irrational fear of or aversion to something” (APA, 2013). DSM, however, categorizes phobia into specifics including animal phobias, natural environment phobias, situational phobias, injury phobias, and other phobias.
Phobias are among the most common types of anxiety disorders. They affect both men and women, although women tend to have a higher percentage in the numbers affected (Wardenaar et al., 2017). According to APA (2013), 8-18% of Americans have phobias, making it one of the most prevalent illnesses among women and the second most common among men above 25 years. Phobias occur in approximately 5% of children, 16% in teenagers and 3-5% among older individuals. In comparison to the US, New Zealand has a phobia prevalence of 10.9%, 10.7% in France, 7.0% in Mexico, and 5.9% in Nigeria (Wardenaar et al., 2017). Wardenaar et al., (2017) research show that overall, women’s phobia prevalence stood at 9.8% in comparison with 4.9 among men. The statistics, thus indicate that women are more prone to phobia than men.
On the causes of phobia, there exist two perspectives associative and non-associative accounts. According to Coelho and Purkis (2009), “The associative perspective holds that fear and phobias occur mainly as a consequence of learning experiences, whereas the non-associative perspective assumes that some fears and phobias reflect an innate spontaneous reaction to relevant evolutionary cues” (p. 335). Traumatic experiences, witnessing, or unexpected panic attacks are among the major causes of phobias, according to the associative perspective. On the other hand, stimuli that arouse fear cause non-associative phobia without an initial direct learning or indirect associative learning. Here, “genetic, familial, environmental, or developmental factors play an important role in the development of this type of specific phobia” (Garcia, 2017, p. 464). The environment herein plays the role of exposing the individual to environmental factors, leading to classical conditioning of fear due to experiences and occurrences within the environment.
Neurobiological advances have been instrumental in understanding fear. According to Garcia (2017), through the advances, fear circuits and mechanisms have been identified. The dysfunction in the mechanisms causes psychiatric disorders among them phobias and PTSD (post-traumatic stress disorder). Garcia (2017) explains brain dysfunction as the cause of phobias stating: “at the brain level, it is a stimulus-specific increase of neuronal responses. In nonexperiential phobia, it is suggested to be supported by dysfunction in “learning-independent” fear circuits (i.e., circuits that include the amygdala and drive defensive behavior without prior learning)” (p. 465). The dysfunctions in the mechanisms cause individuals to work hard towards avoiding the stimuli, regardless of the absence of a threat or danger (Garcia, 2017). Such individuals feel powerless in their attempts to stop the irrational fear.
Assessment of Disorder
Phobias often develop early in childhood although individuals can develop them at any age. At the onset of the phobias, individuals begin by experiencing mild symptoms of the phobia in anxiety and fear. Throughout its development, however, these feelings become stronger, especially when the associative stimuli are in sight (Beard et al., 2010). From the onset of the phobias, it is usually difficult for the child (and adult) to recover from the phobia three to four years after the onset. Stein and Lang (2012) inform that after the onset of specific phobia (among children and adults) it is less likely for the individual to develop or show the onset of a different disorder. Moreover, the phobias whose onset began in childhood do not develop into others. Research indicates that simple phobias in adolescence were only related to simple phobias in adulthood. For social phobia, however, there are chances of remittance. According to Stein and Lang (2012), “One longitudinal study suggested that many cases of social phobia in childhood remit within 3 to 4 years (86.4%) (16). However, when the social phobia is present in adolescence, it is a strong predictor of social phobia in adulthood” (864). This indicates that while children can overcome their social anxiety within 3-4 years, it is more difficult for adolescents, whose social phobia continues into their adulthood.
In the diagnosis of phobias, psychiatrists look for behaviors specific to the disorder. Diagnosis first requires a distinction between the disorder and other possible reactions such as fear. In finding the distinction, the current DSM-V provides a guide to psychiatrists in the diagnosis. According to APA (2013), in making a diagnosis, it is important to refer to the individual’s environment during the diagnosis, especially in using the terms distress and impairment. One of the behavioral manifestations of phobias is excessive paralyzing fear in the presence of an object or situation (Garcia, 2017). On the fear, it is only possible to make the diagnosis in the presence of the stimuli/situation. Therefore, for fear as symptomatic behavior of phobia, individuals with a phobia develop excessive anxiety in the presence of the stimuli such as animals or a social situation.
Recognition of the irrationality of the fear is another threshold for diagnosis of phobias. Garcia (2017) informs that in the previous version of DSM (IV), for recognition of a behavior as a phobia, the individual needed to recognize their reaction to the stimuli as irrational. The current DSM (V) no longer requires this recognition. While the non-recognition was only applicable to children, it has recently been extended to adults, who since the DSM V, do not need to recognize the irrationality of their fears.
Avoidance of the object/situation is another characteristic. Here, the individual goes to extreme lengths to avoid the situation/object, and where he/she is unable to, the endurance is under extreme distress (APA, 2013). Additionally, such behavior must last more than six months are not a result of another disorder. The idea here is to ensure that the behavior is not triggered by a co-occurring disorder or a side-effect of the said disorder. By ensuring that the behavior meets these thresholds, psychiatrists are then able to formulate intervention measures catering to the disorder.
Noteworthy is the fact that some disorders present behaviors similar to phobias. Generalized Anxiety Disorder (GAD) for instance, characterized by “excessive anxiety or worry, which is difficult to control and is accompanied by symptoms of tension and physiologic arousal” (Stein & Lang, 2012, p. 860) has characteristics similar to phobias. However, its characteristics of worrying about the future, personal safety, and somatic complaints including stomachaches and headaches distinguish it from phobias, which do not have such characteristics.
Similarly, panic disorder shares some commonalities with phobias. Panic disorders (PD) is characterized by unexpected and recurrent panic attacks (Stein & Lang, 2012). The attacks cause significant distress to the individual, leading to avoidance of the situation caused by fear of developing the symptoms and being unable to escape. Features that distinguish PD from phobias include somatic symptoms, especially for children with PD and the feelings of losing control, fear of dying or going crazy among adolescents and adults with PD (Stein & Lang, 2012). Individuals with phobias rarely have somatic symptoms and neither do they have the feelings of losing control or going crazy. They, however, have panic attacks and try to avoid situations with the presence of their phobia stimuli.
In the assessment of phobias, practitioners use different tests to ascertain the existence of the phobia. One of the most widely used assessment is the behavior assessment test (BAT). BATs are usually customizable to the individual and involve the use of different stimuli (that trigger the phobia) to assess the individual’s reaction (Gauer et al., 2010). In assessing phobias, practitioners present individuals with images, objects, or situations that trigger the phobias and assess the reaction of the individuals to the different stimuli. In essence, BATs work as controlled experiments testing reactionary responses of the individuals to the stimuli.
Cognitive-Behavior Therapy (CBT) is one of the most widely used treatment procedures for phobias. According to Gauer et al. (2010), CBT focuses on changing thoughts and dysfunctional beliefs as a means of changing the phobic reaction to the stimulus. It is for this reason that it is considered the treatment of excellence. Additionally, CBT aims at “reducing the anticipatory anxiety in fear-related social situations, tackling the physiological symptoms occurred on the course of anxiety, reducing negative self-evaluative cognitions, as well as towards other people, reducing the social-avoidance excuses, treating the associated disorders, reducing patient’s social limitations and to improve patient’s quality of life” (Gauer et al., 2010, p. 94). The idea here is to bring the individual to the realization that the stimuli are not a threat. That while their reaction is warranted, it is irrationally extreme considering the stimuli does not present as much threat as he/she imagines. As part of the CBT process, the patient gets constant gradual exposure to the fear stimulus. Known as the systematic exposure technique, the purpose of gradual exposure is to make the patient gradually overcome the fear of the stimuli, eventually overcoming it.
Alternative treatment may involve a combination of CBT and medication. Gauer et al. (2010) inform that practitioners can prescribe medication as part of the treatment process, combining it with CBT. Anti-depressants known as selective serotonin reuptake inhibitors (SSRIs), can be prescribed in addition to anti-anxiety medication. Anti-anxiety medications are particularly instrumental in calming physical and emotional reactions to stimuli.
Jane is a student and works part-time at the zoo. She has a fear of snakes that interferes with her job given that her work environment at the zoo involves almost constant contact with snakes. Bob referred Jane to me, him being a mutual friend of both Jane and I. Bob works with Jane at the zoo, and has been a close friend for the past five years.
On one of my visits to the zoo after the introduction, I saw Jane’s reaction to the snakes. Given that her office is along the snake pit, Jane runs to her office daily having closed her eyes. At other times, she takes a detour around the building, using the backdoor that does not pass next to the snake pit. Jane screams often at the sight of a snake on a book, on television, or even on her phone. Any snake-like hissing sound put her on edge. During our interview, presenting a rubber snake had Jane screaming as she jumped on her chair and showed a lot of destress. She sweated profusely and shook violently. Removing the rubber snake had Jane relaxed and back in her usual jovial mood.
Doctor: I understand that you have a phobia of snakes?
Jane: Yes. I have had it since I was a small girl.
Doctor: Jane, do you know the cause of this intense fear of snakes?
Jane: No doctor. I know that I don’t like them and that their presence gives me a lot of distress.
Doctor: Well, Jane, your phobia is merely a dysfunction within your brain. The dysfunction in your brain causes the brain to overreact at the sight of the situation or object that they fear, in your case, snakes. The emotional association you have with snakes triggers a stress response, which is exactly what you feel and how you react to any sight of a snake.
Jane: Well that is not comforting…
Doctor: I know, but that is not the only cause of phobias. Sometimes phobias are passed to us by our parents. You know, children with close relatives with phobias are usually at risk of developing phobias. Your fear of snakes might therefore not be an environmental factor or a result of dysfunction in your brain.
Jane: I don’t think I have a relative with a phobia of snakes…
Doctor: You know the environment can also cause phobias. For your case, it could be having seen or experienced a snake bite. You see, any exposure to distressing events within our environment can easily trigger phobias. So, for you Jane, when and how did your fear of snakes start?
Good Therapy: https://www.goodtherapy.org/learn-about-therapy/issues/phobias. This website provides information on mental health as well as a directory to help users find therapists, counselors, rehabs and residential treatment centers. It charges practitioners membership fees for listing as well as get funds from advertising on the website.
Mental Health America: https://www.mhanational.org/. Formed as an organization in 1909, it addresses the needs of people living with mental illness and promotes the overall health of Americans. It has programs ranging from national to state policy advocacy, education and outreach, screening for mental illness, publications, and Annual conferences on mental health. The website is largely funded through donations.
Verywell Mind: https://www.verywellmind.com.This is an online resource providing information on mental health. It produces and maintains content on mental health, mostly written by healthcare professionals. It is part of the Dotdash publishing family and receives funding from advertising, as well as a partner of The Cleveland Clinic.
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.), Arlington: American Psychiatric Publishing.
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Garcia R. (2017). Neurobiology of fear and specific phobias. Learning & memory (Cold Spring Harbor, N.Y.), 24(9), 462–471. doi:10.1101/lm.044115.116
Gauer, G., J., C. et al. (2010). Instruments for assessing social phobias in infants and adolescents in the Portuguese language. Estudos de Psicologia Campinas, 27(1), 93-97
Huberman, A. (2019). Phobias. BMJ Best Practices. Retrieved from https://bestpractice.bmj.com/topics/en-us/693
Stein, M., B. & Lang, A., J. (2012). Anxiety and stress disorders: Course over the lifetime. In Davis, K., L. et al. Neuropsychopharmacology—The Fifth Generation of Progress. Philadelphia: Wiley
Wardenaar, K. J., et al. (2017). The cross-national epidemiology of specific phobia in the World Mental Health Surveys. Psychological medicine, 47(10), 1744–1760. doi:10.1017/S0033291717000174