Specific Phobias

Does this sound like you?

Descriptions of Specific Phobias from Patients' Perspectives

“I am absolutely terrified by snakes. Just looking at the word makes me cringe. But where I live, you really don't come across snakes so it didn't bother me too much. Don't get me wrong, there where still times when I would be frozen with fear being caught off guard at the sight of plastic snakes in a toy store or at a friend's house when their child played with their toys. I know it doesn't make sense, but hearing the word, seeing it, and even seeing just a toy snake makes my heart race, my hands sweat, fills me with fear, and makes me want to run. I was able to get by with these minor inconveniences and avoid just about any contact with snakes for most of my life. But, now there's not just me to consider. I'm now married to a man who loves hiking, camping, and traveling to places like South America. Needless to say, these are all things that I am terrified to do in case I run into a real snake. I fear being bitten. I fear not being able to move because I'll be so scared. This is really making my husband unhappy that I can't share these things that he loves with him, and it is putting a strain on our relationship. Now, for the first time, I'm feeling like it might actually be necessary to confront my fear of snakes.“

“Last year, I choked on a piece of food and it was terrifying. I couldn't breathe and I just remember frantically trying to motion for others to help me. My dad gave me the Heimlich maneuver and the piece of food came out and I was able to breathe again. Since this incident, I have been terrified of choking again. I cut up food into really small pieces and I avoid eating some foods that I think will be more likely to get caught in my throat. My parents also tell me that I chew excessively - I want to make sure that each bite is completely emulsified before swallowing so that nothing will get stuck. The only foods that I feel really comfortable eating now are things that are already not solid like ice cream and yogurt. Once I did try to eat one of the foods I'm afraid of - pretzels. I hate these because they are dry and because of the shape, I fear that they'll get wedged in my throat. When I did try to eat them, I began to feel like it was really happening again. I couldn't catch my breath and I felt like I was choking…but I knew it was different. I was able to take in air whereas before I couldn't-but I still felt like I was suffocating. My friends reassured me and my symptoms went away. But this experience was all I needed to confirm the idea that I need to really be very careful and stay away from certain foods.“

“All my life I have felt very queasy at the sight of blood - mine or anyone else's. When I even hear the word or think about it, my heart starts racing, I start to sweat, and I feel like I'm trembling. I have to be really careful what kinds of movies I go to. If there is any blood in them I start to feel really faint and I need to close my eyes tight until that scene is over. I have actually fainted several times at the sight of real blood or even sometimes just when I imagine it - like when I see my hairdresser in the mirror with her sharp scissors so close to my neck, my veins… can't help but imagine the worst…and sometimes I've fainted while getting my hair cut. Needless to say, my efforts to avoid seeing blood have really limited me.“

“I've never really liked elevators. It feels like I'm trapped in there. Even as a kid, I remember hating seeing the big mouth of the elevator closing, it felt like it was closing in on me and I'd be stuck in this small box forever. What if it plummeted - like in the movies? What if I got stuck in there and no one knew? I might die from lack of food and water… It would make me really nervous when I got into any elevator, my heart would pound and I would become sweaty, but I was able to do it. Of course, I would never take an elevator alone - if I needed to, I would wait for others to go up with me. I would also try to never go up in one without a bottle of water and my cell phone. If I didn't have these, I don't think I'd be able to use one. Although it was really uncomfortable, I got by with this…feeling really nervous, but slightly comforted by having my “safety“ items with me…counting as each floor went by to my destination. I'd keep reminding myself just a little bit longer and I'd be out of there. But, I just got a job that's unfortunately on one of the top floors. I don't think I can bear having to go up and down in that elevator at least twice a day - probably more. I don't think I could handle the mental exhaustion or even be productive at work in the hour or so before I know I'll have to leave and use …the anticipation will build and I wouldn't be able to take it. I don't know what to do. I'm terrified, but I really do want this job.“

Specific Phobias - Prevalence Rates, Onset, and Course

It is estimated that specific phobias affect approximately 6.3 million adults in the United States. As previously stated, the different types of phobias tend to have very different peak ages of onset. For example, for those with blood/injury/injection phobias, the onset of the disorder tends to be from age 7 - 9. However, for those with situational phobias, onset usually occurs either in childhood or in early adulthood (mid-20's). Animal and natural environment phobias usually have a childhood onset.

All types of phobias tend to be very chronic conditions. Although specific phobias are very treatable conditions, people with phobias frequently simply avoid the feared object/situation and do not seek treatment unless the phobic fear begins to significantly interfere with their life or daily functioning.

What Causes Specific Phobias?

The cause of specific phobias is currently unknown, but it is likely due to a combination of factors. As with the other types of anxiety disorders, specific phobias are likely due to “inheriting“ a nonspecific biological vulnerability to developing an anxiety disorder (but not a specific one) combined with individual life experiences. However, there tends to be a stronger genetic link for those with blood/injury/injection phobia.

Research indicates that phobias tend to fall into 4 different types: blood/injury/injection phobias, animal phobias, natural environment phobias (e.g., heights, water), and situational phobias (e.g., flying, driving, bridges). These classes of phobias have many different characteristics from each other - different peak ages of onset, differences in the likelihood of having other co-occurring psychological problems (e.g., depression), and differences in the likelihood that the phobia “runs in the family“.

In terms of the types of life experiences that may make one vulnerable to developing a phobia, researchers propose that there are several different means by which a person can become “conditioned“ (or learn) to fear a particular object or situation. The different modes of fear acquisition are: direct or traumatic conditioning (i.e., where an individual has personally had a terrifying encounter with the phobic object/situation), vicarious observation (i.e., observing someone else having a terrifying encounter with the phobic object/situation), and informational transmission (i.e., hearing about someone else expressing their fears of or their experience with the phobic object/situation). The impact of these types of aversive learning experiences is often mitigated by any previous good/neutral experiences with these objects/situations - thus, accounting for why people can have the same type of traumatic event but some people may develop a phobia and others do not.

Researchers have also speculated that certain phobias are acquired very quickly because we are biologically prepared to fear these objects or situations. In other words, throughout evolution, it was wise to fear these things (e.g., spiders, snakes, heights), so they became more biologically encoded as fearful objects/situations - thus, we are more vulnerable to developing a phobia to these types of things than to other things (e.g., flowers, rolling hills).

What are the Different Types of Specific Phobias?

According to the Anxiety Disorders Interview Schedule for DSM-IV, there are 4 main phobia types and one miscellaneous category:

Animal typesnakes, spiders, dogs, bees/insects, birds
Natural environmentheights (tall buildings, driving in canyons, going up on a ladder), thunderstorms, lightening, water (pool, ocean), darkness
Blood / Injection / Injurygetting shots, seeing someone bleeding, having blood tests, seeing blood from one's own cut/scrape
Situationalforms of transportation (cars, planes, buses, trains), elevators or other small/enclosed places
Miscellaneous loud noises, costumed characters (clowns), doctors/dentists, vomiting

What are the Symptoms of Specific Phobias?

According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), specific phobias have the following characteristics:

1. There is a persistent fear of a specific object or situation that is excessive or unreasonable. This fear is usually triggered by the presence of (or the anticipation of encountering)the feared object/situation.

2. Being in the presence of the feared object/situation almost always produces an immediate and extreme anxiety response. This anxiety response may become so severe that the person has a panic attack (see section on panic disorder for more information on panic attacks). **

3. The person usually recognizes that the fear (or the degree of the fear) is excessive or unreasonable.

4. The phobic situation or being in the presence of the phobic object is avoided or endured with intense anxiety and distress.

5. The avoidance, anxious anticipation, or distress with the feared object/situation significantly interferes with the individual's functioning - school, work, or relationships with family or friends.

Sometimes it may be difficult to differentiate specific phobias from other anxiety disorders - in particular, panic disorder (with or without agoraphobia) or social anxiety disorder. In these cases, an evaluation by an expert is often necessary to determine the diagnosis. In addition, for children, there are certain types of fears that are very age appropriate. For a child to have a phobia of a specific object/situation, it is necessary that they are much more afraid of these objects/situations than other children their age.

** Those with blood/injury/injection phobias are more likely to faint than those with other phobias or other anxiety disorders. Although feeling faint is a common symptom of anxiety in general, it is rare that people actually do faint. However, for those with blood/injury/injection phobia, actual fainting is much more common.

Treatment for Specific Phobias

The treatment of choice for specific phobias is Cognitive-Behavioral Therapy (CBT). Although some people use medications when entering a phobic situation (e.g., take Xanax when they need to go on a plane), this is only effective in temporarily managing the distress in that situation but does not eliminate fear of that situation or the anticipatory anxiety that often occurs (e.g., anxiety due to anticipation of the situation happening). There has been little research into the effectiveness of pharmacotherapy for phobias or the added benefit of taking medications in addition to engaging in CBT. The need for this kind of research is small because CBT is highly effective.

Depending on the type of specific phobia that exists, there are slight variations in the treatment method that is applied. However, a general outline for CBT for specific phobia is presented below. In CBT, treatment usually begins with education about why the phobia may have developed as well as an explanation of CBT and why it is effective in treating phobic fears. In addition, education about the specific phobic stimulus may be necessary (e.g., not all snakes are poisonous) as well as skills information about that stimulus (e.g., how to correctly handle a snake).

The next step in CBT is usually to identify what types of things make that object/situation easier or harder to confront. For example, for those who fear a specific type of situation like heights, the situation may be more fearful if they are high on a hill vs. high up in a building. For those who fear spiders, the size, the color, and how hairy it is may make a difference in terms of how feared the spider would be. In addition, any other safety behaviors that may make the situation/object less frightening are also taken into account. For example, common “safety behaviors“ are taking a friend with you, water bottles, anxiety medications, etc. This will help you and the psychologist you are working with to create your “fear hierarchy“ - in other words, enable you to rank order from easiest to hardest how difficult certain situations would be. Eventually, individuals begin confronting the feared objects/situations on their fear hierarchy - beginning with the least frightening object/situation.

Cognitive restructuring is also another technique that is very beneficial in treating specific phobias. In this technique, the dangerousness of the object/situation as well as the perceived dangerousness of one's response in this situation (e.g., I'll have a heart attack, I'll embarrass myself) is further explored. Frequently, individuals with specific phobias have certain types of cognitive errors such as overestimating the risk of any real danger that exists (e.g., if I try to pet a dog, I'm 99.9% sure that it will bite me) and catastrophizing the situation (e.g., if I hyperventilate, I will faint in the elevator, use up all the oxygen, and die there).

Treatment for phobias is generally short-term and effective.

If you are interested in learning more about anxiety disorders and their treatment, and you live in the Los Angeles area, contact Dr. Nelson at (310) 963-4891 or e-mail her at DrDeniseNelson@yahoo.com.