Phobias

In this condition factsheet:

• The Facts
• Causes
• Symptoms and Complications
• Making the Diagnosis
• Treatment and Prevention

The Facts

Phobias are fears sparked by certain situations that can interfere with a person's coping abilities or lead them to stay away altogether. These situations are not normally dangerous or frightening, but people with phobias experience strong feelings of anxiety when they find themselves in these environments. 1 in 10 people will experience phobias at some point in their lives. These individuals can be calm and rational most of the time, yet find themselves paralyzed with fear when they are faced with a particular situation.

Phobias can be categorized into a number of different types:

• Agoraphobia is the fear of going into public places, including fear of open spaces and of crowds. Agoraphobia affects mostly women, who tend to develop the condition early in adult life.
• Social phobia is an avoidance of social situations, resulting from extreme shyness or fear of being embarrassed in public. Social phobia affects men and women equally. It often starts in childhood or adolescence and may be accompanied by other anxiety disorders or depression.
• Specific (isolated) phobias include many types of intense fear reactions. These include:
• fear of animals (e.g., spiders [arachnophobia] or snakes [ophidiophobia])
• environmental fears (e.g., of heights [acrophobia], or water [aquaphobia])
• situational fear (e.g., fear of airplanes, or fear of enclosed spaces or elevators [claustrophobia])
• fear of blood-injection-injury (e.g., fear of needles, blood, or invasive medical procedures such as dental work or surgery)other phobias (e.g., fear of loud noises, choking, or vomiting)

Twice as many women are affected as men, and tend to develop their fears in childhood or early adolescence, with the phobias persisting into adulthood.

Causes

Social and specific phobias sometimes run in families, providing evidence of a genetic connection. Some people are born with a predisposition towards anxiety, which makes them particularly susceptible to developing phobias.

Phobias may develop as a response to pressure or following traumatic events. In other cases, unreasonable fears may develop with no apparent trigger. Adults generally recognize that their fears are irrational or excessive, and this can act as an isolating factor. The affected person might not talk to friends and family about a fear that they believe is silly.

Phobias may also be learned through observation. Observing someone behave fearfully to their phobia(s) can lead to development of phobias despite lack of personal interaction. Media exposure may be responsible for the development of certain phobias. Phobias are also a natural part of development. Most children go through stages where they are scared of the dark, of monsters, or of strangers. Many teens develop anxieties associated with self-image and others' perception of them. While these fears are normal and often get left behind over time, they can sometimes persist or become incapacitating.

Symptoms and Complications

Anxiety suffered by a person with a phobia can be experienced as both mental and physical symptoms. The level of functional impairment can vary from minimal to significant.

Mentally, a person can become so worried about encountering or avoiding a particular situation that it can disrupt sleep, cause fatigue or irritability, or even make it difficult to concentrate on other matters.

Physically, anxiety in the face of fear can make a person sweat, breathe heavily, or experience irregular heartbeats (palpitations), dizziness, or faintness. Anxiety can also cause muscle pain or tension, and may even interfere with digestion, resulting in diarrhea, for instance.

Particular phobias are identified when the fear of – or exposure to – specific situations is so extreme that the person loses the ability to cope under those circumstances. A person's attempts to avoid such situations can become sufficiently disruptive to their life as to be debilitating.

Panic attacks can help lead to the development of certain phobias. Panic disorder is marked by recurrent, sudden, and extreme feelings of terror and panic (panic attacks) that is combined with persistent worry about having another attack, or changes in behaviour as a result of the attacks. A panic attack can cause a person's heart to pound and make them feel dizzy, faint, weak, or sweaty. Nausea, chest pains, a sense of unreality, and a loss of control often mark an episode, which can occur at any time, night or day. Panic disorder is not a phobia but an anxiety disorder. However, having a panic attack in an elevator can result in a fear of elevators or of confined spaces; fear of having attacks in public places may cause a person to avoid those places, leading to agoraphobia. Similarly, panic attacks can become symptoms of phobias, and may be triggered by exposure to the things or situations that people fear.

There are two types of social phobia. Generally, the phobia encompasses all social situations outside of family contact, and may be associated with low self-esteem and fear of criticism. Avoidance of social situations often leads to social isolation. Another type of social phobia may occur in people who are normally comfortable with informal social contact, but become excessively nervous, anxious, and flustered when they're the centre of attention. This is likely to affect individuals who must perform or speak in public, even those who have considerable experience being in the spotlight.

Agoraphobia is typically associated with the lack of an easily available exit or escape route to a safe place (usually a person's home). People become frightened of being in public places, stores, or crowds, or of travelling alone, and are prone to panic attacks when they go out alone. The phobia may consist of a cluster of different fears that overlap, often resulting in people who are too frightened to leave the safety of their own homes. For this reason, agoraphobia is considered the most incapacitating of anxiety disorders.

Specific phobias generally develop in young adults and, if left untreated, persist for decades. When individuals are easily able to avoid the phobic situation, the impact of the phobia will not be as great. However, when a person has to go to great lengths to avoid certain situations, the phobia becomes disruptive to normal functioning. It's most important to get help. Treatment or therapy will enable a person to work and have an active social life.

Making the Diagnosis

When someone recognizes that the feelings of anxiety or distress in any type of phobia become worrying, or are interfering with daily life or relationships, a doctor or therapist can help pinpoint the problem. A health professional may start with a range of questions to evaluate if symptoms and behaviour are consistent with a phobia. This can include asking about:

• the person's specific responses to certain situations
• how long the condition has been evident
• how often the person experiences the symptoms of a phobia
• how much of the person's time is taken up by thoughts of encountering something that's feared

Based on the answers, the particular type and cause of the phobia can be pinpointed.

Usually, the best clue to a diagnosis is if someone often or always tries to avoid any situation that triggers the symptoms. Symptoms need to have been present for at least six months for diagnosing specific phobias.

Treatment and Prevention

Treatment can either take place through use of psychological interventions or medications.

Cognitive behavioral therapy (CBT) is a non-medicinal psychological intervention in the treatment of social phobias, panic disorders, and specific phobias. Cognitive therapy, the specific psychological intervention that is effective in social phobias and panic disorders, aims at changing thinking patterns and finding ways of redefining or coming to terms with core beliefs behind certain fears. Behavioral therapy, specifically desensitization therapy, is effective for certain phobias where the person is gradually exposed to the feared situation while they are taught how to cope with and manage the resultant anxiety. Confronting fears in the safety of a therapeutic environment helps to dull people's phobias, and gradually helps them put the fears – and their responses to them – into perspective. Other components of CBT include psychoeducation, anxiety management, and reduction of safety behaviours.

Exposure therapy is also used and has shown to be effective in treating phobias. It is a psychological treatment that helps people confront their fears. If you avoid something you are fearful of, it can help reduce feelings of fear in the short term, but it could make the fear become even worse over the long term. With exposure therapy, people with phobias will practice getting used to the anxiety-provoking situation and feel comfortable gradually. This can be used with CBT.

Talking about a specific fear can help to alleviate the intense anxiety associated with it. Trusted friends and family can provide good support, especially when anxiety follows some trauma in a person's life. Self-help groups can also be very therapeutic by allowing people to share experiences and to find out how others with similar problems cope with their fears. Relaxation and stress-management techniques – learned from professionals, groups, books, videos, or online resources – can go a long way towards helping people to control their anxiety.

Treatment using medications involves antidepressant medications that are effective in treating the various symptoms associated with social phobia, panic attacks, and co-occurring depression. Anti-anxiety agents (benzodiazepines) and beta-blockers may also play a role in treatment. Available medications include:

• Benzodiazepines are effective anti-anxiety medications that can be very helpful in the short-term treatment of anxiety, for immediate use during an acute panic attack, and during behavioural treatment as a person attempts to face their feared situation or specific phobia. Generally, they are not used for long-term treatment.
• Beta-blockers – normally used in the treatment of heart conditions – are effective in the treatment of social phobia. They are specifically prescribed for individuals who must perform or talk in public and require short-term medication to stop the associated physical symptoms of the phobia from developing SSRIs (selective serotonin reuptake inhibitors) alter the levels of serotonin in the brain, and have fewer side effects than the other anti-depressant medications. Although they can be helpful in alleviating symptoms like sweating, fast heart rate, and trembling, they do not treat anxiety itself.  
• Tricyclic antidepressants used in low doses have been widely used in treating anxiety disorders; however, these medications have side effects such as dizziness, drowsiness, dry mouth, and weight gain.
• MAOIs (monoamine oxidase inhibitors) work well on panic disorder and social phobia; these medications require people to adhere to a restrictive diet that at times can be troublesome. Failure to adhere to the diet can result in very serious reactions.

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