Phobia

Phobias - What is a phobia?

Fears are a common part of an individual’s life. However, a phobia is more than a simple fear. It starts and develops into something massive when the affected person begins to organise their life around avoiding the feared object – be it an animal, insect, place, situation or just about anything. 1-5

Pathophysiology & effects on normal functioning

According to psychiatric parlance phobias are a form of anxiety disorders. The feared object is avoided at all costs and coming face to face with the feared object may lead to increased anxiety and often episodes of panic.

In case the phobia is related to an animal or insect such as a snake or a cockroach, it is not faced every day and does not significantly affect the workings of the day-to-day life.

But those with phobias that affect going out in open spaces (agoraphobia) or being in closed spaces like elevators (claustrophobia), normal life can be severely hampered.

Symptoms

Reactions to phobias vary in different sufferers. Symptoms of the anxiety include:

  • fast breathing (hyperventilation)

  • palpitations and rapid heartbeats

  • choking sensations

  • flushes

  • sweating

  • muscle tension and pains

  • indigestion

  • diarrhea

  • feeling dizzy or faint

Other symptoms include feeling worried and anxious, feeling tired, poor concentration, irritability and loss of sleep.

Types of phobia

Phobias are classified as simple or complex phobias.

Simple phobias are fears of specific objects, animals, situations or activities including dogs, snakes, spiders, closed spaces, flying, visiting dentists, needles etc. Some people suffer from a mild anxiety when confronted with the object of their fear and in some people this may manifest as a full blown panic attack and reactions may be severe.

Complex phobias are more difficult to cope with because they are often associated with a deep-rooted fear or anxiety. These include agoraphobia (fear of being in spaces from where escape is difficult like a shopping center, public transport etc.) and social phobia (fear of interacting with people). People with a social phobia have a fear of embarrassing themselves before people.

Epidemiology of phobias

Anxiety disorders come in many varieties and more often than not go undiagnosed. Simple phobias, especially those of objects or events not required to confront in daily lives, are usually unreported.

This could be fear of snakes that a person does not face in his or her day to day life. However, phobias are the most common type of anxiety disorder.

In the UK, an estimated 10 million people have phobias. The condition may affect both sexes and all ages and socioeconomic situations.

Simple phobias like fear of needles may begin as childhood and continue till adulthood. Some of these like fear of the dark may emerge at early ages between four and eight (or earlier) and often disappear on their own as the child gets older and usually do not cause problems in adulthood.

Complex phobias usually start later in life. Social phobia for example begins during teenage years and agoraphobia in the late teens to early twenties. These may last several years and if left untreated caused severe debility. Those with social phobias or with agoraphobia may be rendered unable to leave their homes at all.

Treatment of phobias

Phobias, regardless of their complexity and severity, can be successfully treated and cured. Those with simple phobias may be exposed gradually to their object of fear. This is known as desensitisation or self-exposure therapy.

Those with complex phobias however require counselling, psychotherapy, cognitive behavioral therapy and other approaches over a long period of time to be cured of their fears.

Medication is not usually used to treat phobias. Some may need medications for their symptoms of anxiety, panic attacks and depression. Commonly used drugs include antidepressants, tranquilizers and beta blockers.

Causes of phobias

Fear is normal for all individuals. Phobias are specific anxiety disorders when the fear for an object, animal, bird, insect, situation or event is extreme and affect normal living.

The sufferer usually avoids the feared object or situation at all costs. When confronted with it they may face severe anxiety and panic reactions.

The exact cause of phobias is largely unknown. Phobias usually develop during childhood, adolescence or early adulthood. This may commonly follow a frightening event or a stressful situation. What exactly triggers the phobic reaction that persists for years is as yet unclear. 1-6

Causes of simple phobias

Simple phobias usually develop in early childhood. The classic symptoms may begin between ages of four and eight. An unpleasant episode like visit to the doctor for shots or to the dentists for a painful tooth extraction often grows in the child’s mind to give risk to a phobia.

Children who have for example been trapped in a closed, dark and confined space by accident or as punishment may develop a fear of enclosed spaces (claustrophobia) when they are older.

Simple phobias are also acquired from members of the family by children. For example, children with a family member who is scared of cockroaches or spiders may be “learned” by the child. These phobias are said to run in the families. However, they are not genetically transmitted from parents to their offspring.

Age is thus an important factor in phobia assessment. In children phobias revolve around loud noises, dark, monsters, painful stimulus like blood, needles etc.

In the prehistoric times risk of injuries from animals, dark, deep waters and being trapped into small spaces was something that most children were conditioned to be scared of. This was the preservation of self and deeply ingrained in the brain.

The brain appears to be ready to develop some types of fears more than others. These are called “prepared fears”. These are usually protective and include dangerous animals like snakes etc.

Those situations that was dangerous to primitive humans like heights, deep waters, injuries and wild animals still trigger phobias more easily than situations which are more benign such as household objects etc.

Causes of complex phobias

The cause of complex phobias is as yet unclear. They are said to be brought about by complex interactions between an unpleasant experience, chemistry and chemical messengers of the brain and genetics.

Social phobias for example occur after an earlier humiliating experience in public that undermines the person’s social confidence and as an alternative this confidence fails to develop after childhood.

Both agoraphobia and social phobias begin in teenage years or start at early teens to late twenties. They may last for years or a lifetime and may be severely debilitating.

Phobias may also be brought about by an unrelated unpleasant event in life. Sometimes the fear may develop after a stressful event or bereavement.

Phobias are also more common in persons who have high general levels of anxiety. Phobias can also result from witnessing the trauma of someone else. This type of learning a fear is called “conditioning”. Conditioning may also occur by seeing trauma occur to others in real life or in movies etc.

Types of phobias

Phobias are abnormal fear of a specific object, animal, bird, insect, activity or a certain situation. It is a type of anxiety disorder which can precipitate a panic attack.

Those with phobias tend to avoid the feared object or activity as much as possible and become anxious when they anticipate having to confront them.

This may be fears of an animal which they may well avoid in daily life for example the snake.

However, in some the fears may be of more common objects and situations like fear of flying, interacting with people (social phobias) or using a closed lift (claustrophobia). This may severely hamper a person’s day to day life.

Mild phobias are very common, particularly in childhood, although most of these fears disappear by the age of six or eight. People can also develop phobias when going through a particularly stressful period of their lives.

Research shows that approximately five per cent of adults develop agoraphobia (fear of open spaces) and around one per cent of the population develop severe debility due to this phobia.

Agoraphobia usually starts when a person is in their late 20s and is more common in women than men. Around one to two per cent of men and women develop social phobia.

To be classed as a phobia, the symptoms must be due to anxiety, and not to symptoms arising from another problem, either physical or psychological. 1-5

Classification of phobias

Phobias may be grouped into two broad classes:-

  • Simple or specific phobias like those of an object, animal or situation. Specific phobias include fear of:
    • Spiders
    • Snakes
    • Dogs
    • Thunder
    • closed spaces
    • flying etc.

Simple phobias may also be a fear of blood, medical interventions such as injections, or injury. Sufferers may faint in the presence of blood or injury, following a reduction in their heart rate and blood pressure.

This is called a vasovagal response which leads to fainting. It does not normally occur with other anxiety disorders. In other phobias and panic disorders the person’s heart beat and blood pressure usually increases as their arousal rate increases.

Complex phobias – e.g. Social and agoraphobias. Social phobias are fears of interacting with people or social gatherings and agoraphobias are fears of open spaces or public places from where escape is difficult like shopping malls, public transport buildings etc.

Agoraphobia is commonly associated with depression and marital or family disharmony. Both social and agoraphobia may lead to confinement of the patient within their homes.

Common phobias

The most common phobias include fear of:

  • spiders (Arachnophobia)

  • social situations (social phobia)

  • flying (Aviatophobia)

  • open spaces (Agoraphobia)

  • confined spaces (Claustrophobia)

  • heights (Acrophobia)

  • cancer (Cancerophobia)

  • thunderstorms (fear of lightening – astraphobia; fear of thunder – Brontophobia)

  • death (Necrophobia)

  • heart disease (Cardiophobia)

Less common phobias

Other less common phobias are fears of:

  • needles/sharp objects (Aichmophobia)

  • cats (Ailurophobia)

  • people (Anthropophobia)

  • men (Androphobia)

  • sex (Genophobia)

  • women, (Gynophobia)

  • homosexuals (Homophobia)

  • water (Aquaphobia)

  • bees (Apiphobia)

  • toads (Bufonophobia)

  • dogs (Cynophobia)

  • dentists and doctors (Dentophobia and Iatrophobia respectively)

  • creepy, crawling things or reptiles (Herpetophobia)

  • sleep (Hypnophobia)

  • mice (Musophobia)

  • dirt and germs (Mysophobia)

  • anything new (Neophobia)

  • night (Noctiphobia)

  • darkness (Nyctophobia)

  • snakes (Ophidiphobia)

  • fire (Pyrophobia)

  • being buried alive (Taphophobia)

  • God (Theophobia)

  • strangers (Xenophobia)

  • animals (Zoophobia)

Diagnosis of phobias

Phobias are irrational and abnormal fears of common and not so common objects, animals, situations and activities. Most sufferers are usually fully aware that they have a phobia and try to avoid their feared object as much as possible.

These people may live with a phobia without having it formally diagnosed and treated. This may, in severe cases, hamper and interfere with their daily living.

Types of phobias

Phobias are broadly classed as simple (specific) phobias and complex phobias. Specific phobias include fears of animals, insects, birds, reptiles, activities like flying, situations like closed spaces etc. Complex phobias include social phobia and agoraphobias.

Diagnosis of phobias is made in accordance with the guidelines laid down by the diagnostic and statistical manual (Text revision) of the American Psychiatrists Association, known as DSM-IV-TR.

The conditions are listed in the World Health Organization's International Classification of Diseases (ICD-10) as well.

Specific phobia diagnosis

Specific phobia diagnosis according to the DSM IV TR criteria includes questions like presence of marked and persistent fear that is excessive or unreasonable, cued by the presence or anticipation of a specific object or situation.

There should be an immediate anxiety reaction, which might reach the severity threshold of a panic attack on exposure to the feared object or situation.

In children there might be crying, tantrums, freezing, or clinging in response to a similar exposure. The patient realizes that the anxiety is excessive or unreasonable. This latter may be absent in children.

The situations or objects are avoided or endured with intense anxiety or distress. This avoidance or endurance with distress interferes significantly with the person’s normal routine, academic functioning, or social activities or relationships.

Diagnosis of agoraphobia

This is an anxiety disorder that occurs in individuals who fear open spaces. The commonly asked questions include if the person avoids certain situations because they fear a panic attack.

Another question is whether a panic attack has been triggered, especially over the last 6 months by:

  • going away or out of their homes

  • standing in long queues

  • being in a tunnel or underground space

  • home alone

  • being in wide open spaces such as a field

  • being in crowded places

Patients are asked if they do all they can to avoid such situations. These may be diagnostic of agoraphobia.

Diagnosis of social phobia

Social phobia diagnosis includes a list of questions to help people identify their fear. This includes if the person fears embarrassing themselves before others, worries about what people might think of them and feels anxious in social situations.

The patient is asked if he is scared of public speaking, eating, drinking and writing in front of other people or going to parties and other social gatherings.

If a person has been avoiding any such situations consistently for the past six months or more, social phobia may be diagnosed.

Ruling out alternative diagnoses

Other mental health conditions need to be ruled out before phobias are diagnosed. This includes ruling out depression, obsessions, delusions, unnatural fears or hallucinations that may signify deeper diseases like Schizophrenia, paranoias etc.

Social and agoraphobias for example also need to be distinguished from simple or specific phobias like fear of men (andropophobia) or women (gynophobia).

They need to be differentiated from panic disorders, Separation anxiety disorder, General anxiety disorder, Schizoid personality disorder, Asperger’s syndrome and autism, Avoidant personality disorder etc. (1-4)