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specific phobias

What is a Specific Phobia?
A specific phobia is an extreme fear of a specific object or situation that is out of proportion to the actual danger or threat. In addition, an individual with a specific phobia is distressed about having the fear, or experiences significant interference in his or her day-to-day life because of the fear. Many people have a fear of a particular object or situation, but most of the time these would not be considered phobias. For example, a person who has an extreme fear of spiders would not have a phobia if the situation rarely arises, if he or she is not bothered by having the fear, and if the fear does not interfere with functioning. On the other hand, an individual with a fear of spiders who frequently avoids activities such as camping, going in the basement, and gardening, and has trouble sleeping at night because of a fear of encountering spiders, might have a specific phobia. Other examples of fears that might be considered phobias (assuming all the necessary criteria are met) include:

• A construction worker with a fear of heights who avoids taking jobs in high places
• A medical student who drops out of school due to an extreme fear of blood
• An executive with a strong fear of flying who turns down a promotion that would have involved a lot of travel.
• An individual who works on the 20th floor of an office tower who must take the stairs each day due to an intense fear of elevators and other enclosed places.

Official Criteria for Specific Phobia
Based on criteria from the Fourth Edition of the Diagnostic and Statistical Manual of Mental Disorders, Text Revision (DSM-IV-TR; American Psychiatric Association, 2000)

• The individual experiences excessive and persistent fear of a specific object or situation. Examples of common specific phobias are listed in the next section.
• The individual experiences feelings of anxiety, fear, or panic immediately upon encountering the feared object or situation.
• The person recognizes that the fear is excessive, unreasonable, or out of proportion to the actual risk in the situation.
• The individual tends to avoid the feared object or situation, or if he or she doesn’t avoid it, endures encounters with the feared object or situation with intense anxiety or discomfort.
• The individual’s fear, anxiety, or avoidance causes significant distress (i.e., it bothers the person that he or she has the fear) or significant interference in the person’s day-to-day life. For example, the fear may make it difficult for the person to perform important tasks at work, meet new friends, attend classes, or interact with others.
• In children younger than 18 years of age, the problem must be present for at least six months before a diagnosis of specific phobia would be considered appropriate.
• The person’s fear, panic, and avoidance are not better explained by another disorder. For example, an individual with an extreme and impairing fear of public speaking only, and who is concerned that others will judge him or her negatively, might be considered to have social anxiety disorder, rather than a specific phobia.

Types of Specific Phobia:

(1) Animal Type: These include fears of animals such as dogs, cats, spiders, bugs, mice, rats, birds, fish, and snakes.
(2) Natural Environment Type: These include fears of heights, storms, and being near water.
(3) Blood-Injection-Injury Type: These include fears of seeing blood, receiving a blood test or injection, watching medical procedures on television, and for some individuals, even just talking about medical procedures.
(4) Situational Type: These include fears of situations such as driving, flying, elevators, and enclosed places.
(5) Other Type: These include other specific fears, including fears of choking or vomiting after eating certain foods, fears of balloons breaking or other loud sounds, or fears of clowns.

Causes of Specific Phobia
The causes of specific phobias are complex, probably involving a history of negative experiences in the feared situation, other psychological factors, as well as biological factors.

Learning History
• Direct Learning Experiences – Specific phobias can sometimes begin following a traumatic experience in the feared situation. For example, someone who is bitten by a dog might develop a fear of dogs, or someone who has a car accident might develop a fear of driving.

• Observational Learning Experiences – There is evidence that people can learn to fear particular situations by watching others show signs of fear in the same situation. For example, growing up with parents who fear heights could lead to a fear of heights in some children.

• Informational Learning – This involves learning to fear a particular object or situation by hearing or reading that the situation is dangerous. Examples include learning to fear flying by hearing about plane crashes in the news, or learning to fear driving by continually receiving warnings from others that driving is dangerous.

• Note that only some individuals with specific phobias report that their fears began through direct learning, observational learning, or informational learning. Many individuals report that their fear started without any obvious trigger or cause. Some individuals report having had their fear for as long as they can remember. Also, note that most people are exposed to negative experiences (e.g., car accidents, being bitten by dogs) and do not develop phobias. So, the interesting question is, “who develops a phobia following one of these experiences and who doesn’t?” This question is still being answered by researchers.

• Several factors may contribute to any one individual developing a specific phobia after having a negative experience that involves a particular object or situation. One factor is the individual’s previous experience in the situation. For example, an individual who has grown up with dogs may be less likely to develop a fear of dogs after being bitten, compared to an individual who is bitten the first time he or she encounters a dog. A second factor is subsequent exposure to the situation (after the negative experience occurs). For example, an individual who gets right back behind the wheel following a car accident may be less likely to develop a phobia of driving than someone who avoids driving for a period of time after the accident.

Other Psychological Factors
• Attention and Memory – Generally people with specific phobias tend to pay more attention to threatening information that relates to their fear. For example, individuals with spider phobias are often the first people to see a spider if there is one in the room. People with phobias also tend to have distortions in their memories for encounters with the objects and situations they fear. For example, people with an animal phobia may remember a particular animal that they have encountered as larger, faster, or more frightening than it actually was.

• Beliefs and Interpretations about Feared Objects and Situations – People with specific phobias tend to hold beliefs and to interpret situations in such a way as to maintain or increase their anxiety. For example, people with fears of heights may assume that they are likely to fall. People who fear enclosed places, such as elevators, may believe that they will run out of air, or that they will be unable to escape.

• Avoidance and other Anxious Behaviors – Avoidance of feared situations prevents people with specific phobias from learning that the situations they fear are not as “dangerous” as they feel. In addition, relying on “safety behaviors” (e.g., driving extra slowly to avoid an accident, always wearing long pants to prevent spiders from touching one’s legs) can also help to maintain a person’s fears.

Biological Factors
Unlike other types of anxiety disorders, there has been relatively little research on the role of biology in causing or maintaining specific phobias. Still, there is evidence that specific phobias sometimes run in families and that genetics may play a role. In addition, when a person is exposed to a feared object or situation, there are many biological changes that occur in the body, including changes in brain activity, the release of certain hormones (e.g., cortisol, insulin, growth hormone), and an increase in physical arousal symptoms (e.g., increased heart rate and blood pressure).

Effective Treatments for Specific Phobia

Specific phobias are the only anxiety disorder for which psychological treatments are almost always considered to be the best approach to treatment. There are no controlled studies showing that medications are an effective treatment for specific phobias.

Psychological Treatments
• Exposure to Feared Situations – This technique, also called in vivo exposure , is the treatment of choice for specific phobias. Essentially, it involves confronting a feared situation repeatedly, until the situation no longer triggers fear. For example, someone with a fear of spiders might begin treatment by looking at pictures of spiders, or by standing 30 feet away from a spider in a sealed jar and gradually moving closer and closer to the spider (eventually even touching it). Someone with a fear of storms might be taught to stand near the window or on the front porch during a storm, instead of hiding in the basement. Someone with a fear of elevators would be taught to ride elevators repeatedly until the fear decreases. Exposure works best when it occurs frequently (e.g., several times per week), and lasts long enough for the fear to decrease (up to two hours). Exposure-based treatments for some specific phobias (e.g., animals, blood) have been shown to work in as little as one session.

• Applied Muscle Tension – This technique is used specifically to treat people with blood and needle phobias who have a history of fainting in the situation (see the “Did you know….” section below). It combines exposure to blood and needles with exercises that involve tensing all of the muscles of the body, which temporarily raises the person’s blood pressure and prevents fainting.

• Cognitive Therapy – Involves learning to identify one’s anxious thoughts and to replace them with more realistic thoughts. For example, an individual who is convinced that an airplane will crash might be encouraged to consider the evidence supporting that belief. In reality, the odds of a commercial flight crashing are about one in ten million, and the most dangerous part of any flight is the drive to the airport! Note that cognitive therapy alone is generally not considered an appropriate treatment for a specific phobia. However, some individuals may benefit from using cognitive strategies along with repeated exposure to feared situations.

Biological Treatments
There is very little research on the use of medications to treat specific phobias, and most experts believe that medications are not an appropriate form of treatment for this problem. Still, some individuals with specific phobias (especially those from the situational type, e.g., flying, driving) report some benefit from using either selective serotonin reuptake inhibitors, such as paroxetine (Paxil) and similar medications, or anti-anxiety medications such as diazepam (Valium) and related drugs. However, for long term improvement, medications are no substitute for behavioral treatments such as exposure. There is probably little benefit gained over the long term from combining medications with behavioral treatments for specific phobia.

Did you know ...?

• Blood, Injection, and Injury phobias are the only phobias that are associated with fainting in the feared situation. For example, more than two thirds of people with a blood phobia, and about half of people with a needle phobia report a history of fainting in the situation. The fainting response is related to an extreme drop in blood pressure that occurs upon exposure to situations involving blood, surgery, and needles. In fact, most people experience a slight drop in blood pressure in these situations, but not to the degree experienced in people with specific phobias of this type.

• Specific phobias occur in about 11% of the population, making them one of the most prevalent psychological problems. However, despite being very common, people with specific phobias are less likely to seek treatment than people with other anxiety disorders.

• The most common specific phobias are fears of spiders, snakes, and heights.

• The age of onset for specific phobias varies depending on the fear. Animal phobias and storm phobias typically begin in early childhood. The average age of onset for height phobias is in the teens, whereas specific phobias of enclosed places often begin in early adulthood.

• Some specific phobias (e.g., spiders, storms) are much more common among women than men, whereas others (e.g., blood phobias) are more equally found in men and women.

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