Phobia

The term phobia (from the greek φόβος, phóbos, “panic, fear”) indicates an irrational and persistent fear and repulsion of certain situations, objects, activities, animals or people, which can, in severe cases limit the autonomy of the subject as in the case of avoidance, but that does not represent a real danger to the person. A phobia is a marked and persistent fear with peculiar characteristics:

  • disproportionate to the actual danger of the object or situation
  • Cannot be controlled by rational explanation, demonstration, or reasoning;
  • exceeds the subject’s capacity for voluntary control;
  • Produces systematic avoidance of the feared stimulus;
  • persists for a prolonged period of time without resolution or diminution;
  • involves some degree of maladaptation for the individual;
  • the individual recognizes that the fear is unreasonable and not based on the actual dangerousness of the feared object, activity, or situation.

Thus, a phobia is an extreme, irrational, and disproportionate fear of something that poses no real threat and with which others can cope without particular psychological distress. In fact, the sufferer is overcome with terror at the thought of possibly coming into contact with a harmless animal such as a spider or lizard, or when faced with the prospect of performing an action that leaves most people indifferent (e.g., the claustrophobic person cannot use the elevator or subway).

People with phobias are fully aware of the irrationality of their fear, but they cannot control it.
Phobic or “phobic” anxiety is expressed by physiological symptoms such as tachycardia, dizziness, extrasystole, gastric and urinary disturbances, nausea, diarrhea, choking, flushing, excessive sweating, trembling, and exhaustion. With fear, you feel sick and want only one thing: to run away! Running away is an emergency strategy.

The tendency to avoid all situations or conditions associated with fear, although it reduces the effects of the phobia in the moment, is actually a deadly trap: each avoidance confirms the dangerousness of the avoided situation and prepares for the next avoidance (in technical terms, each avoidance negatively reinforces the fear).

Such a spiral of progressive avoidance leads not only to an increase in one’s distrust of one’s own resources, but also to an increase in one’s phobic reaction, to the point where it significantly interferes with one’s normal routine, work or school functioning, or social activities or relationships. The discomfort becomes increasingly limiting.

For example, a person with an airplane phobia may avoid traveling, and it becomes embarrassing when it is necessary to travel for work. Those who are afraid of needles and syringes may forgo necessary medical checkups or deprive themselves of the experience of pregnancy. Those who are afraid of pigeons may not walk through squares or enjoy coffee at outdoor cafes, and so on.

The physiological symptoms experienced by those who suffer from phobias are: tachycardia, dizziness, gastric and urinary disorders, nausea, diarrhea, sense of suffocation, redness, excessive sweating, trembling and exhaustion. Obviously, these pathological manifestations are implemented only at the sight of the feared thing or at the thought of being able to see it. Phobics are basically anxious and as such they function in the sense that they tend to avoid situations associated with fear, but in the long run this mechanism becomes a real trap. In fact, avoidance only confirms the dangerousness of the avoided situation and prepares for subsequent avoidance.

Phobics are basically anxious and as such they act, in the sense that they tend to avoid situations associated with fear, but in the long run this mechanism becomes a real trap. In fact, the avoidance does nothing but confirm the danger of the situation avoided and prepares the next avoidance. A vicious circle is thus created, which on the one hand leads to lack of confidence in one’s own abilities and on the other compromises social relationships, because in order to avoid the feared thing one is ready to give up an evening with friends. For example, those who have a phobia of needles and syringes may renounce medical check-ups; those who are afraid of pigeons will not cross the squares, those who fear dogs will avoid all situations in which they will be present, and so on.

Specific phobias: what they are

Specific phobias were among the first psychopathological phenomena to be observed and described. As early as 1700, Benjamin Rush (1798) defined phobias as “fears of imaginary demons or unreasonable fears of real things,” and went so far as to classify different types of phobias, including cat phobia, mouse phobia, insect phobia, odor phobia, and so on.

A specific phobia, then, is an intense, persistent, and enduring fear experienced for a specific trigger stimulus (object, animal, place, situation, etc.). It is a disproportionate emotional manifestation for something that poses no real threat. A process is set in motion that causes the person to experience disproportionate states of fear and terror about the phobic stimulus (the specific object that causes the fear), so that he or she engages in avoidance behaviors in situations in which he or she is likely to encounter the stimulus. The phobic stimulus varies greatly from person to person: many specific phobias are well established and common (heights, dangerous animals, needles), while some people may develop a specific phobia for very unusual stimuli, such as certain foods, colors, or sounds, which often causes these people to feel ashamed of their fear.

Specific phobias are therefore fears that are disproportionate to something that does not represent a real danger, but the person perceives this state of anxiety as uncontrollable and even engages in useful behavioral strategies or brooding to cope with the situation. The physiological symptoms experienced by those suffering from specific phobias are: tachycardia, dizziness, gastric and urinary disorders, nausea, diarrhea, choking, flushing, excessive sweating, trembling and exhaustion. Obviously, such pathological manifestations are triggered only by the sight of the feared thing or the thought of being able to see it.

These symptoms of physiological overactivation are alleviated if the person believes that he or she has avoided the stimulus, moved away from it, or is in an environment that he or she feels is safe. Conversely, other people may experience an opposite response at the physiological level, with a sharp drop in blood pressure and slowing of the heart rate, even to the point of fainting or passing out. Such reactions are typical of phobias related to fear of injections, the sight of blood, or wounds.
Generally, the person with a specific phobia recognizes that his or her fear is excessive by experiencing such an overreaction as egodystonic.

On the behavioral level, the person with a specific phobia tends to avoid situations associated with the fear, but in the long run this mechanism becomes a real trap, similar to anxiety disorders in general. In fact, avoidance only confirms the dangerousness of the avoided situation and prepares for the next avoidance. Thus, a vicious circle is created that leads to mistrust of one’s own abilities on the one hand, and on the other hand, it jeopardizes social relationships, because in order to avoid the feared thing, one is willing to give up an evening with friends. For example, a person who has a phobia of needles and syringes may not go to medical check-ups; someone who is afraid of pigeons will not cross the squares, someone who is afraid of dogs will avoid all situations where they are present, and so on.

Diagnosis of specific phobia

For a correct diagnosis of specific phobia, it is necessary to evaluate a number of symptoms that the person experiences in the presence of the phobic stimulus.
 First of all, the person must have a pronounced fear and anxiety about a certain object or situation (such as flying, heights, animals, receiving an injection, seeing blood, etc.). In addition, for a specific phobia to be diagnosed, the following conditions must be present:

  • The phobic element almost always causes immediate fear and anxiety.
  • The phobic element is actively avoided or experienced with intense fear and anxiety.
  • Fear and anxiety are disproportionate to the actual danger posed by the phobic stimulus.
  • Fear and anxiety are always present and persist for more than 6 months
  • Fear and anxiety cause significant distress and impairment in relational, occupational, and other important areas of functioning.

It is also important to consider whether the disorder is not better explained by symptoms of another mental disorder, including fear, anxiety, and avoidance of situations associated with panic or other disabling symptoms (as in agoraphobia); objects or situations associated with obsessions (as in obsessive-compulsive disorder); memories of traumatic events (as in post-traumatic stress disorder); separation from home or significant others (as in separation anxiety disorder); or social situations (as in social anxiety disorder).

In fact, specific phobias can be confused with other types of disorders that share characteristics of fear and avoidance: agoraphobia, for example, is a condition in which the person feels paralyzed by the fear of being in large, crowded spaces or of not being able to leave certain places because they are trapped, but it should be distinguished from specific phobia in that agoraphobia encompasses many different situations and is not as well defined as specific phobia.

Social anxiety differs from specific phobia in that the cause of the anxiety is not a fear of the social situation itself, but a fear of being judged negatively by others. 
Panic disorder is characterized by a variety of panic attacks that occur unexpectedly. It is often the case that people with a specific phobia experience a panic attack or some of its symptoms in the face of the phobic stimulus, but to distinguish the two disorders it is important to note that in phobia the panic occurs only in the face of the feared stimulus, whereas in panic disorder the attacks are unpredictable, seem unmotivated, and the trigger cannot be traced.

In obsessive-compulsive disorder (OCD), the person is obsessed with certain stimuli, usually in the form of intrusive thoughts that cause distress and anxiety: in order to suppress the symptomatology, he or she performs compulsions (repetitive behaviors) to try to control them. If there are obsessions and compulsions about stimuli, it is necessary to analyze the situation to better diagnose an obsessive-compulsive disorder rather than a specific phobia.

If the phobia arises as a result of a major traumatic event, it is necessary to check for post-traumatic stress disorder. In this case, there is a sense that the severe trauma suffered is imprinted on the mind, whereas with a phobia, there is often no precise memory of when one began to fear the phobic stimulus.

If the phobic stimulus coincides exclusively with elements related to food and eating, the person is most likely to have an eating disorder such as anorexia nervosa or bulimia nervosa.

Onset and causes of specific phobias

Specific phobias can develop in a variety of ways: generally, after a negative event (e.g., being attacked by an animal), an association occurs in which one associates the stimulus that caused the discomfort (the animal that attacked us) with the feeling of discomfort one experienced, transforming it into a phobic stimulus.
 Passive observation can also generate a specific phobia: if an object has harmed others, it could also harm the observer, so the same association mechanism is created and generates a phobia. 
The association is even stronger when a panic attack occurs during an experience. In this case, the person associates what he or she was doing or observing with the feeling of discomfort and intense fear of the attack. In these cases, the most bizarre specific phobias can be generated: for example, a person may begin to fear the color blue because he or she was facing a wall of that color at the time of the attack, associating an irrelevant element with the feeling of panic. Hence the wide variety of phobias, often embarrassing to the sufferer, but justified by this mechanism.
 Finally, specific phobias can be generated by the transmission of information about a subject by others. The person worries, thinks about the danger of what he or she has learned, and if he or she is seized with fear, he or she may develop a specific phobia.

In all of these cases, however, the mechanism of the phobia is to associate a specific stimulus with a negative emotion of fear: the person who learns that his or her fear is caused by the specific phobic stimulus will want to avoid it at all costs, will limit his or her social functioning, and will live in a state of heightened tension and anxiety.

Thus, specific phobias do not hide an unconscious symbolic meaning, and the fear is simply related to involuntary mislearning experiences toward something. In this case, the person automatically associates danger with an objectively non-threatening object or situation.

This association occurs through classical conditioning, i.e., the thought-object association is created by the first frightening exposure that occurs and is maintained over time through avoidance to avoid experiencing the terrible emotion of intense fear that follows.

In general, anxious people are more likely to develop phobias, just as people who have been abused (physically, sexually) in childhood are more likely to develop anxiety disorders in general, including specific phobias, especially if the object of the phobia is related to the context of the abuse. In addition, there is evidence from studies in the literature that those who have family members who suffer from phobias are more likely to suffer from phobias themselves.

Main types of phobias

There are generalized phobias, such as agoraphobia, fear of open spaces, and social phobia, fear of public exposure, and specific phobias, generally managed by avoiding the feared stimuli, which can be:

  • Situational type. In cases where the fear is caused by a specific situation, such as public transport, tunnels, bridges, elevators, flying, driving, or closed places (claustrophobia or agoraphobia).
  • Animal type. Spider phobia (arachnophobia), bird phobia or pigeon phobia (ornithophobia), insect phobia, dog phobia (cynophobia), cat phobia (ailurophobia), rat phobia, etc..
  • Natural Environment Type. Phobia of thunderstorms (brontophobia), phobia of heights (acrophobia), phobia of the dark (scotophobia), phobia of water (hydrophobia), etc..
  • Blood-injection-injury type. Blood phobia (hemophobia), needle phobia, syringe phobia, etc.. In general, if the fear is caused by the sight of blood or a wound or by receiving an injection or other invasive medical procedure.
  • Other type. In this case, the fear is triggered by other stimuli such as: fear of situations that could lead to contracting a disease, etc. There is a particular form of phobia that concerns the body or parts of the body that the person perceives as disproportionate, unsightly, horrible compared to how they really show themselves (dysmorphic phobia).

Phobias do not conceal any unconscious symbolic meaning and the fear is simply related to experiences of involuntary mislearning about something. In this case, the organism automatically associates dangerousness with an objectively non-dangerous object or situation.

This association occurs by classical conditioning, that is, the relationship between thought and object is created by the first frightening exposure that occurred and is maintained over time because of the avoidance put in place to avoid feeling that terrible emotion of strong anxiety that follows.

Among the various specific phobias, in addition to those described above, we can mention a few:

  • Dental phobia has been recognized as a true specific phobia; people with dental phobia usually tend to postpone treatment continuously; special attention is paid to childhood, a sensitive period when the onset of fear of the dentist and fear of dental treatment is most common.
  • Amaxophobia (from the ancient Greek amaxos, “chariot”) is the disabling fear of driving a motor vehicle. Clinically, amaxophobia can be classified as a specific situational subtype of phobia in DSM-5 (American Psychiatric Association, 2015) and ICD-10 (World Health Organization, 2011).
  • Hemetophobia consists of the specific phobia of vomiting or watching someone else vomit. Any symptom of discomfort is immediately interpreted as a signal that will cause the person to vomit. Often, the person obsessively controls everything he or she eats for fear of ingesting foods that might cause vomiting. Unlike other eating disorders that involve food control, emetophobia is not caused by dissatisfaction with one’s body, but by an aversion to vomiting.
  • Tocophobia consists of an intense fear of childbirth and may be primary if it exists before conception or secondary to a traumatic event. 
When a specific fear or terror of death during childbirth predominates throughout pregnancy and is so intense as to induce “avoidance” of childbirth (tokos), it is a specific phobic state called tocophobia (Margaria and Gollo, 2001).
  • Gerascophobia is defined as a persistent, abnormal, and unjustified fear of aging. It is generally classified as a specific phobia and may be associated with the fear of being alone, without resources, and unable to care for oneself in old age, which sometimes leads to the use of cosmetic surgery.
  • A specific phobia recently discovered in the literature is trypophobia, a condition in which people experience disgust, nausea, and anxiety in response to stimuli characterized by circular shapes, such as soap bubbles or holes in a sponge (Le, Cole, & Wilkins, 2015). The existence of such a phobia was only reported in the scientific literature in 2013 (Cole & Wilkins, 2013) and appears to be associated with anxiety, distress, and specific phobic disorder.

Managing anxiety: treatment for specific phobias

Cognitive-behavioral psychotherapy is the most effective treatment for specific phobias. The most widely used technique in this area is gradual exposure to the feared stimuli: the subject is gradually brought closer to the stimulus until he or she has direct contact with the stimulus, which becomes neutral in his or her eyes thanks to a parallel process of restructuring irrational ideas related to the stimulus (e.g., “If a spider lands on my leg, it will surely sting me and I will die”). For example, if a person has a specific phobia of elevators, the therapist will agree with the person on a series of stimuli of increasing intensity. This goes from looking at a picture of an elevator, to watching a video of people using it, to standing next to an open elevator with the therapist, to entering the elevator with the therapist while holding the door open, to going up a few floors with the therapist and using the elevator alone. All of these steps are strictly gradual, and one does not move on to the next step until the patient feels completely comfortable with the current step.

For psychological therapy, only cognitive behavioral therapy (CBT) and relaxation training are recommended, as these therapies have been shown to be effective. Self-help interventions and psychoeducational groups are also conducted according to a cognitive therapy orientation. (National Institute for Health and Clinical Excellence, NICE, 2011).

For specific phobias, the literature has amply demonstrated how cognitive-behavioral psychotherapeutic treatment yields excellent results. Pharmacological treatment is a short-term solution to control acute anxiety crises and episodes. The most commonly used medications are benzodiazepines (anxiolytics) and antidepressants. Beta-blockers may also be used to control tremors and palpitations. However, benzodiazepines tend to be addictive, and when they are stopped, the symptoms usually return. Thus, medications for specific phobias have the important function of effectively treating the symptoms of the phobia, but they do not eliminate the underlying cause of the disorder, which requires psychotherapy.

Treatment of phobias

The treatment of phobias is relatively simple, if not complicated by other psychological disorders, and primarily involves a course of short-term cognitive-behavioral psychotherapy (often within 3-4 months).

The treatment of phobias, after a period of case assessment that usually ends within the first month, necessarily involves the use of graded exposure techniques to the feared stimuli.

The patient is progressively exposed to the phobic stimuli, starting with those that are farthest from the central object or situation (e.g., the image of a new syringe for a needle phobic, or a can of food for a dog phobic). Exposure to such stimuli is maintained until habit inevitably takes over and they no longer cause fear. Only then is exposure to a slightly more anxiety-provoking stimulus introduced, in a hierarchy carefully prepared a priori in the session. In this way, over the course of a few weeks, one is able to move up the hierarchy to much stronger exposures, never causing too much anxiety in the subject, and repeating each exercise until it has become “neutral”.

Such a procedure can be very frightening for people suffering from a phobia, since it involves facing the feared object or situation, but if done well, with the help of an experienced therapist, it is absolutely applicable and guarantees success in 90-95% of cases in curing the phobia.

In some cases, to make the method more effective, the patient is taught physiological relaxation strategies and asked to use them just before being exposed to the anxiety-provoking stimuli, thus facilitating the creation of a new conditioning in which the body associates relaxation rather than anxiety with such stimuli.

In the case of disabling phobias, it is very common to use anxiolytic drugs “as needed” to manage anxiety by forcing oneself to deal with certain feared situations (e.g., before flying). Such a strategy makes it possible to survive the event, but achieves nothing more than the effect of reinforcing the phobia. More useful, though not comparable and certainly less effective than cognitive-behavioral techniques, may be appropriate and prolonged SSRI antidepressant therapies under careful medical evaluation.

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