Phobias – Causes, Signs and Symptoms

Phobias

Summary

Phobias are persistent, irrational fears of objects or situations that persist even though the fear has no base in current reality. 

People with phobias may experience intense mental and physical symptoms when exposed to something that triggers their phobia. In addition to feeling intense anxiety and fear, they may sweat, develop rapid heartbeat, have breathing difficulties and experience other symptoms that may escalate to a full-blown panic attack (a sudden, brief episode of fear and anxiety).

There are three major types of phobias:

  • Specific phobia. Also known as simple phobia, it is diagnosed in people who have phobias associated with specific objects or situations (e.g., animals, elevators) that do not have intrinsic danger.

  • Social phobia. Diagnosed in people who have extreme anxiety in certain social and public situations.

  • Agoraphobia. Diagnosed in people whose fears cause them to avoid most or all situations which involve leaving their home.

It is not well understood what causes phobias, although genetics, biology and biochemical factors all appear to play a role. In many cases, phobias are a symptom of anxiety disorders or other mental illnesses such as depression, substance abuse or eating disorders. Some phobias (e.g., simple phobia) begin in childhood whereas others (e.g., social phobia) often begin during the teen years. Phobias often peak during the 20s. A combination of psychotherapy and medication therapy is often successful in helping patients to treat their phobia effectively.

About phobias

Phobias are persistent, irrational fears of objects or situations that others view as harmless. 

People who have certain phobias go to great lengths to avoid the places or actions which cause their feelings of fear and anxiety. For example, people who fear the ocean or speaking in front of large audiences may be able to simply sidestep these fears by avoiding the situations that cause problems.

Phobias are considered to be mental disorders when they become so uncontrollable that they interfere with day-to-day life (including job duties and social interactions).

Phobias differ from simple fear or anxiety. For example, a student may have anxiety about making a presentation in a school assembly. If the student has not prepared, anxiety about failure or embarrassment is expected. A well-prepared student who still experiences an unreasonable amount of anxiety may have a phobia about public speaking. In many cases, a person with a phobia recognizes that the fear is unreasonable, but they remain afraid.

Phobias commonly begin in adolescence or early adulthood, although they may also begin in childhood. Children with phobias may not recognize that their fear is unreasonable and express the fear through crying, tantrums or clinging to adults. Many people who have phobias leave them untreated. Instead, they avoid the anxiety-producing situations, are unaware of their problem or are too embarrassed by it to seek help. However, untreated phobias can be associated with significant mental health problems, including depression and substance abuse. In their worst form, phobias can result in patients attempting suicide.

Types and differences of phobias

There are three major types of phobias. They include:

  • Specific phobias. Also known as simple phobias, they are diagnosed in people who have phobias associated with specific objects or situations that do not possess intrinsic danger. People who have this fear know that it is irrational, but feel powerless to control it. When faced with one of these objects or situations, the person becomes nervous or panicky. This is known as anticipatory anxiety. Patients may experience full-blown panic attacks – sudden episodes of extreme fear and anxiety that usually last between 10 and 15 minutes and cause symptoms such as racing heartbeat, heavy perspiration and shortness of breath – in some of these situations.

    According to the National Institute of Mental Health (NIMH), about 19.2 million Americans aged 18 years and older have some type of specific phobia in a given year. They usually begin in childhood, and the median age of onset is 7 years.

    Specific phobia is divided into several subtypes:

    • Situational type. Includes fear of enclosed spaces (claustrophobia), flying, crossing bridges and public transportation.

    • Natural environment type. Includes fear of thunderstorms, water and heights (acrophobia).

    • Blood-injection-injury type. Fear initiated by seeing blood or an injury or receiving an injection. It can cause a vasovagal response, in which reduced heart rate and blood pressure cause a person to faint.

    • Animal type. Fear of certain animals or insects (e.g., cats, spiders). Commonly begins in childhood.

    • Other type. Fear from other stimuli, including fear of choking, vomiting or loud sounds.

  • Social phobia. Also known as social anxiety disorder, social phobia is diagnosed in people who have extreme anxiety in certain social and public situations. Unlike shyness, people with social phobia are often at ease with people most of the time, but experience extreme discomfort in certain situations. As a result, they avoid these social situations. Patients may worry for days or weeks in advance of a dreaded social situation.

    People with social phobia exaggerate the impact of mistakes and feel that all eyes are on them, watching to see them sweat, blush or otherwise show fear, and that others are ready to pass judgment when they fail. Fear of speaking in public, dating or talking to people in authority are hallmarks of this condition. Patients may also fear using public restrooms or eating in front of others, or talking on the phone or writing while others watch. They tend to believe that showing anxiety is a sign of weakness, and believe that other people are more confident or competent than they really are.

    According to the NIMH, about 15 million Americans aged 18 years and older have social phobia in a given year. It often begins in childhood or early adolescence, typically around age 13, although it is not diagnosed in children unless it lasts for at least six months. Patients may find it difficult to make and maintain friends, and may avoid school, work or other day-to-day situations. When they are in situations that provoke anxiety, they may experience symptoms such as blushing, profuse sweating, trembling, muscle tension, nausea and difficulty talking.

    Feelings of inferiority and low self-esteem appear to be at the root of social phobia. Some research indicates that social phobia has a genetic component, as the disorder is more common in people who have first-degree relatives diagnosed with the phobia. The type of social phobia that a patient suffers from may depend on gender. For example, fear of blushing is more prevalent among women than men. In other cases, fears may be based on experience. Fear of eating in front of others is more likely in someone who has had a past embarrassing episode while eating in public.

    Social phobia is often associated symptom seen with other anxiety disorders and depression. Many patients self-medicate by using drugs and alcohol, sometimes leading to substance abuse problems.

  • Agoraphobia. Diagnosed in people who fear being caught in a situation from which escape might be difficult or embarrassing, or who fear being trapped in circumstances in which medical help might not be available during an emergency (e.g., having a panic attack in a public place). These people may seldom or never leave their home due to their fears.

    Agoraphobia is closely linked with panic disorder, a type of anxiety disorder in which a person regularly experiences panic attacks. In many cases, panic disorder is actually the cause of agoraphobia. In other cases, people have agoraphobia without a history of panic disorder. These people fear panic-related symptoms, but may not have had panic attacks or been diagnosed with panic disorder.

    About 1.8 million Americans aged 18 years and older have agoraphobia without a history of panic disorder, according to the NIMH. Agoraphobia tends to begin in a person’s 20s. Women are affected more often than men.

Risk factors and causes of phobias

It is not well understood what causes specific phobias, although genetics appear to play a role and scientists are working to identify which genes may affect anxiety and fearfulness. In addition, environmental factors may play a role. For instance, children may learn certain phobias from observing the reactions of their parents and others to certain stimuli – seeing a parent recoil from a snake is likely to give the child a fear of snakes.

Researchers also believe that biochemical factors may influence development of phobias. A neurotransmitter called serotonin helps regulate mood and emotions, and it is believed that an imbalance of this biochemical may help cause phobias.

The structure of the brain may also be partly responsible for phobias. The amygdala, which is located deep inside the brain, appears to be responsible for controlling the fear response. People with an overactive amygdala may have heightened anxiety.

Certain phobias tend to occur more in one gender than another, and at different ages. Both social phobia and specific phobias, for instance, tend to begin in childhood or adolescence. Specific phobias are most likely to begin in childhood, around age 7, whereas the incidence of social phobia peaks in the middle teens. Women and men are equally likely to have social phobia. However, women are far more likely than men to develop specific phobias.

Signs and symptoms of phobias

People who have phobias may experience a number of symptoms, including the following that are common to all types of phobias:

  • Persistent, irrational fear of an object, activity or situation

  • Anxiety from mere anticipation of an encounter with a feared stimulus

  • Physical symptoms such as sweating, rapid heartbeat, breathing difficulties and intense anxiety (e.g., panic attack)

  • Impaired ability to engage in normal tasks due to fear

  • Inability to control fear despite knowledge that it is irrational or out of proportion with the stimulus causing the fear

  • Strong desire to avoid the source of fear, including taking unusual measures to keep away from such objects, people or situations

Symptoms associated with specific phobias include:

ConditionSymptoms
AgoraphobiaFear of being caught without a means to escape Agitation, short temper Feeling disconnected from others Confused thoughts Staying home to avoid feared situations
Specific phobiaFear of clearly defined objects or situations Fear of losing control
Social phobiaFear of social or performance situations Fear of embarrassment or being judged Blushing Poor social skills

Diagnosis of phobias

People who experience symptoms associated with phobias – such as anxiety and persistent, irrational fears – may not be aware of the source of their problem. However, if these feelings interfere with their daily lives or become debilitating, they should see a physician.

Before diagnosing a phobia, a physician may perform a complete physical examination and compile a thorough medical history if the physician feels these steps are warranted. Patients will be asked to describe their symptoms and to explain what triggers them and how often they occur. The physician will also want to rule out other medical conditions that could be causing symptoms, such as a heart problem, overactive thyroid gland or substance abuse problems.

In attempting to diagnose a phobia, a physician may ask questions of patients, such as:

  • Do they feel intense fear in situations where they are unable to escape or unable to find help?

  • Does the thought of being exposed to certain objects or situations cause fear?

  • Do they fear social or performance situations (such as public speaking) where they may be judged?

  • Do they avoid certain situations that seem to provoke anxiety?

All anxiety disorders have their own criteria as defined by the American Psychiatric Association (APA) in the Diagnostic and Statistical Manual IV-TR (DSM-IV). Some criteria apply to all phobias. For instance, a phobia is not diagnosed when there is another illness (medical or emotional) causeing the symptoms but is when the patient either avoids certain situations or objects (to the point where the phobia interferes with normal living), or endures them with great anxiety.

In addition, the patient will generally recognize that their reaction to a stimulus is unreasonable or excessive.

Specific criteria for the three major phobias include the following:

ConditionCriteria
AgoraphobiaAnxiety associated with being in places or situations where escape may be difficult or embarrassing or in which help may not be available if needed, resulting in reduction or elimination of leaving the home
Specific phobiaPersistent, excessive or unreasonable fear when exposed to or in anticipation of encountering a specific object or situation

Exposure to the stimulus provokes immediate anxiety response

In patients under age 18, duration of symptoms is at least six months
Social phobiaMarked, persistent fear of social or performance situations in which a person is exposed to strangers or scrutiny by others

Exposure to the stimulus provokes immediate anxiety response

In patients under age 18, duration of symptoms is at least six months

A patient who appears to have a phobia may be referred to a psychiatrist or other mental health care professional who can help make a specific diagnosis and treat the condition. Patients may be asked to fill out questionnaires or self-assessments that can help pinpoint a diagnosis. In many cases, phobias are symptoms of other anxiety disorders or mental illnesses such as depression, substance abuse or eating disorders.

Treatment and prevention of phobias

Most people with phobias do not get better on their own and require treatment. Psychotherapy is an effective way of treating most phobias. It is likely to focus on reducing anxieties and fears and managing reactions to fear-inducing stimuli. Cognitive behavior therapy is a common treatment for phobias.

Cognitive therapy involves learning new skills to react differently to situations that typically trigger anxiety. Patients also learn about negative thought patterns that increase anxiety and ways to redirect such thinking.

In the behavioral portion of therapy, the patient learns to change specific actions and to use different techniques to stop harmful behavior. The patient may learn relaxation techniques such as deep breathing and may be gradually exposed to situations that are frightening and in which the patient can test new coping skills. This is known as exposure therapy. For example, a person with fear of flying may first visit an airport. On a later visit, they will sit on an airplane that does not leave. Eventually, the patient will take a flight.

In addition, medications may be prescribed to help reduce the anxiety that patients feel. Antidepressant medications are usually effective in treating anxiety disorders, even in patients who are not depressed. These drugs sometimes take several weeks to become effective, so patients should not become discouraged if they do not see immediate improvement.

Anti-anxiety medications may also be prescribed. They are generally used only for short periods of time to stabilize an acute situation because patients may develop a physical and psychological dependence on them. Patients should not stop using anti-anxiety medications unless under close supervision of a physician because this may cause withdrawal symptoms.

The use of both antidepressant and anti-anxiety medications should be closely monitored. Patients should be aware that a physician may need to adjust the dosage or change medications to achieve the best results with minimal side effects. In addition, the U.S. Food and Drug Administration (FDA) has advised that antidepressants may increase the risk of suicidal thinking in some patients, especially children and adolescents, and all people being treated with them should be monitored closely for unusual changes in behavior.

Beta-blocker medications – which are typically used to treat heart conditions – are also effective in treating some of the symptoms associated with phobias, particularly social phobia. These medications work by blocking the stimulating effect of the hormone adrenaline. Patients who know in advance that they soon will be in an anxiety-provoking situation – such as giving a speech – may use beta blockers to reduce symptoms such as a pounding heart or trembling hands

Questions for your doctor regarding phobias

Preparing questions in advance can help patients have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following questions about phobias:

  1. What causes phobias in general?
  2. What may have caused my phobia?
  3. What are the specific types of phobias?
  4. Am I at risk for developing a phobia if my parents or siblings have a phobia?
  5. If I have one phobia, am I likely to develop another?
  6. Can I simply avoid the situation or object of my phobia?
  7. What are my treatment options?
  8. Do I need medication for my phobia? If so, what are the side effects?
  9. How effective are treatments?
  10. How can I prevent symptoms associated with phobias?
  11. How can I prevent relapse of my phobia?
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