Phobia

BIBLIOGRAPHY

Phobias are morbid, irrational fear reactions to specific objects and situations. Phobias are among the most prevalent mental disorders worldwide. The term phobia comes from the name Phobos, the son of Aries, the Greek war god. Phobos was so fearsome-looking that enemies on the battlefield became panic-stricken when they saw him. Specific phobias are named by combining the Greek word for the object or situation with phobia. Thus, fear of thunder becomes brontophobia, and fear of closed spaces becomes claustrophobia. Phobias have been described for at least 2,500 years, going back to the ancient Greek physician Hippocrates (c. 460–377 BCE), the “father of medicine.”

Phobias are classified as types of anxiety disorders by the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM -IV-TR, 2000). The major diagnostic characteristics of a phobia are that an individual consistently reacts to some object or situation with intense fear and seeks to escape or avoid that stimulus; this fear is sufficiently strong that it interferes with the person’s normal functioning. Three types of phobias are differentiated by the nature of the circumstances that precipitate the strong fear reaction: specific phobia, social phobia, and agoraphobia.

Specific phobias include fears of clearly identifiable objects or situations, such as looking down from a tall building or seeing a snake. There are four basic subtypes of specific phobia: natural environment (water, storms); animals (snakes, spiders); situations (enclosed places, bridges); and blood, injections, and injuries (dentistry). Specific phobias that do not fall into these four subtypes are classified as other.

Social phobia, also called social anxiety disorder, is defined by a persistent and intense fear reaction and avoidance of social and performance situations in which one might be embarrassed or negatively evaluated by others. Common social phobic situations include public speaking, meeting strangers or persons of the opposite sex, using public restrooms, and writing one’s name in public. Social phobias typically begin in adolescence or young adulthood.

Agoraphobia, literally “fear of open spaces,” is more accurately the fear of having a panic attack in a public place, such as a shopping mall or a theater, from which one might have difficulty escaping to safety. Due to this fear, agoraphobics avoid public situations and, in many cases, become totally housebound.

Phobias share many characteristics with other anxiety disorders. For example, a person with panic disorder experiences intense panic attacks that are similar to what phobics experience, except that these attacks seem to come out of nowhere and are not clearly attached to specific circumstances. The majority of agoraphobics will be diagnosed as having panic disorder with agoraphobia. Posttraumatic stress disorder is also similar to phobias in that following a severely traumatic experience in which people believe that they or someone else might die (such as war or rape), some people continue to react with intense fear and avoidance when reminded of the original trauma.

Although the exact details of how phobias develop are not clear, there is a broad consensus that classical or Pavlovian conditioning-like processes are involved, in which an individual experiences a strong fear reaction in the presence of a specific object or situation, forming an associative link. Subsequently, when the object is reexperienced, it triggers a panic attack. Recent theories suggest that cognitive or thinking processes contribute to some phobia development. For example, the mere observation of another person being injured or frightened can initiate a phobia. Although most phobias develop via conditioning or observation, a considerable number of phobics have no recollection of having been frightened or injured in the presence of their phobic stimulus, either directly or vicariously.

Evolutionary theory enters in as well to explain why some objects are more frequently found to be phobic stimuli than others. American psychologist Martin Seligman’s theory of biological preparedness hypothesizes that due to their evolutionary significance as potential dangers, we are prone (prepared) to develop conditioned responses more readily to objects that were dangers in our evolutionary past, such as small, poisonous animals (e.g., snakes). We are less prone to develop conditioned responses to more modern but equally dangerous stimuli, such as guns.

Specific phobias are the most successfully treated of the anxiety disorders. The basic paradigm guiding most successful treatment follows from the conceptualization of the phobia’s origin as a conditioning-like process. To overcome or to extinguish a conditioned fear reaction, the phobic must engage the stimulus that elicits the panic reaction. With repeated exposure to the triggering stimulus, the panic reaction diminishes progressively until it is extinguished. The engagement with the triggering stimulus can be done gradually in small increments, or the phobic can be immersed or confronted with the stimulus full-strength. When presented in small increments, an anxiety hierarchy can be constructed that consists of a series of graded representations of the feared stimulus. Starting at the bottom, each item is presented to the phobic, who tolerates the fear until it diminishes, after which the phobic moves up to the next item in the hierarchy. Alternately, a phobic might be immersed in the feared stimulus through a procedure called flooding. Here the stimulus is presented at full strength, eliciting a strong fear reaction that diminishes over time.

These exposures can be accomplished with direct, live confrontation with the feared stimulus or through a procedure in which the patient brings elements of the anxiety hierarchy to mind as mental images. In a version of this treatment, called systematic desensitization, patients learn deep relaxation, which helps them remain relaxed as each item of the hierarchy is imagined. With repetition, each item is progressively mastered. Although systematic desensitization was the first method found to be truly efficacious in treating phobias, it requires an average of eleven one-hour treatment sessions. Live, direct exposure to the stimulus elements extinguishes the fear reaction more quickly. Swedish psychologist Lars-Goran Öst has shown that a single five-hour session of live exposure is highly effective for treating many phobias. More recently, computer-generated stimuli presented as virtual reality have been shown to be effective for treating phobias.

In practice, several of these approaches are often combined with cognitive mechanisms that help phobics believe that they can tolerate the feared stimulus. One method, called modeling, is particularly effective with children. Dog-fearful children, for example, observe nonfearful children playing safely with dogs, and this exposure by observation diminishes the phobic child’s fear.

Similar methods using live or imagined exposure to a feared situation are also effective for social phobia and agoraphobia. However, in contrast to specific phobias, where psychotropic drugs are generally ineffective, some medications can assist in the treatment of social and agoraphobia. A class of antianxiety drugs called benzodiazepines can be useful adjuncts to exposure treatments, but such drugs must be used with caution because they are addictive. Another class of medication, selective serotonin reuptake inhibitors, can also assist in some cases by diminishing the number of panic attacks among social phobics and agoraphobics. Although effective, the exact psychological mechanisms underlying these phobia treatments remain unclear.

SEE ALSO Anxiety; Post-Traumatic Stress

BIBLIOGRAPHY

American Psychiatric Association. 2000. Diagnostic and Statistical Manual of Mental Disorders (DSM -IV-TR). 4th ed., text rev. Washington, DC: Author.

Craske, Michelle G. 2003. Origins of Phobias and Anxiety Disorders: Why More Women than Men? London: Elsevier.

Craske, Michelle G., Martin M. Antony, and David H. Barlow. 1997. Mastery of Your Specific Phobia. Boulder, CO: Graywind.

Rachman, Stanley J. 1990. Fear and Courage. 2nd ed. New York: Freeman.

Ronald A. Kleinknecht