Fears and Phobias

Normal fear vs a phobia

Fear is a normal, protective response to danger. Many children go through phases of fearing the dark, animals or strangers that fade with age. A fear becomes a phobia when:

• it is far stronger than the actual risk
• it appears almost every time you face the trigger, or even think about it
• you go out of your way to avoid the trigger, or endure it with intense distress
• it has lasted 6 months or more
• it interferes with work, school, relationships or daily life

Adults with phobias usually know their fear is excessive but cannot control it.

Types of phobias

Specific phobias

Fear of a particular object or situation. Common groups:

Blood-injection-injury phobia is unusual: instead of the heart racing, blood pressure drops after an initial rise, so people often faint.

Social anxiety disorder

Intense fear of being judged, embarrassed or scrutinized in social or performance situations. It is broader than a specific phobia and often starts in the teenage years. See social phobia.

Agoraphobia

Fear of situations where escape might be difficult or help unavailable if panic strikes, such as crowds, public transport, open spaces or leaving home alone. It often develops after panic attacks. See agoraphobia.

Symptoms

When facing the feared object or situation, or anticipating it:

• racing or pounding heart, sweating, trembling
• shortness of breath or a choking feeling
• chest tightness, nausea, dizziness
• a strong urge to escape
• a sense of dread or losing control
• full panic attacks

In children, fear may show as crying, tantrums, freezing or clinging.

Causes and risk factors

Phobias usually develop from a combination of:

• Direct experience: a dog bite, being stuck in an elevator, a frightening flight
• Learning from others: seeing a parent's fear or hearing about bad events
• Temperament: being naturally cautious or anxious
• Genetics: anxiety disorders run in families
• Evolutionary preparedness: humans more readily fear snakes, heights and spiders than modern hazards

Specific phobias often start between ages 7 and 11. Women are diagnosed about twice as often as men.

Conditions that overlap with phobias

• Panic disorder: unexpected panic attacks not tied to one trigger
• Generalized anxiety disorder: broad, everyday worry
• Obsessive-compulsive disorder: fear of contamination or harm driving compulsions
• PTSD: fear and avoidance of reminders of a traumatic event
• Depression, which commonly accompanies long-standing phobias

How phobias are diagnosed

A primary care doctor, psychologist or psychiatrist will ask what you fear, how you react, how long it has lasted, and how much it limits your life. Questionnaires can measure severity. Physical causes of anxiety symptoms, such as thyroid problems or heart rhythm problems, may be checked when symptoms are unclear.

Treatment

Exposure therapy

The most effective treatment for specific phobias. With a therapist, you face the feared object or situation gradually, starting with something only slightly scary (for example, a picture of a spider) and building up step by step until the fear fades. Many people improve markedly within a handful of sessions, and some specific phobias respond to a single longer session of about 3 hours. Virtual reality exposure is used for flying and heights.

Cognitive behavioral therapy (CBT)

CBT combines exposure with learning to recognize and challenge catastrophic thoughts. It is the first-line treatment for social anxiety disorder and agoraphobia.

Applied tension

For blood-injection-injury phobia, tensing the muscles of the arms, legs and body raises blood pressure and prevents fainting during exposure.

Medicines

• SSRIs or SNRIs are effective for social anxiety disorder, agoraphobia and panic disorder.
• Beta-blockers can reduce physical symptoms in predictable performance situations.
• Benzodiazepines are sometimes used briefly, for example before a flight or dental procedure, but they can interfere with learning through exposure and carry a risk of dependence.

Specific phobias are mainly treated with therapy, not medicine.

Self-help that helps

• Do not avoid: small, regular, planned exposures reduce fear over time.
• Learn slow breathing (in for 4 seconds, out for 6) to ease physical symptoms.
• Limit caffeine and alcohol, which worsen anxiety.
• Try evidence-based self-help books or apps based on CBT.
• Tell a trusted person and practice exposures together.

Frequently asked questions

What is the difference between a fear and a phobia?

A fear is a normal reaction to a real or possible danger. A phobia is a fear that is excessive, lasts 6 months or more, causes intense anxiety, and leads to avoidance that interferes with daily life. Adults with a phobia usually recognize the fear is out of proportion.

What are the most common phobias?

Common specific phobias include fear of heights, spiders, snakes, dogs, flying, enclosed spaces, needles, blood and storms. Social anxiety disorder, the fear of being judged in social situations, is also very common. Agoraphobia, fear of places where escape is difficult, is less common.

Can phobias be cured?

Many can. Exposure therapy leads to lasting improvement for most people with specific phobias, sometimes after only one to a few sessions. Social anxiety and agoraphobia take longer but respond well to CBT, sometimes combined with medicine. Practicing exposure afterward helps prevent relapse.

What causes a phobia?

Phobias usually come from a mix of a frightening experience, learning fear from others, an anxious temperament and family genetics. Some people cannot recall how their phobia started. Avoidance keeps a phobia going, because it prevents the brain from learning that the feared thing is safe.

When should I get help for a phobia?

Get help if the fear limits your work, travel, health care or relationships, causes panic attacks, or leads you to use alcohol or drugs to cope. A primary care doctor can refer you for therapy. Treatment is effective and usually short.