Specific phobias

Definition

Specific phobia is a type of disorder in which the affected individual displays a marked and enduring fear of specific situations or objects. Individuals with specific phobias experience extreme fear as soon as they encounter a defined situation or object, a phobic stimulus. For example, an individual with a specific phobia of dogs will become anxious when coerced to confront a dog. The specific phobia triggers a lot of distress or significantly impairs an affected individual.

Mental health professionals use the Diagnostic and Statistical Manual of Mental Disorders (the DSM ) to diagnose mental disorders. The 2000 edition of this manual (the Fourth Edition Text Revision, also called the DSM-IV-TR ) classifies specific phobia as a type of anxiety disorder. Formerly, specific phobia was known as simple phobia. In the last few years, mental health professionals have paid more attention to specific phobias.

Description

Specific phobia has a unique position among the anxiety disorders in that individuals with this disorder do not experience pervasive anxiety nor do they seek treatment as readily as individuals with other anxiety disorders. Unlike individuals with other anxiety disorders, the fear of individuals with specific phobias is limited to defined situations or objects. Individuals with specific phobias experience impairment or a significant amount of anguish. They may lead restricted lifestyles depending upon the phobia type. Adults and adolescents with specific phobias recognize that their fear is unreasonable. Children, on the other hand, may not recognize that their fear of the phobic stimulus is unreasonable or extreme.

The types of specific phobias include situational, object, and other. The situational type is diagnosed if an individual's fear is cued by a defined situation. Examples include situations such as flying, enclosed places, tunnels, driving, bridges, elevators, or public transportation. Object types include animal, natural environment, and blood-injection-injury types. Animal type is diagnosed if an individual's fear is cued by animals or insects. Natural environment type is diagnosed if an individual's fear is cued by storms, water, or heights. Blood-injection-injury type is diagnosed if an individual's fear is cued by seeing an injury or blood or by an injection or other invasive medical treatment. Other type is diagnosed if an individual's fear is cued by other stimuli such as fears of vomiting, choking, becoming ill, and falling down if far from a means of physical support, and a child's fears of loud noises or characters in costumes.

Researchers have found that the frequency of type for adults in clinical settings, from least to most frequent, is: animal, blood-injection-injury, natural environment, and situational. The most common phobias for community samples, however, include phobias of heights, mice, spiders, and insects.

Causes and symptoms

Causes

The development of a specific phobia may be determined by a variety of factors. Behavioral, cognitive, and social theories of learning and conditioning, psychodynamic models such as the psychoanalytic theory of Freud, physiological studies of the brain , family background and genetic predisposition, variations in sociocultural themes, and theories on trauma can influence the development of specific phobia disorder. Some theorists propose that biological researchers have ignored specific phobias because pharmacological treatment is not the treatment of choice for this disorder.

LEARNING AND CONDITIONING CAUSES. As of 2002, research on phobias focuses on information-processing, learning, and conditioning themes. Learning to experience fear is the core of a conditioning perspective. Informational and instructional factors can result in the formation of fears. For example, an individual who frequently hears of plane crashes in the news may develop a specific phobia of flying. Research shows that individuals with specific phobias pay more attention to information about danger than do individuals who do not have specific phobias. Vicarious acquisition occurs when an individual witnesses a traumatic event or sees another individual behave with fear when confronting a phobic stimulus. Direct conditioning occurs when an individual is frightened by a phobic stimulus.

A major determinant of specific phobias is conditioning. Association and avoidance are types of conditioning. In association conditioning, a stimulus that was initially neutral begins to trigger an anxiety response. For example, if an individual was driving one day and experienced a strong anxiety response, an association may form between driving and anxiety. Individuals do not learn to become phobic until they begin to avoid. In avoidance conditioning, individuals learn to avoid a stimulus that triggers anxiety. Every time individuals avoid the phobic stimulus—driving, for example—they are rewarded by the relief from anxiety.

TRAUMATIC CAUSES. A determinant of specific phobias includes traumas. For example, individuals who have been attacked by a dog may develop a specific phobia disorder and become conditioned to fear dogs. Individuals who observe others experiencing a trauma (the others are "modeling" behavior for the individual who will be affected) may become predisposed to developing specific phobia disorder. For example, individuals who witness people falling from a building may develop a specific phobia disorder. Phobias with a traumatic origin may develop acutely, or, in other words, have a more sudden onset than other phobias that develop more gradually.

PSYCHODYNAMIC CAUSES. Psychodynamic theorists explain that phobias emerge because individuals have impulses that are unacceptable, and they repress these impulses. More specifically, Freud proposed that phobias emerge because of an unresolved oedipal conflict. According to Freud's theory, an oedipal conflict is a developmental conflict that emerges during the third (or oedipal) stage of Freud's psychosexual development stages. During this stage, a conflict emerges with regard to the triad of father, mother, and child. The conflict concerns the sexual impulses that the child has toward the parent of the opposite gender and the hostile impulses that the child has towards the parent of the same gender. During this stage, the developmental conflict concerns a resolution of oedipal issues. Psychoanalysts propose that when repression does not work, individuals with phobias displace their anxiety connected to the unresolved oedipal conflict upon a situation or object that is less relevant. The feared situation or object symbolizes the source of the conflict. For example, a specific phobia may be connected to an individual's conflict about aggressive or sexual thoughts and feelings. In one sense, a phobia protects individuals from realizing their emotional issues.

The case of Hans, a boy with a horse phobia, is Freud's paradigm example of a phobia. Freud attributed Hans' fear of horses to an oedipal conflict that was not resolved, and he explained that Hans repressed his sexual feelings for his mother and his wish that his father would die. Freud proposed that Hans feared that his father would discover his wish, repressed his wish to attack his father, and displaced his fear of his father's aggression onto horses. The young boy resolved the conflict of loving and hating his father by hating horses rather than admitting that he had aggressive feelings towards his father. Hans was better able to avoid the feared horses than his father. Thus, the phobia in the case of Hans represents a compromise of intrapsychic movement.

PHYSIOLOGICAL CAUSES. Some research has suggested that the high activation of brain pathways that correspond to the cognitive and emotional constituents of anxiety biologically predispose individuals to specific phobias.

GENETIC AND FAMILY CAUSES. Although specific phobia is frequently attributed to environmental issues such as modeling , learning by association, and negative reinforcement , genetic predisposition can influence this disorder. An individual who has a family member with a specific phobia is at an increased risk for developing this disorder. Some research indicates that the pattern of types are similar within families. For example, a first-degree biological relative of individuals with a situational type is likely to have phobias of situations. Studies indicate that the blood and injury phobias have strong familial patterns.

SOCIOCULTURAL CAUSES. There is a paucity of information about cultural differences in specific phobias. Phobia content may vary by culture. Fear of a phobic stimulus such as magic or spirits, present in several cultures, is diagnosed as a specific phobia only if the fear is excessive for a particular culture and if the fear triggers major distress or interferes with functioning. Some research indicates that African Americans are more likely than whites to report specific phobias. Some studies show that specific phobias are less common among whites born in the U.S. or immigrant Mexican-Americans than among Mexican-Americans born in the U.S. Research suggests mixed data with regard to socioeconomic level, with some data associating specific phobia disorder with a lower socioeconomic level.

PERSONAL VARIABLES. Studies suggest a relationship between age and specific phobia. Research indicates some connections between the age of individuals with specific phobias and insight into the extreme quality of their fears. Insight increases with age. Children, unlike adults and adolescents, often do not report feelings of distress about having phobias. Insight into the unreasonable nature of the fear is not required for a diagnosis of specific phobia in children. The animal and natural environment types of specific phobia are common and generally transitory in children. Some studies indicate a connection between gender and specific phobia. Research shows that specific phobias from the animal type are more common among women. Some studies suggest that women are more likely to report specific phobias and to seek treatment than men.

Symptoms

DSM-IV-TR delineates seven diagnostic criteria for specific phobia:

• Significant and enduring fear of phobic stimulus: Patients with specific phobia display marked and enduring fear when they encounter a defined situation or object, the phobic stimulus.
• Anxiety response to phobic stimulus: Patients with specific phobia display anxiety as soon as they confront the phobic stimulus. When they confront the phobic stimulus, a defined situation or object, patients with specific phobia may experience a panic attack related to the specific situation. Children may cry, cling, freeze, or display tantrums when they express their anxiety in the face of the phobic stimulus.
• Recognition: Although adolescents and adults realize that their fear is unreasonable and disproportionate to the situation, children may not recognize that their fear is excessive.
• Avoidance: Individuals with specific phobia avoid the phobic stimulus or endure it with deep distress and anxiety.
• Impairment and distress: Individuals with specific phobia display avoidance, distress, and anxious anticipation when they encounter the phobic stimulus. Their avoidance reactions interfere with their daily functioning, or they express significant distress about having a phobia.
• Duration: To diagnose specific phobia in a patient who is under 18 years of age, the duration of the disorder needs to be at least six months.
• Not accounted for by another disorder: A diagnosis of specific phobia is assigned if the phobic avoidance, panic attacks, or anxiety related to the defined situation or object are not better accounted for by other disorders.

Demographics

General United States population

Specific phobias are common. The prevalence rates of specific phobia in community samples range from 4% to 8%. Over the course of a lifetime, the prevalence estimates in community samples range from 7.2% to 11.3%.

High-risk populations

Individuals whose family members have specific phobia are at a higher risk for developing this disorder.

Cross-cultural issues

Prior to assigning a diagnosis of specific phobia, clinicians need to consider whether a patient's fear is extreme in the context of a particular culture and whether the phobia causes difficulties in daily functioning or triggers a lot of distress. Further research is needed on the effects of culture upon the symptoms of specific phobia.

Gender issues

There are twice as many women with specific phobia than there are men with this disorder. The gender ratio variable varies depending upon the type of specific phobia. Approximately 75%–90% of people with the animal, situational, and natural environment types are female. Approximately 55%–70% of people with the blood-injection-injury subtype are female. For height phobias, there are fewer women than men than for other specific phobia types; however, illness phobias are more common in men.

Diagnosis

The diagnosis of specific phobia is complicated by factors such as degree of impairment and differential diagnosis. Although fears of specified situations or objects are common, a diagnosis of specific phobia relies on the degree of sufficient impairment.

With regard to differentiating specific phobia types, factors such as the focus of fear and the predictability and timing of the reaction to the phobic stimulus across the specific phobia types can assist clinicians to differentiate. With regard to differentiating specific phobia from other disorders, there are several disorders with similar symptoms. They include panic disorder with agoraphobia , social phobia , post-traumatic stress disorder , obsessive-compulsive disorder , hypochondriasis , schizophrenia , delusional, and other psychotic disorders. Generally, a diagnosis of specific phobia rather than panic disorder is made when there are no spontaneous panic attacks and no fear of panic attacks. It is often difficult to differentiate specific phobia, situational type, from panic disorder with agoraphobia. Specific phobia, situational type, is commonly diagnosed when an individual displays situational avoidance without unexpected and recurrent panic attacks. On the other hand, panic disorder with agoraphobia is diagnosed if an individual experiences an initial onset of panic attacks that are not anticipated and subsequently experiences avoidance of several situations considered triggers of panic attacks. Although individuals with specific phobia, unlike individuals with panic disorder with agoraphobia, do not display enduring anxiety, anxious anticipation may occur when confrontation with a phobic stimulus is more likely to occur. DSM-IV-TR outlines differentiating factors as the type and number of panic attacks, the number of avoided contexts, and the focus of the fear. At times, both diagnoses, specific phobia and panic disorder with agoraphobia, need to be assigned.

Psychological measures

Measures used to diagnose specific phobia include behavioral observation, clinical interviews, physiological evaluation, and self-report measures. The Behavioral Avoidance Task (BAT) is a common behavioral observation method used to assess specific phobia. Often, the diagnosis of specific phobia is made on the basis of an individual's responses to semistructured interviews such as the Anxiety Disorders Interview Schedule for DSM-IV (ADIS-IV) and the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-IV). To assist in differential diagnosis between specific phobias and other disorders with similar characteristics, clinicians use the Anxiety Disorders Interview Schedule for DSM-IV (ADIS-IV). Physiological evaluations usually include heart rate monitors. Self-report questionnaires include measures such as the SUDS (subjective units of discomfort/distress scale), the most frequently used self-report measure, the Fear Survey Schedule (FSS-III), and the Mutilation Questionnaire, specifically for measuring fear of the blood type of specific phobia.

Time of onset/symptom duration

Generally, the initial symptoms of specific phobia occur when an individual is a child or a young adolescent. The type of phobia determines the age of onset. The blood, animal, and natural environment types begin when an individual is a child; however, many new cases of the natural environment type occur when an individual is a young adult. The onset for the height type begins in adolescence. The onset age for the situational type occurs in childhood, but peaks again in the mid-twenties. There is no specific onset age for phobias with a traumatic origin.

Individual variations in specific phobia

Classification systems distinguish between individuals with different types of specific phobias. The types of specific phobia, situation, object, and other, relate to particular features such as the age, gender, and culture of an individual. Some researchers propose that to distinguish individual differences in treatment planning, it is more helpful to simply name the specific phobia rather than to use the type classification system. For example, researchers have found that for the animal type, some animals such as a tiger or a bear did not trigger disgust for tiger-phobic or bear-phobic individuals, but other animals such as a spider triggered disgust for some spider phobic individuals, but did not trigger disgust for other spider phobic individuals.

Dual diagnoses

Specific phobia often occurs with other disorders of mood and anxiety, and with substance-related disorders. When specific phobias occur with other disorders in clinical contexts, the primary diagnosis is associated with greater distress than is the specific phobia. The blood-injury-injection type of specific phobia may occur with physical symptoms such as vasovagal fainting. The vasovagal fainting response is characterized by a short heart rate acceleration and blood pressure elevation. Then, the heart rate decelerates and the blood pressure drops. Research shows that individuals who have one specific phobia type are more likely to have other phobias of the same type.

Treatments

Specific phobias are highly treatable. They are most effectively treated by psychological rather than biological treatments. The primary goal of most treatments of specific phobias is to reduce fear, phobic avoidance, impairment, and distress. Approximately 12%–30% seek treatment for specific phobias.

Cognitive-behavioral therapy

Cognitive-behavioral therapy has been effective in treating specific phobias. There has not been much research on the effects of cognitive therapy alone on specific phobias. Cognitive therapists challenge fearful thoughts and replace them with more positive thoughts. Although some studies show benefits in that cognitive therapy may assist patients to decrease anxiety related to their exposure exercises, research indicates that cognitive therapy alone is probably not an effective treatment for specific phobia. Researchers suggest adding panic management strategies such as cognitive restructuring to assist with behavioral treatments.

Several studies indicate that real-life (in vivo) desensitization or exposure is the most effective and long-lasting treatment for a broad range of specific phobias. Systematic desensitization includes a process by which individuals unlearn the association between the phobic stimulus and anxiety. Incremental exposure involves the patient's gradual facing of the phobic stimulus through a series of graded steps. Wolpe's imagery desensitization is suggested so that patients with specific phobias can face the fear in imagery prior to attempting in vivo exposure. Unlike many of the other treatments, the treatment gains of in vivo exposure are maintained upon follow-up. Some desensitization treatments employ flooding as a useful strategy. When flooding is used, patients maintain a high anxiety level without retreating. Similar to desensitization, flooding can be used both in imagination and in vivo. Flooding is not suggested for most individuals because it can trigger a higher level of sensitization and fear reinforcement. For in vivo treatment, a patient needs to be highly motivated because the treatment may lead to temporary discomfort. The primary reasons for poor compliance with cognitive-behavioral treatment include lack of time, anxiety, and low motivation.

Psychodynamic therapy

Psychodynamic psychotherapy , or insight-oriented therapy assists patients to become more aware of the symbolic nature of their anxiety and to explore traumatic past events. Insight-oriented therapy is a psychodynamic therapy that aims to expose and reduce patients' unconscious conflicts, increase patients' understanding of their underlying thoughts, and assist patients to gain conscious control over their psychological conflicts. In psychodynamic therapy, for example, patients may discover that their anxiety may be connected to aggressive or sexual feelings and thoughts.

Group therapy

There is little research on group therapy for specific phobia disorder. Some studies suggest that group treatment has been effective for dental and spider phobias.

Medications

There has been a paucity of research on the relationship between medication and specific phobia. Generally, pharmacotherapy has not been considered to be a treatment of choice for individuals with specific phobias. Benzodiazepines, however, (medications that slow the central nervous system to ease nervousness and tension) may decrease anticipatory anxiety prior to an individual's entrance into a phobic situation. A low dose of a benzodiazepine such as clonazepam (Klonopin) or alprazolam (Xanax) is indicated to decrease some fear arousal prior to in vivo exposure. The reduction of symptoms, however, may interfere with the treatment. Prior to beginning in vivo exposure, an antidepressant such as sertraline (Zoloft) or paroxetine (Paxil) is suggested to increase motivation for undertaking an uncomfortable treatment. Beta blockers can assist individuals to confront the specific phobia.

Alternative therapies

Research shows some benefits for specific phobias with applied relaxation. Relaxation training includes abdominal breathing and muscle relaxation on a regular basis. Studies have indicated that applied muscle tension has been highly effective for individuals with blood type phobias who faint in that the treatment triggers an early response. When using applied tension, therapists request that patients tense their muscles several times. The repeated muscle tensing results in a temporary increase in blood pressure and prevents fainting when patients see blood. Similar to in vivo exposure, the gains from applied tension are maintained upon follow-up. Some alternative therapies include immersive virtual reality, hypnotherapy , eye-movement desensitization and reprocessing (EMDR), and energy balance approaches such as massage and acupuncture .

Prognosis

If specific phobias exist in adolescence, they have a greater chance of persisting in early adulthood. Specific phobias that continue into adulthood generally become chronic if they are not treated. Furthermore, there is a greater chance for an individual diagnosed with specific phobia to develop new phobias as a young adult. Phobias contracted during childhood or adolescence that continue when individuals become young adults remit approximately 20% of the time. Individuals with specific phobias do not often seek treatment. For those who seek treatment, research suggests that compared to individuals with specific phobias whose fear diminishes slowly during exposure, individuals with specific phobias whose fear diminishes more rapidly have a better prognosis for recovery.

A consideration of prognosis takes into account the distinction between fear onset and phobia onset. Studies indicate that individuals with specific phobias of animal, blood, heights, and driving had a fear onset nine years earlier than their phobia onset. Some studies have shown that generalized anxiety level, severity of symptoms, and prior experience with the phobic stimulus are factors that have been associated with treatment outcome.

Although most mental health professionals consider specific phobia that begins in childhood to be a benign disorder, it can last for years if left untreated. Some studies indicate, however, that specific phobia does not become worse and usually diminishes as an individual ages. Without treatment, the prognosis is poor for an individual who has several phobias.

Prevention

Early detection is a key to assisting individuals with mild cases of specific phobia to seek treatment to prevent the development of full-blown cases of the disorder. Individuals who are at risk for developing specific phobia as well as individuals who already have been diagnosed with specific phobia need to avoid caffeine because caffeine can increase arousal. Further research is needed to discover variables that predict the reason that only certain individuals will develop specific phobias after conditioning or acquiring information that leads to fear.

See also Anxiety-reduction techniques; Generalized anxiety disorder; Exposure treatment

Resources

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th edition, text revised. Washington, DC: American Psychiatric Association,2000.

Antony, Martin, M., Ph.D., and David H. Barlow, Ph.D. "Social Phobia, Specific Phobia." In Psychiatry. Volume 2. Edited by Allan Tasman, M.D., Jerald Kay, M.D., and Jeffrey A. Lieberman, M.D. Philadelphia: W. B. Saunders Company, 1997.

Antony, Martin, M., Ph.D., and Richard P. Swinson. Phobic Disorders and Panic in Adults: A Guide to Assessment and Treatment. Washington, DC: American Psychological Association, 2000.

Bourne, Edmund J., Ph.D. The Anxiety and Phobia Workbook. 3rd Edition. Oakland, CA: New Harbinger Publications,2001.

Bourne, Edmund J., Ph.D. Beyond Anxiety and Phobia: A Step-by-Step Guide to Lifetime Recovery. Oakland, CA: New Harbinger Publications, 2001.

Donahue, Brad, and James Johnston. "Specific Phobia." In Diagnosis, Conceptualization, and Treatment Planning for Adults: A Step-by-Step Guide, edited by Michel Hersen and Linda K. Porzelius. Mahwah, New Jersey: Lawrence Erlbaum Associates, Publishers, 2002.

Elkin, David, M.D., and Cameron S. Carter, M.D. "Anxiety Disorders." In Introduction to Clinical Psychiatry, edited by G. David Elkin, M.D. 1st edition. Stamford, Connecticut: Appleton and Lange, 1999.

PERIODICALS

Mager, Ralph, Alex H. Bullinger, Franz Mueller-Spahn, Marcus F. Kuntze, and Robert Stoermer. "Real-Time Monitoring of Brain Activity in Patients with Specific Phobia during Exposure Therapy, Employing a Stereoscopic Virtual Environment." CyberPsychology and Behavior 4, no. 4 (2001): 465–469.

ORGANIZATIONS

American Psychological Association. 750 First Street NE, Washington, D.C. 20002-4242. (202) 336-5500. <http://www.apa.org>.

Anxiety Disorders Association of America (ADAA). 11900 Parklawn Drive, Suite 100, Rockville, MD. 20852-2624.(301) 231-9350. <http://www.adaa.org>.

Phobics Anonymous. P.O. Box 1180, Palm Springs, CA. 92213. (760) 322-COPE.

Judy Koenigsberg, Ph.D.

313. Phobias

See also 28. ATTITUDES ; 41. BEHAVIOR ; 156. FEAR ; 254. MANIAS ; 311. -PHILE, -PHILIA, -PHILY ; 334. PSYCHOLOGY .

N.B.:

noun forms end in -phobe and adjective forms end in -phobic, unless otherwise noted.

acarophobia

a fear of skin infestation by mites or ticks.

achluophobia

scotophobia.

acidophobia

an inability to accommodate to acid soils, as certain plants.

acousticophobia

an abnormal fear of noise.

acrophobia

an abnormal fear of heights. Also called altophobia, batophobia, hypsophobia .

aelurophobia

ailurophobia.

aerophobia

an abnormal fear or dislike of drafts. Cf. ancraophobia, anemophobia .

agoraphobia

an abnormal fear of being in crowded, public places, like markets. Cf. demophobia .

agyrophobia

an abnormal fear of crossing streets. Also dromophobia .

aichmophobia

an abnormal fear of pointed objects.

ailurophobia, aelurophobia, elurophobia

an abnormal fear of cats. Also called gatophobia, felinophobia .

albuminurophobia

a fear of albumin in one’s urine as a sign of kidney disease.

algophobia

an extreme fear of pain. Cf. odynophobia .

altophobia

acrophobia.

amathophobia

an abnormal fear of dust.

amaxophobia

an abnormal fear of being or riding in vehicles.

ancraophobia

an abnormal fear of wind. Cf. aerophobia, anemophobia .

androphobia

1. an abnormal fear of men.

2. a hatred of males. Cf. gynephobia .

anemophobia

an abnormal fear of drafts or winds. Cf. aerophobia, ancraophobia .

anginophobia

an abnormal fear of quinsy or other forms of sore throat.

Anglophobia

a hatred or fear of England and things English.

anthophobia

an abnormal fear of flowers.

anthropophobia

an abnormal fear of people, especially in groups.

antlophobia

an abnormal fear of floods.

apeirophobia

an abnormal fear of infinity.

aphephobia

an abnormal fear of touching or being touched. Also called haphephobia, haptephobia, thixophobia .

apiphobia, apiophobia

an intense fear of bees. Also called melissophobia .

arachnephobia

an abnormal fear of spiders.

asthenophobia

an abnormal fear of weakness.

astraphobia, astrapophobia

an abnormal fear of lightning. Cf. brontophobia, keraunophobia.

astrophobia

siderophobia.

ataxiophobia, ataxophobia

an abnormal fear of disorder.

atelophobia

an abnormal fear of imperfection.

atephobia

an abnormal fear of ruin.

aulophobia

an abnormal fear of flutes.

aurophobia

an abnormal dislike of gold.

automysophobia

an abnormal fear or dislike of being dirty. Cf. misophobia .

autophobia, autophoby

an abnormal fear of being by oneself. Also called eremiophobia, eremophobia, monophobia .

bacillophobia

an abnormal fear of germs. Also called bacteriophobia .

ballistophobia

an abnormal fear of missiles.

barophobia

an abnormal fear of gravity.

basophobia, basiphobia

in plants, an inability to accommodate to alkaline soils.

bathmophobia

an abnormal dislike or fear of walking.

bathophobia

1. an abnormal fear of depth.

2. an intense dislike of bathing.

batophobia

1. acrophobia.

2. an abnormal fear of passing high buildings.

batrachophobia

an abnormal fear of frogs and toads.

belonephobia

an abnormal fear of pins and needles.

bibliophobia

an abnormal dislike for books.

blennophobia

an abnormal fear or dislike of slime. Also called myxophobia .

bogyphobia

a dread of demons and goblins.

bromidrosiphobia

an abnormal fear of having an unpleasant body odor.

brontophobia

an abnormal fear of thunder and thunderstorms. Also called tonitrophobia . Cf. astraphobia, keraunophobia .

cainophobia

an abnormal fear or dislike of novelty. Also called cainotophobia, neophobia .

carcinomophobia, carcinomatophobia, carcinophobia

an abnormal fear of cancer. Also called cancerophobia .

cardiophobia

an abnormal fear of heart disease.

cathisophobia

an abnormal fear or dislike of sitting down.

catoptrophobia

an abnormal fear of mirrors.

Celtophobia

an intense dislike of Celts.

cenophobia, kenophobia

an abnormal fear of a void or of open spaces.

ceraunophobia

keraunophobia.

chaetophobia

an abnormal fear of hair.

cheimaphobia, cheimatophobia

an abnormal fear or dislike of cold. Cf. cryophobia, psychrophobia .

cherophobia

an abnormal fear of gaiety.

chinophobia

an abnormal fear or dislike of snow.

cholerophobia

an intense fear of cholera.

chrematophobia

an intense fear or dislike of wealth.

chrometophobia

an abnormal fear or dislike of money.

chromophobia

an abnormal fear of colors.

chronophobia

an abnormal discomfort concerning time.

cibophobia

an abnormal fear of food. Also called sitophobia, sitiophobia . Cf. phagophobia .

claustrophobia

an abnormal fear of enclosed spaces. Also called cleistophobia .

cleptophobia

kleptophobia.

clinophobia

an abnormal fear or dislike of going to bed.

coitophobia

an abnormal fear of sexual intercourse. Also called genophobia . Cf. erotophobia .

cometophobia

an abnormal fear of cornets.

computerphobia

intense fear or dislike for computers and things associated with them.

coprophobia

an abnormal fear of excrement.

cremnophobia

an abnormal fear of precipices.

cryophobia

an abnormal fear of ice or f rost. Cf. cheimaphobia .

crystallophobia

an abnormal fear of glass. Also called hyalophobia .

cymophobia

an abnormal fear of waves.

cynophobia

1. an intense dread of dogs.

2. kynophobia.

cypridophobia

an abnormal fear of venereal disease. Also called venereophobia .

deipnophobia

an abnormal fear or dislike of dining and dinner conversation.

demonophobia

an abnormal fear of spirits.

demophobia

an intense dislike of crowds. Cf. agoraphobia .

dermatophobia

an abnormal fear of skin disease. Also called dermatosiophobia, dermatopathophobia .

dextrophobia

an abnormal fear of objects on the right side of the body. Cf. levophobia .

diabetophobia

an intense fear of diabetes.

dikephobia

an abnormal fear or dislike of justice.

dinophobia

an abnormal fear of whirlpools.

diplopiaphobia

an abnormal fear of double vision.

domatophobia

an abnormal fear of being in a house.

doraphobia

an abnormal fear or dislike of fur.

dromophobia

1. agyrophobia.

2. kinetophobia.

dysmorphophobia

an abnormal dread of deformity, usually in others. Also called dysmorphomania .

ecclesiophobia

an abnormal fear or dislike of church.

ecophobia, oecophobia, oikophobia

an abnormal fear of or aversion to home surroundings.

eisoptrophobia

an abnormal fear of mirrors.

eleutherophobia

an abnormal fear of freedom.

elurophobia

ailurophobia.

emetophobia

an abnormal fear of vomiting.

enetophobia

an abnormal fear of needles.

entomophobia

an abnormal fear of insects.

eosophobia

an abnormal fear of the dawn.

eremiophobia, eremophobia

autophobia.

ergasiophobia

an abnormal fear or dislike of work.

ergophobia

a hatred of work.

erotophobia

an abnormal fear of sexual feelings and their physical expression. Also called miserotica . Cf. coitophobia .

erythrophobia

1. an abnormal fear of the color red.

2. an abnormal fear of blushing.

eurotophobia

an abnormal fear of female genitals.

febriphobia

an abnormal fear of fever.

felinophobia

ailurophobia.

Francophobia, Callophobia

a hatred of France or things French.

galeophobia

an abnormal fear of sharks.

Gallophobia

Francophobia.

gamophobia

an abnormal fear or dislike of marriage.

gatophobia

ailurophobia.

genophobia

coitophobia.

gephyrophobia

an abnormal fear of crossing a bridge.

gerascophobia

an abnormal fear of growing old.

Germanophobia

a hatred of Germany, or things German. Also called Teutophobia, Teutonophobia .

geumophobia

an abnormal fear of tastes or flavors. Cf. olfactophobia .

glossophobia

an abnormal fear of speaking in public or of trying to speak.

graphophobia

a dislike of writing.

gringophobia

in Spain or Latin America, an intense dislike of white strangers.

gymnophobia

an abnormal fear of nudity. Also called nudophobia .

gynephobia, gynophobia

an abnormal fear or hatred of women. Cf. androphobia, parthenophobia .

hadephobia

an abnormal fear of heil. Also called stygiophobia .

haemaphobia

hemophobia.

hagiophobia

an intense dislike for saints and the holy.

hamartophobia

an abnormal fear of error or sin.

haphephobia, haphophobia, haptephobia, haptophobia

aphephobia. Also called thixophobia .

harpaxophobia

an abnormal fear of robbers. Cf. kleptophobia .

hedonophobia

an abnormal fear of pleasure.

heliophobia

1. an abnormal sensitivity to the effects of sunlight.

2. an abnormal fear of sunlight.

helminthophobia

an abnormal fear of being infested with worms. Cf. scoleciphobia .

hemaphobia, haemaphobia, hemophobia

an abnormal fear of the sight of blood. Also called hematophobia .

herpetophobia

an abnormal fear of reptiles. Cf. ophidiophobia .

hierophobia

an abnormal fear or dislike of sacred objects.

hippophobia

an abnormal fear of horses.

hodophobia

an abnormal fear or dislike of travel.

homichlophobia

an abnormal fear of fog.

homilophobia

a hatred for sermons.

homophobia

fear of or apprehension about homosexuality. Cf. uranophobia .

hyalophobia

crystallophobia.

hydrophobia

1. an abnormal fear of water.

2. the occurrence in humans of rabies. Also called lyssa .

hydrophobophobia

an abnormal fear of rabies. Also called lyssophobia . Cf. kynophobia .

hygrophobia

an abnormal fear of liquids in any form, especially wine and water.

hylephobia

an intense dislike for wood or woods.

hypengyophobia

an abnormal fear of responsibility. Cf. paralipophobia .

hypnophobia

an abnormal fear of sleep.

hypsophobia, hypsiphobia

acrophobia.

iatrophobia

an abnormal fear of going to the doctor.

ichthyophobia

an abnormal fear of fish.

iophobia

an abnormal fear of poisons. Cf. toxiphobia .

isopterophobia

an abnormal fear of termites.

Judophobism, Judophobia

a hatred of Jews and of Jewish culture. Also called Judaeophobia .

kakorrhaphiophobia

an abnormal fear of failure or defeat.

katagelophobia

an abnormal fear or dislike of ridicule.

keraunophobia, ceraunophobia

an abnormal fear of thunder and lightning. Cf. astraphobia, brontophobia .

kinetophobia

an abnormal fear or dislike of motion. Also called dromophobia .

kleptophobia, cleptophobia

an abnormal fear of thieves or of loss through thievery. Cf. harpaxophobia .

kopophobia

an abnormal fear of mental or physical examination.

kynophobia, cynophobia

an abnormal fear of pseudorabies. Cf. hydrophobophobia .

laliophobia, lalophobia

an abnormal fear of talking.

lepraphobia

an abnormal fear of leprosy.

levophobia

an abnormal fear of objects on the left side of the body. Cf. dextrophobia .

Iimnophobia

an abnormal fear of lakes.

linonophobia

an abnormal fear of string.

logophobia

an abnormal fear or dislike of words.

lyssophobia

1. an abnormal fear of becoming insane.

2. hydrophobophobia.

maieusiophobia

tocophobia.

maniaphobia

an abnormal fear of madness.

mastigophobia

rhabdophobia.

mechanophobia

an abnormal aversion to or fear of machinery.

melissophobia

apiphobia.

meningitophobia

an abnormal fear of meningitis.

merinthophobia

an abnormal fear of being bound.

metallophobia

an abnormal fear of metals.

meteorophobia

an abnormal fear of meteors or meteorites.

misophobia, musophobia, mysophobia

an abnormal fear of dirt, especially of being contaminated by dirt. Cf. automysophobia, rhypophobia .

molysomophobia

an abnormal fear of infection.

monopathophobia

an abnormal fear of sickness in a specified part of the body

monophobia

autophobia.

motorphobia

an abnormal fear or dislike of motor vehicles.

musicophobia

an intense dislike of music.

musophobia

1. an abnormal fear of mice.

2. misophobia.

mysophobia

misophobia.

mythophobia

an abnormal fear of making false statements.

myxophobia

blennophobia.

necrophobia

1. Also called thanatophobia . an abnormal fear of death.

2. an abnormal fear of corpses.

negrophobia

a strong dislike or fear of Negroes.

neophobia

cainophobia.

nephophobia

an abnormal fear of clouds.

noctiphobia

an abnormal fear of the night. Cf. nyctophobia .

nosophobia

an abnormal fear of contracting disease.

nudophobia, nudiphobia

gymnophobia.

nyctophobia

an abnormal fear of darkness or night. Cf. noctiphobia .

ochlophobia

an abnormal fear of crowds.

ochophobia

an abnormal fear of vehicles.

odontophobia

an abnormal fear of teeth, especially those of animals.

odynophobia

an abnormal fear of pain. Cf. algophobia .

oenophobia, oinophobia

a dislike of or hatred for wine.

olfactophobia

an abnormal fear or dislike of smells. Also called osmophobia, osphresiophobia . Cf. geumophobia .

ombrophobia

an abnormal fear of rain.

ommatophobia

an abnormal fear of eyes.

onomatophobia

an abnormal fear of a certain name.

ophidiophobia

an abnormal fear of snakes. Also called ophiophobia . Cf. herpetophobia .

ornithophobia

an abnormal fear of birds.

osmophobia

olfactophobia.

osphresiophobia

olfactophobia.

ouranophobia

uranophobia.

paedophobia

pedophobia.

panophobia

1. a nonspecific fear; a state of general anxiety.

2. an abnormal fear of everything. Also panphobia, pantaphobia, pantophobia .

papaphobia

an intense fear or dislike of the pope or the papacy.

paralipophobia

an abnormal fear of neglect of some duty. Cf. hypengyophobia .

paraphobia

an abnormal fear of sexual perversion.

parasitophobia

an abnormal fear of parasites.

parthenophobia

an extreme aversion to young girls. Cf. gynephobia .

pathophobia

an abnormal fear of disease.

peccatiphobia, peccatophobia

an abnormal fear of sinning.

pediculophobia

an abnormal fear of lice. Also called phthiriophobia .

pedophobia, paedophobia

an abnormal fear or dislike of dolls.

pellagraphobia

an abnormal fear of catching pellagra.

peniaphobia

an abnormal fear of poverty.

phagophobia

an abnormal fear of eating. Cf. cibophobia .

pharmacophobia

an abnormal fear of drugs.

phasmophobia

an abnormal fear of ghosts. Cf. pneumatophobia, spectrophobia .

phengophobia

an abnormal fear of daylight.

philosophobia

an abnormal fear or dislike of philosophy or philosophers.

phobophobia

an abnormal fear of fear itself.

phonophobia

an abnormal fear or dislike of noise.

photalgiophobia

an abnormal fear of photalgia, pain in the eyes caused by light.

photophobia

1. an abnormal fear of light.

2. a painful sensitivity to light, especially visually. Also called photodysphoria .

3. a tendency to thrive in reduced light, as exhibited by certain plants.

phronemophobia

an abnormal fear of thinking.

phthiriophobia

pediculophobia.

phthisiophobia

an abnormal fear of tuberculosis. Also called tuberculophobia .

pneumatophobia

an abnormal fear of incorporeal beings. Cf. phasmophobia, spectrophobia .

pnigophobia

an abnormal fear of choking.

pogonophobia

an abnormal fear or dislike of beards.

poinephobia

an abnormal fear of punishment.

politicophobia

a dislike or fear of politicians.

polyphobia

an abnormal fear of many things. Cf. panophobia, def. 2.

ponophobia

an abnormal fear of fatigue, especially through overworking.

potamophobia

a morbid fear of rivers.

proctophobia

Medicine. a mental apprehension in patients with a rectal disease.

proteinphobia

a strong aversion to protein foods.

psychophobia

an abnormal fear of the mind.

psychrophobia

an abnormal fear of the cold. Cf. cheimaphobia .

pteronophobia

an abnormal fear of feathers.

pyrexiophobia

an abnormal fear of fever. Cf. thermophobia .

pyrophobia

an abnormal fear of fire.

rhabdophobia

1. an abnormal fear of being beaten.

2. an abnormal fear of magic.

rhypophobia

an abnormal fear of filth. Cf. misophobia .

Russophobism, Russophobia

an excessive fear or dislike of Russians and things Russian.

Satanophobia

an excessive fear of Satan.

scabiophobia

an abnormal fear of scabies.

scatophobia

1. coprophobia.

2. an abnormal dread of using obscene language.

sciophobia

an abnormal fear of shadows.

scoleciphobia

an abnormal fear of worms. Also called vermiphobia . Cf. helminthophobia .

scopophobia

an abnormal fear of being looked at. Also scoptophobia .

scotophobia

an abnormal fear of the dark. Also called achluophobia .

selaphobia

an abnormal fear or dislike of flashes of light.

siderodromophobia

an abnormal fear or dislike of railroads or of traveling on trains.

siderophobia

an abnormal fear of the stars. Also called astrophobia .

sitophobia, sitiophobia .

cibophobia.

Slavophobia

fear or hatred of things Slavic, especially of their real or imagined political influence.

spectrophobia

an abnormal fear of specters or phantoms. Cf. phasmophobia, pneumatophobia .

stasibasiphobia

1. an abnormal conviction that one cannot stand or walk.

2. an abnormal fear of attempting to do either.

stygiophobia

hadephobia.

symmetrophobia

an abnormal fear or dislike of symmetry.

syphiliphobia, syphilophobia

an abnormal fear of becoming infected with syphilis. Cf. cypridophobia .

tabophobia

an abnormal fear of a wasting sickness.

tachophobia

an abnormal fear of speed.

taphephobia, taphiphobia, taphophobia

an abnormal fear of being buried alive.

tapinophobia

an abnormal fear of small things.

taurophobia

an abnormal fear of bulls.

teleophobia

a dislike and rejection of teleology.

telephonophobia

an abnormal fear of using the telephone.

teratophobia

an abnormal fear of monsters or of giving birth to a monster.

Teutophobia, Teutonophobia

Germanophobia.

thaasophobia

an abnormal fear or dislike of being idle.

thalassophobia

an abnormal fear of the sea.

thanatophobia

necrophobia, def. 1.

theatrophobia

an abnormal fear of theaters.

theophobia

an abnormal fear of God.

thermophobia

an abnormal fear or dislike of heat. Cf. pyrexiophobia .

thixophobia

aphephobia.

tocophobia, tokophobia

an abnormal fear of childbirth. Also called maieusiophobia .

tomophobia

an abnormal fear of surgical operations.

tonitrophobia, tonitruphobia

brontophobia.

topophobia

Rare. an abnormal fear of certain places.

toxiphobia, toxicophobia

an abnormal fear of being poisoned. Cf. iophobia .

traumatophobia

an excessive or disabling fear of war or physical injury.

tremophobia

an abnormal fear of trembling.

trichinophobia

an abnormal fear of trichinosis. Also called trichophobia, trichopathophobia .

tridecaphobia

triskaidekaphobia.

triskaidekaphobia

an abnormal fear of the number 13. Also called tridecaphobia .

trypanophobia

vaccinophobia.

tuberculophobia

phthisiophobia.

tyrannophobia

an intense fear or hatred of tyrants.

uranophobia

1. an abnormal fear of homosexuals and homosexuality. Also homophobia.

2. an abnormal fear of the heavens. Also called ouranophobia .

urophobia

an abnormal fear of passing urine.

vaccinophobia

an abnormal fear of vaccines and vaccination. Also called trypanophobia .

venereophobia

cypridophobia.

vermiphobia

scoleciphobia.

xenophobia

an abnormal fear or hatred of foreigners and strange things.

xerophobia

an abnormal fear of dryness and dry places, like deserts.

zelophobia

an abnormal fear of jealousy.

zoophobia

an abnormal fear or dislike of animals.

Phobias

Freud and psychoanalysis

Some individual phobias

BIBLIOGRAPHY

A phobia is an irrational, persistent fear of a particular object or place, class of objects or places, etc. Used as a noun or combining form, phobia denotes fear or dread, and in medicine and psychiatry it is joined either with names of objects, situations, etc., or with Greek-derived forms of such names; thus, street phobia, or agoraphobia (from the Greek agora, or “market place”). As a symptom complex the phobia also includes any avoidances and inhibitions employed to forestall impending attacks of anxiety. Thus, an agoraphobic person may be unable to leave his home without incurring anxiety and may therefore remain in it constantly. A person with rat phobia may stop his ears when rats are mentioned in conversation. The phobic person may elaborate and form compromises to keep the dreaded object, or the idea of it or allusion to it, at a distance (e.g., by restricting his activities, putting general or special taboos on certain localities, etc.).

Whether a state of mind is to be considered rational or irrational eventually depends on commonsense judgment. This judgment is usually that of the phobic person himself, who knows that the feared object is harmless or in any case should not provoke such intense, unmasterable anxiety. Often ashamed or aware of the absurdity, the phobic patient may nevertheless try to rationalize that there is a possibility of “danger.” Accessory circumstances often determine whether a given fear is rational or not, but judging the degree of rationality is still ultimately a matter of common sense.

In early childhood the matter of rationality is irrelevant. The fears of small children are rarely rational according to adult standards. Children’s insecurity and fear of strangers are neither rational nor irrational. Animal phobias of small children resemble in many ways the fears of certain savages, with whom they share a “totemistic” attitude, the differentiation between man and other animals not being well established. Gradual development of the sense of reality through experience and education leads to such differentiation.

History and semantics. Modern interest and ideas about the phobias began with an article by Westphal, “Die Agoraphobie” (1871). The term agoraphobia was invented in this case to denote a morbid fear of open places and is usually extended to mean a fear of streets or the outdoors generally. The German words used were Platzangst and Platzfurcht, which retain the idea of an open square. To one of Westphal’s three patients, a certain square in Berlin looked as if it were miles wide. The patient complained that any attempt to cross the square or to walk on certain streets brought on a severe attack of anxiety accompanied by trembling, head sensations, palpitation, etc. The presence of a companion prevented or assuaged the anxiety and enabled the patient to skirt the square with somewhat lessened fear. He did not fear traffic; indeed, he felt no anxiety if he could stay near a carriage while crossing. To see houses with windows was also reassuring, but to walk along windowless walls, like those of certain barracks, would bring on an anxiety attack, and he could not go into the Tiergarten, where there were no houses. Absence of human beings or signs of life, an empty street or park, was more dangerous than traffic.

Phobeio, the Greek word from which phobia is derived, means “I fear,” but in earliest times it meant both “I am afraid” and “I am put to flight”; for Homeric Greeks, emotion and tendency to action were “close together” (Onians 1951, p. 19). Greek words can be readily used in compounds, and phobo- and -phobia were used as combining forms. Hence, -phobia easily became one of a large class of suffixes (including -mania, -philia, -pathy, etc.) that were adopted by medical and psychological writers. Thus we have hydrophobia, fear of water, at one time also called phobodipsia, fear of drinking; photophobia, fear and avoidance of light, a medical but not necessarily a psychiatric term; xenophobia, fear and avoidance of strangers or foreigners. An obsolete term of this sort is panophobia, the night terror of infants. (See Sauvages 1763.)

Name inventing has periodically flourished and waned in science and medicine. In the late eighteenth and early nineteenth centuries, partly in emulation of Linnaeus, imaginative nomenclature was in vogue. Psychiatrists participated heartily in wordbuilding, particularly after Esquirol’s adventures with the suffix -mania (1838). They made such wide use of the suffix -phobia that Benjamin Rush (1825) jocularly suggested the name rum phobia for what he opined must be “a very rare distemper.” He also facetiously suggested doctor phobia and church phobia (cited in Menninger et al. 1963). Such near-slang usage emphasizes the avoidance aspect and ignores any anxiety. It has been resuscitated in current psychiatric writings in such terms as school phobia, job phobia, and the like, where the anxiety may not be of the conscious phobic type at all.

The modern popularity of the word and suffix began with Westphal’s coining of agoraphobia. The new term was widely accepted, and many analogous terms were invented (see Janet & Raymond 1903). For several decades after Westphal many types of phobias were described and named. Some names are still in use, some are obsolete, and others are met with only occasionally. Claustrophobia still refers to the morbid fear of entering or staying in closed spaces, and ereuthophobia is a word generally understood to mean a fear of blushing. Aelurophobia and gephyrophobia are rather rare and are ordinarily superseded by cat phobia and bridge phobia, respectively. Zoophobia, or animal phobia, is inclusive, applying to dogs, cats, birds, etc. Besides the newly described phobias, others were retrieved from earlier literature and given new names. By 1914, G. Stanley Hall could list 136 words ending in -phobia; many of these were never subjects of clinical description but were apparently purely philological virtuoso inventions. The history of this period and pertinent references are to be found in Krafft-Ebing (1895), Janet (see in Janet & Raymond 1903), and Loewenfeld (1904).

The study of the phobias and other neuroses went well beyond philology. Obsessions and compulsions were described by Westphal (1877), and many studies dealt with nervousness, neurasthenia, and anxiety states other than phobias, such as hysteria and hypochondria. This work culminated in a general conception of the neuroses, or psychoneuroses, a group of conditions with all sorts of nonpsychotic psychological symptoms not attributable to recognizable pathological changes in the body. [SeeObsessive–compulsive disorders.]

Classification. The general tendency was to group phobias along with obsessions and compulsions under one heading, on the grounds that they were “compulsive emotions” (Zwangsaffekte). Even today German textbooks usually put quotation marks around the word phobia or refer to die sogenannten Phobien—the so-called phobias (Bumke 1924; Bleuler 1916). French writers, following Janet (see in Janet & Raymond 1903), group phobias with other anxiety states, compulsions, and obsessions under the general rubric psychasthenia. Such classification has some point, at least superficially, for many adults troubled by obsessions and compulsions also may have one or more phobias. However, there are certain cases, adult and infantile, in which there are phobias but no obsessional symptoms. Moreover, Stekel (1908), psychoanalyzing phobic patients of the “pure” type, found that they resembled the conversion hysterics he had treated, differing only in that where the phobic patient suffered an anxiety attack, the classical hysterical patient would manifest a conversion symptom. For this nearly pure type of case Freud suggested to Stekel the designation anxiety hysteria and justified this term in a paper on a childhood phobia (1909). As psychoanalytic conceptions of anxiety developed, and particularly as analysis of phobias in small children progressed, it became evident that phobias might or might not be found in obsessional persons and that they were to be found in patients of all types. Freud’s final theory of anxiety (1926), which interpreted phobias in a novel and original way, lessened the interest in classification.

Although in a general way earlier authors recognized psychological influences as precipitating and predispositional factors, they did not distinguish the phobia from other neurotic disorders in regard to etiology. From the mid-nineteenth century through the beginning of the twentieth, all neuroses were supposed to arise from constitutional weakness or deficiency (“degeneration” in some authors’ terminology) and essentially from a subtle hereditary or inherent defect of the nervous system. Except for Freud and those who accepted his views phobias were, in short, stigmata of the degénérés supérieurs or of psychasthenia.

Freud and psychoanalysis

Freud’s early papers on anxiety and the neuroses contained incidental discussion of certain phobias (1894; 1895a; 1895b), but he first clearly expressed his thoughts on this matter in the case history of “little Hans” (1909; see also Strachey 1962). There he recognized a class of phobias of psychic origin, resembling in many ways the agoraphobia previously described; he gave them the name anxiety hysteria. Phobias were conceived not as illnesses, nor yet precisely as signs of an illness, but as a set of findings: anxiety plus certain special avoidances and inhibitions. In such cases, as time goes on, overt anxiety decreases pari passu as restrictive measures increase. An anxiety state becomes more and more of a phobia.

Infantile zoophobias

Freud characteristically looked to the phobias of children for a situation that would furnish a clue, uncomplicated by later elaborations, to their essential meaning, much as he had found simple, direct wish fulfillments in children’s dreams that threw light on the complicated and distorted wish-fulfilling dreams of adults. The childhood zoophobias did indeed provide a relatively simple picture of the elements in the formation of phobias and ultimately of psychogenic symptoms in general. The two cases best studied and most cited are the horse phobia of “little Hans” (Freud 1909) and the wolf phobia of the young Russian referred to as “the wolf-man” (1918). In later discussions of anxiety, anxiety hysteria, and symptom formation Freud constantly used the material of these cases to illustrate and develop his theories (see 1915a; 1915b; 1926).

In The Problem of Anxiety (1926) Freud explained Hans’s phobia as originating in oedipal wishes. Hans was in love with his mother and was jealous of his father, toward whom he harbored hostile wishes; these wishes came into conflict with his love for his father. The aggression led to a fear of castration, the possibility of which he believed to be a reality. Repressing his love for his mother and his hostility toward his father from consciousness, he displaced his aggression and consequent fear from his father to horses, which he feared would bite off his penis. Thus, to form his phobic symptom, after his repression of the original impulses, Hans used three defense mechanisms: displacement, reversal, for actually his feelings were dangerous to his father rather than the other way round, and regression from the genital idea of castration to the oral idea of being bitten.

The wolf-man’s phobia arose from a different component of the Oedipus complex, from an inverted oedipal wish. Having observed parental coitus, he identified himself with his apparently castrated mother and feared castration if he permitted himself feminine longings for his father. His fear of castration was displaced to the picture of a wolf in a storybook. The fear that came to consciousness when he ran the risk of seeing the picture was of being devoured—an oral equivalent of the desired passive genital satisfaction. Memories recovered during his analysis established the connection between the wolf and the idea of castration. Avoidance here took the convenient form of not looking at the wolfs picture.

From these and other cases of childhood zoophobia Freud asserted that the motive for repression was castration anxiety and that the repressed wishes were the erotic or aggressive components of the Oedipus complex, whether normal or inverted. Repression was then followed by an appropriate displacement, determined by individual experience. Other infantile phobias are based on other types of anxiety, particularly on a fear of losing love, which serve as motives for repression.

Because of a child’s limited experience, the choice of animals is not large. The Angsttier (“dreaded animal”) is apt to be a horse, cow, dog, cat, bird, chicken, beetle, or wasp.

Totemism and zoophobia

The study of the zoophobias showed that a child could displace his feelings about his father to an animal and that this displacement reflected ambivalence. Hans not only feared horses but admired them, and at one point in his therapy he began to jump around like a horse and even bit his father (Freud 1909). His ambivalent attitude and his identification with the animal gave Freud one argument for interpreting the totem animals of primitive peoples as substitutes for the father, and he spoke of the “return of totemism in childhood” (1913, chapter 4).

Mechanisms in the phobia

The defense mechanism of displacement, by which the repressed wishes return to consciousness in disguise, is basic for all phobias, including those of adults. Avoidance behavior or restriction of function follows upon this. In adult phobias, too, the wishes are aggressive or erotic—largely the latter; they are the revived wishes of childhood, usually in new garb. Freud compared the content of the phobia to the manifest façade of the dream (1916–1917), implying that many defense mechanisms may alter the original content and give a conscious picture different from the unconscious latent fantasy. Thus regression modified the wolf-man’s fantasy of being castrated into a conscious fear of being devoured. This further altered the picture, in which the father had already been changed to a wolf by displacement. The displacement mechanism is fundamental, since it is the first and invariable means used by the ego in distorting material that comes back from repression. Other defense mechanisms, such as regression, reversal, and identification, are accessory or secondary in altering the content of the manifest phobic picture. Additional defense mechanisms are described by Sigmund Freud (1926) and some relevant to children by Anna Freud (1936). In the more complicated adult phobias several instinctual wishes may gain expression at the same time through the same content, as a dream may fulfill several wishes at the same time through what is called overdetermination (see Deutsch 1929; Weiss 1935; Fenichel 1944; Lewin 1952).

From the study of the simple phobias Freud constructed a paradigm for the formation of neurotic symptoms in general: threatened eruption of an instinct from repression (or from the id); anxiety or threatened anxiety as the signal of such impending danger; subsequent alterations in the ego by means of defense mechanisms that produce symptoms, each type of which (conversion, phobia, obsession, etc.) appears because of the predominance of one (or a few) defense mechanisms. Thus, the meaning of the word symptom is completely altered. No longer an indication of some underlying illness, it is considered a “structure” composed of alterations in ego functioning due to the mutual interaction of id, ego, and superego.

Some individual phobias

Like the dream, the phobia may show much variation in regard to its manifest façade. However, as certain frequent types of dreams have a nearly standard interpretation, so certain phobias, studied through psychoanalysis, show a relative constancy in unconscious meaning. For example, many wellstudied cases of agoraphobia show that the feared streets are unconsciously conceived as places suitable for sexual adventures (see Deutsch 1929; Katan 1937; Miller 1953; Weiss 1935). The companion chosen as protector by some agoraphobes represents a person to whom they are unconsciously hostile and whom they therefore put in the same jeopardy as themselves. Fear of crossing bridges is a feminine fear of childbirth. A fear of falling, on the street or elsewhere, is also feminine, one of its meanings referring to the figurative sexual fall. Claustrophobic anxiety is connected with unconscious ideas of being buried alive and with prenatal life (Lewin 1935). Generally speaking, these unconscious fantasies are either of temptation or punishment. Fear of being alone often indicates a temptation to masturbate under such circumstances. Fears of insanity may include this temptation, as well as a fear of symbolic castration (head equals penis). Fears of dirt refer to sexuality thus conceived. Animal fears have been discussed above. An interesting phobia is the fear of spiders, representing the devouring and dangerous female genitalia. Butterflies may represent beautiful and tempting women; beetles and crawling insects may represent genitalia of small children. This list could be extended greatly; but many other interpretations depend on the individual prephobic history, which determines the relative importance of the fantasy and the suitability of the object chosen for its representation.

Bertram D. Lewin

[For a conception of phobias that contrasts with the one in this article, seeMental disorders, treatment of, article onbehavior therapy; see alsoAnxietyandEmotion. Other relevant material may be found inDefense mechanisms; Hysteria; Mental disorders, article onChildhood mental disorders; and in the biography ofFreud.]

BIBLIOGRAPHY

Abraham, Karl (1922) 1953 The Spider as a Dream Symbol Pages 326–332 in Karl Abraham, Selected Papers. Volume 1: Selected Papers on Psychoanalysis. New York: Basic Books. → First published as “Die Spinne als Traumsymbol.”

Benedek, Therese 1925 Notes From the Analysis of a Case of Ereuthophobia. International Journal of Psycho-analysis 6:430–439.

Bleuler, Eugen (1916) 1951 Textbook of Psychiatry. Authorized English edition by A. A. Brill, with a biographical sketch by Jacob Shatsky. New York: Dover. → First published as Lehrbuch der Psychiatric

Bornstein, Berta (1931) 1935 Phobia in a Two-and-a-half-year-old Child. Psychoanalytic Quarterly 4:93 119. → First published in German.

Bornstein, Berta 1949 The Analysis of a Phobic Child: Some Problems of Theory and Technique in Child Analysis. Psychoanalytic Study of the Child 3/4:181–226.

Bumke, Oswald (1924) 1948 Lehrbuch der Geisteskrankheiten. 7th ed. Berlin: Springer.

Deutsch, Helene 1929 The Genesis of Agoraphobia. International Journal of Psycho-analysis 10:51–69.

Deutsch, Helene (1930) 1932 Psychoanalysis of the Neuroses. London: Hogarth. → First published in German. See especially Chapter 6, “Anxiety States”; Chapter 7, “A Case of Hen Phobia”; and Chapter 8, “Agoraphobia.”

Esquirol, Jean E. D. (1838) 1845 Mental Maladies: A Treatise on Insanity. Philadelphia: Lea & Blanchard. → First published in French.

Fenichel, Otto (1932) 1934 Outline of Clinical Psychoanalysis. New York: Norton. → First published as Spezielle psychoanalytische Neurosenlehre. See especially Chapter 2.

Fenichel, Otto 1944 Remarks on the Common Phobias. Psychoanalytic Quarterly 13:313–326.

Fenichel, Otto 1945 The Psychoanalytic Theory of Neurosis. New York: Norton. → See especially “Anxiety as Neurotic Symptom: Anxiety Hysteria,” pages 193–215.

Ferenczi, SÁndor (1913) 1952 A Little Chanticleer. London: Hogarth. → First published as “Ein kleiner Hahnemann.”

Freud, Anna (1936) 1957 The Ego and the Mechanisms of Defense. New York: International Universities Press. → First published as Das Ich und die Abwehrmechanismen.

Freud, Sigmund (1894) 1962 The Neuro-psychoses of Defense. Volume 3, pages 43–61 in Sigmund Freud, The Standard Edition of the Complete Psychological Works of Sigmund Freud. London: Hogarth; New York: Macmillan. → First published as “Die AbwehrNeuropsychosen.”

Freud, Sigmund (1895a) 1962 On the Grounds for Detaching a Particular Syndrome From Neurasthenia Under the Description “Anxiety Neurosis.” Volume 3, pages 87–139 in Sigmund Freud, The Standard Edition of the Complete Psychological Works of Sigmund Freud. London: Hogarth; New York: Macmillan. → First published as “Über die Berechtigung von der Neurasthenie einen bestimmten Symptomen-Komplex als ‘Angstneurose’ abzutrennen.”

Freud, Sigmund (1895b) 1962 Obsessions and Phobias: Their Physical Mechanism and Their Aetiology. Volume 3, pages 71–81 in Sigmund Freud, The Standard Edition of the Complete Psychological Works of Sigmund Freud. London: Hogarth; New York: Macmillan. → First published in French.

Freud, Sigmund (1909) 1955 Analysis of a Phobia in a Five-year-old Boy. Volume 10, pages 3–149 in Sigmund Freud, The Standard Edition of the CompletePsychological Works of Sigmund Freud. London: Hogarth; New York: Macmillan.

Freud, Sigmund (1913) 1955 Totem and Taboo. Volume 13, pages ix-162 in Sigmund Freud, The Standard Edition of the Complete Psychological Works of Sigmund Freud. London: Hogarth; New York: Macmillan.

Freud, Sigmund (1915a) 1957 Repression. Volume 14, pages 143–158 in Sigmund Freud, The Standard Edition of the Complete Psychological Works of Sigmund Freud. London: Hogarth; New York: Macmillan.

Freud, Sigmund (1915b) 1957 The Unconscious. Volume 14, pages 161–204 in Sigmund Freud, The Standard Edition of the Complete Psychological Works of Sigmund Freud. London: Hogarth; New York: Macmillan.

Freud, Sigmund (1916–1917) 1952 A General Introduction to Psychoanalysis. Authorized English translation of the rev. ed. by Joan Riviere. Garden City, N.Y.: Doubleday. → First published as Vorlesungen zur Einfiihrung in die Psychoanalyse.

Freud, Sigmund (1918) 1955 From the History of an Infantile Neurosis. Volume 17, pages 3–122 in Sigmund Freud, The Standard Edition of the Complete Psychological Works of Sigmund Freud. London: Hogarth; New York: Macmillan.

Freud, Sigmund (1926) 1936 The Problem of Anxiety. New York: Norton. → First published as Hemmung, Symptom und Angst. A British edition was published by Hogarth in 1936 under the title Inhibitions, Symptoms and Anxiety.

Friedman, Paul 1952 The Bridge: A Study in Symbolism. Psychoanalytic Quarterly 21:49–80.

Hall, G. Stanley 1914 A Synthetic Genetic Study of Fear American Journal of Psychology 25:149–200, 321–392.

Janet, Pierre; and Raymond, Fulgence (1903) 1919 Les obsessions et la psychasthénie. 3d ed. 2 vols. Paris: Alcan. → Pierre Janet was the sole author of Volume 1.

Katan, Anny A. (1937) 1951 The Role of “Displacement” in Agoraphobia. International Journal of Psychoanalysis 32:41–50.

Kraepelin, Emil (1883) 1909–1915 Psychiatrie. 8th ed., rev. 4 vols. Leipzig: Barth. → See especially Volume 4, Part 3.

Krafft-Ebing, Richard Von 1895 Nervosität und neurasthenische Zustande. Volume 12, part 2 in H. Nothnagel (editor), Specielle Pathologie und Therapie. Vienna: Hölder.

Lewin, Bertram D. 1935 Claustrophobia. Psychoanalytic Quarterly 4:227–233.

Lewin, Bertram D. 1952 Phobic Symptoms and Dream Interpretation Psychoanalytic Quarterly 21:295–322.

Loewenfeld, Leopold 1904 Die psychischen Zwangserscheinungen. Wiesbaden (Germany): Bergmann. → See especially pages 330–355.

Menninger, Karl; Mayman, Martin; and Pruyser, Paul 1963 The Vital Balance: The Life Processes in Mental Health and Illness. New York: Viking. → See especially page 444.

Miller, Milton L. 1953 On Street Fear. International Journal of Psycho-analysis 34:232–240.

Onians, Richard B. 1951 The Origins of European Thought. Cambridge Univ. Press.

Rush, Benjamin 1825 Medical Inquiries and Observations Upon the Diseases of the Mind. Philadelphia: Grigg.

Sauvages De La Croix, Francois Boissier De (1763) 1768 Nosologia methodica sistens morborum classes juxtd sydenhami mentem & botanicorum ordinem. 2 vols. Amsterdam: Tournes.

Stekel, Wilhelm (1908) 1923 Conditions of Nervous Anxiety and Their Treatment. London: Routledge. → First published in German. See especially Part 2, pages 163–376.

Sterba, Editha (1933) 1935 Excerpt From the Analysis of a Dog Phobia. Psychoanalytic Quarterly 4:135160. → First published in German.

Strachey, James 1962 Appendix [to Freud’s “Obsessions and Phobias”]. Volume 3, pages 83–84 in Sigmund Freud, The Standard Edition of the Complete Psychological Works of Sigmund Freud. London: Hogarth; New York: Macmillan.

Weiss, Edoardo 1935 Agoraphobia and Its Relation to Hysterical Attacks. International Journal of Psychoanalysis 16:59–83.

Weiss, Edoardo 1936 Agorafobia: Isterismo d’angoscia. Rome: Cremonese.

Westphal, Carl F. O. 1871 Die Agoraphobie: Eine neuropathische Erscheinung. Archiv fur Psychiatrie 3:138–161.

Westphal, Carl F. O. 1877 Über Zwangsvorstellungen. Berliner klinische Wochenschrift 46:669; 47:687.

Wulff, M. W. 1928 A Phobia in a Child of Eighteen Months International Journal of Psycho-analysis 2: 354–359.

Phobias

Definition

A phobia is an intense but unrealistic fear that can interfere with the ability to socialize, work, or go about everyday life, brought on by an object, event or situation.

Description

Just about everyone is afraid of something—an upcoming job interview or being alone outside after dark. But about 18% of all Americans are tormented by irrational fears that interfere with their daily lives. They aren't crazy—they know full well their fears are unreasonable—but they can't control the fear. These people suffer from phobias.

Phobias belong to a large group of mental problems known as anxiety disorders that include obsessive-compulsive disorder (OCD), panic disorder , and post-traumatic stress disorder . Phobias themselves can be divided into three specific types:

• specific phobias
• social phobia
• agoraphobia

Specific phobias

As its name suggests, a specific phobia is the fear of a particular situation or object, including anything from airplane travel to dentists. Found in one out of every 10 Americans, specific phobias seem to run in families and are roughly twice as likely to appear in women. If the person doesn't often encounter the feared object, the phobia doesn't cause much harm. However, if the feared object or situation is common, it can seriously disrupt everyday life. Common examples of specific phobias, which can begin at any age, include fear of snakes, flying, dogs, escalators, elevators, high places, disease, or open spaces.

Social phobia

People with social phobia have deep fears of being watched or judged by others and being embarrassed in public. This may extend to a general fear of social situations—or be more specific, such as a fear of giving speeches or of performing (stage fright). More rarely, people with social phobia may have trouble using a public restroom, eating in a restaurant, or signing their name in front of others.

Social phobia is not the same as shyness. Shy people may feel uncomfortable with others, but they don't experience severe anxiety, they don't worry excessively about social situations beforehand, and they don't avoid events that make them feel self-conscious. On the other hand, people with social phobia may not be shy—they may feel perfectly comfortable with people except in specific situations. Social phobias may be only mildly irritating, or they may significantly interfere with daily life. It is not unusual for people with social phobia to turn down job offers or avoid relationships because of their fears.

Agoraphobia

Agoraphobia is the intense fear of feeling trapped and having a panic attack in a public place. It usually begins between ages 15 and 35, and affects three times as many women as men—about 3% of the population.

An episode of spontaneous panic is usually the initial trigger for the development of agoraphobia. After an initial panic attack, the person becomes afraid of experiencing a second one. Sufferers literally fear the fear, and worry incessantly about when and where the next attack may occur. As they begin to avoid the places or situations in which the panic attack occurred, their fear generalizes. Eventually the person completely avoids public places. In severe cases, people with agoraphobia can no longer leave their homes for fear of experiencing a panic attack.

Causes & symptoms

Experts don't really know why phobias develop, although research suggests they may arise from a complex interaction between heredity and environment. Some hypersensitive people have unique chemical reactions in the brain that cause them to respond much more strongly to stress . These people also may be especially sensitive to caffeine , which triggers certain brain chemical responses.

Advances in neuroimaging have also led researchers to identify certain parts of the brain and specific neural pathways that are associated with phobias. One part of the brain that is currently being studied is the amygdala, an almond-shaped body of nerve cells involved in normal fear conditioning. Another area of the brain that appears to be linked to phobias is the posterior cerebellum.

While experts believe the tendency to develop phobias runs in families and may be hereditary, a specific stressful event usually triggers the development of a specific phobia or agoraphobia. For example, someone predisposed to develop phobias who experiences severe turbulence during a flight might go on to develop a phobia about flying.

Social phobia typically appears in childhood or adolescence, sometimes following an upsetting or humiliating experience. Certain vulnerable children who have had unpleasant social experiences (such as being rejected) or who have poor social skills may develop social phobias. The condition also may be related to low self-esteem, unassertive personality, and feelings of inferiority.

A person with agoraphobia may have a panic attack at any time for no apparent reason. While the attack may last only a minute or so, the person remembers the feelings of panic so strongly that the possibility of another attack becomes terrifying. For this reason, people with agoraphobia avoid places where they might not be able to escape if a panic attack occurs.

While the specific trigger may differ, the symptoms of different phobias are remarkably similar (e.g., feelings of terror and impending doom, rapid heartbeat and breathing, sweaty palms, and other features of a panic attack). Patients may experience severe anxiety symptoms in anticipating a phobic trigger. For example, someone who is afraid to fly may begin having episodes of pounding heart and sweating palms at the mere thought of getting on a plane in two weeks.

Diagnosis

A mental health professional can diagnose phobias after a detailed interview and discussion of both mental and physical symptoms. Social phobia is often associated with other anxiety disorders, depression , or substance abuse.

Treatment

People who have a specific phobia that is easy to avoid (such as snakes) and that doesn't interfere with their lives may not need to seek treatment. In all types of phobias, symptoms may be eased by lifestyle changes, such as:

• eliminating caffeine
• cutting down on alcohol
• eating a good diet
• getting plenty of exercise
• reducing stress

Meditation and mindfulness training can be beneficial to patients with phobias and panic disorder. Hydrotherapy, massage therapy , and aromatherapy are useful to some anxious patients because they can promote general relaxation of the nervous system. Relaxation training, which is sometimes called anxiety management training, includes breathing exercises and similar techniques intended to help the patient prevent hyperventilation and relieve the muscle tension associated with the fight-or-flight reaction of anxiety. Yoga , aikido, t'ai chi , and dance therapy help patients work with the physical, as well as the emotional, tensions that either promote or are created by anxiety.

Herbs known as adaptogens may be prescribed to treat the anxiety related to phobias. These herbs are thought to promote adaptability to stress, and include Siberian ginseng (Eleutherococcus senticosus ), and ginseng (Panax ginseng ). Adrenal modulators such as licorice (Glycyrrhiza glabra ) and borage (Borago officinalis ), nervine herbs such as chamomile (Chamaemelum nobile ) and skullcap (Scutellaria lateriafolia ), and antioxidal herbs like milk thistle (Silybum marianum ) are also beneficial. Tonics of skullcap and oats (Avena sativa ) may also be recommended to ease anxiety.

Allopathic treatment

When phobias interfere with a person's daily life, a combination of psychotherapy and medication can be quite effective. Medication can block the feelings of panic, and when combined with cognitive-behavioral therapy, can be quite effective in reducing specific phobias and agoraphobia.

Cognitive-behavioral therapy adds a cognitive approach to more traditional behavioral therapy . It teaches patients how to change their thoughts, behavior, and attitudes, while providing techniques to lessen anxiety, such as deep breathing, muscle relaxation, and refocusing.

One cognitive-behavioral therapy is desensitization (also known as exposure therapy), in which people are gradually exposed to the frightening object or event until they become used to it and their physical symptoms decrease. For example, someone who is afraid of snakes might first be shown a photo of a snake. Once the person can look at a photo without anxiety, he might then be shown a video of a snake. Each step is repeated until the symptoms of fear (such as pounding heart and sweating palms) disappear. Eventually, the person might reach the point where he can actually touch a live snake. Three-fourths of patients are significantly improved with this type of treatment.

Another more dramatic cognitive-behavioral approach is called flooding, which exposes the person immediately to the feared object or situation. The person remains in the situation until the anxiety lessens.

Several drugs are used to treat specific phobias by controlling symptoms and helping to prevent panic attacks. These include anti-anxiety drugs (benzodiazepines) such as alprazolam (Xanax) or diazepam (Valium). Blood pressure medications called beta blockers, such as propranolol (Inderal) and atenolol (Tenormin), appear to work well in the treatment of circumscribed social phobia, when anxiety gets in the way of performance, such as public speaking. These drugs reduce overstimulation, thereby controlling the physical symptoms of anxiety.

In addition, some antidepressants may be effective when used together with cognitive-behavioral therapy. These include the monoamine oxidase inhibitors (MAO inhibitors) phenelzine (Nardil) and tranylcypromine (Parnate), as well as selective serotonin reuptake inhibitors (SSRIs) like fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft), and fluvoxamine (Luvox).

A medication that shows promise as a treatment for social phobia is valproic acid (Depakene or Depakote), which is usually prescribed to treat seizures or to prevent migraine headaches. Researchers conducting a twelve-week trial with 17 patients found that about half the patients experienced a significant improvement in their social anxiety symptoms while taking the medication. Further studies are underway.

Treating agoraphobia is more difficult than other phobias because there are often so many fears involved, such as open spaces, traffic, elevators, and escalators. Treatment includes cognitive-behavioral therapy with antidepressants or anti-anxiety drugs. Paxil and Zoloft are used to treat panic disorders with or without agoraphobia.

Expected results

Phobias are among the most treatable mental health problems; depending on the severity of the condition and the type of phobia, most properly treated patients can go on to lead normal lives. Research suggests that once a person overcomes the phobia, the problem may not return for many years—if at all.

Untreated phobias are another matter. Only about 20% of specific phobias will go away without treatment, and agoraphobia will get worse with time if untreated. Social phobias tend to be chronic, and without treatment, will not likely go away. Moreover, untreated phobias can lead to other problems, including depression, alcoholism , and feelings of shame and low self-esteem.

A group of researchers in Boston reported in 2003 that phobic anxiety appears to be a risk factor for Parkinson's disease (PD) in males, although it is not yet known whether phobias cause PD or simply share an underlying biological cause.

While most specific phobias appear in childhood and subsequently fade away, those that remain in adulthood often need to be treated. Unfortunately, most people never get the help they need; only about 25% of people with phobias ever seek help to deal with their condition.

Prevention

There is no known way to prevent the development of phobias. Medication and cognitive-behavioral therapy may help prevent the recurrence of symptoms once they have been diagnosed. Early detection and treatments may decrease severity.

Resources

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision. Washington, DC: American Psychiatric Association, 2000.

Bloomfield, Harold H. Healing Anxiety with Herbs. New York: Harper Collins, 1998.

Peurifoy, Reneau Z. Anxiety, Phobias and Panic: A Step by Step Program for Regaining Control of Your Life. New York: Warner Books, 1996.

"Phobic Disorders. " Section 15, Chapter 187 in The Merck Manual of Diagnosis and Therapy, edited by Mark H. Beers, MD, and Robert Berkow, MD. Whitehouse Station, NJ: Merck Research Laboratories, 2002.

Schneier, Franklin, and Lawrence Welkowitz. The Hidden Face of Shyness: Understanding and Overcoming Social Anxiety. New York: Avon Books, 1996.

Stern, Richard. Mastering Phobias: Cases, Causes and Cures. New York: Penguin USA, 1996.

PERIODICALS

Kinrys, G., M. H. Pollack, N. M. Simon, et al. "Valproic Acid for the Treatment of Social Anxiety Disorder." International Clinical Psychopharmacology 18 (May 2003): 169–172.

Modica, Peter. "Social phobia may run in the family." American Journal of Psychiatry 155 (1998): 90-97.

Ploghaus, A., L. Becerra, C. Borras, and D. Borsook. "Neural Circuitry Underlying Pain Modulation: Expectation, Hypnosis, Placebo." Trends in Cognitive Science 7 (May 2003): 197–200.

Rauch, S. L., L. M. Shin, and C. I. Wright. "Neuroimaging Studies of Amygdala Function in Anxiety Disorders." Annals of the New York Academy of Sciences 985 (April 2003): 389–410.

Weisskopf, M. G., H. Chen, M. A. Schwarzschild, et al. "Prospective Study of Phobic Anxiety and Risk of Parkinson's Disease." Movement Disorders 18 (June 2003): 646–651.

ORGANIZATIONS

Agoraphobics Building Independent Lives. 1418 Lorraine Ave., Richmond, VA 23227.

Agoraphobics In Motion. 605 W. 11 Mile Rd., Royal Oak, MI 48067.

American Psychiatric Association (APA). 1400 K Street, NW, Washington, DC 20005. (888) 357-7924. <http://www.psych.org>.

Anxiety Disorders Association of America. 11900 Parklawn Dr., Ste. 100, Rockville, MD 20852. (301) 231-9350.

National Anxiety Foundation. 3135 Custer Dr., Lexington, KY 40517. (606) 272-7166. http://www.lexington-online.com/naf.html.

National Institute of Mental Health (NIMH) Office of Communications. 6001 Executive Boulevard, Room 8184, MSC 9663, Bethesda, MD 20892-9663. (866) 615-NIMH or (301) 443-4513. <http://www.nimh.nih.gov>.

OTHER

Anxiety Network Homepage. http://www.anxietynetwork.com.

National Institute of Mental Health (NIMH). Anxiety Disorders. NIH Publication No. 02-3879. Bethesda, MD: NIMH, 2002.

Paula Ford-Martin

Rebecca J. Frey, PhD

Phobias

Definition

A phobia is an intense but unrealistic fear that can interfere with the ability to socialize, work, or go about everyday life, brought on by an object, event or situation.

Description

Just about everyone is afraid of something—an upcoming job interview or being alone outside after dark. But about 18% of all Americans are tormented by irrational fears that interfere with their daily lives. They are not "crazy"—they know full well their fears are unreasonable-but they can not control the fear. These people have phobias.

Phobias belong to a large group of mental problems known as anxiety disorders that include obsessive-compulsive disorder (OCD), panic disorder, and post-traumatic stress disorder. Phobias themselves can be divided into three specific types:

• specific phobias (formerly called "simple phobias")
• social phobia
• agoraphobia

Specific phobias

As its name suggests, a specific phobia is the fear of a particular situation or object, including anything from airplane travel to dentists. Found in one out of every 10 Americans, specific phobias seem to run in families and are roughly twice as likely to appear in women. If the person rarely encounters the feared object, the phobia does not cause much harm. However, if the feared object or situation is common, it can seriously disrupt everyday life. Common examples of specific phobias, which can begin at any age, include fear of snakes, flying, dogs, escalators, elevators, high places, or open spaces.

Social phobia

People with social phobia have deep fears of being watched or judged by others and being embarrassed in public. This may extend to a general fear of social situations—or be more specific or circumscribed, such as a fear of giving speeches or of performing (stage fright). More rarely, people with social phobia may have trouble using a public restroom, eating in a restaurant, or signing their name in front of others.

Social phobia is not the same as shyness. Shy people may feel uncomfortable with others, but they don't experience severe anxiety, they don't worry excessively about social situations beforehand, and they don't avoid events that make them feel self-conscious. On the other hand, people with social phobia may not be shy-they may feel perfectly comfortable with people except in specific situations. Social phobias may be only mildly irritating, or they may significantly interfere with daily life. It is not unusual for people with social phobia to turn down job offers or avoid relationships because of their fears.

Agoraphobia

Agoraphobia is the intense fear of feeling trapped and having a panic attack in a public place. It usually begins between ages 15 and 35, and affects three times as many women as men—about 3% of the population.

An episode of spontaneous panic is usually the initial trigger for the development of agoraphobia. After an initial panic attack, the person becomes afraid of experiencing a second one. Patients literally "fear the fear," and worry incessantly about when and where the next attack may occur. As they begin to avoid the places or situations in which the panic attack occurred, their fear generalizes. Eventually the person completely avoids public places. In severe cases, people with agoraphobia can no longer leave their homes for fear of experiencing a panic attack.

Causes and symptoms

Experts don't really know why phobias develop, although research suggests the tendency to develop phobias may be a complex interaction between heredity and environment. Some hypersensitive people have unique chemical reactions in the brain that cause them to respond much more strongly to stress. These people also may be especially sensitive to caffeine, which triggers certain brain chemical responses.

Advances in neuroimaging have also led researchers to identify certain parts of the brain and specific neural pathways that are associated with phobias. One part of the brain that is currently being studied is the amygdala, an almond-shaped body of nerve cells involved in normal fear conditioning. Another area of the brain that appears to be linked to phobias is the posterior cerebellum.

While experts believe the tendency to develop phobias runs in families and may be hereditary, a specific stressful event usually triggers the development of a specific phobia or agoraphobia. For example, someone predisposed to develop phobias who experiences severe turbulence during a flight might go on to develop a phobia about flying. What scientists don't understand is why some people who experience a frightening or stressful event develop a phobia and others do not.

Social phobia typically appears in childhood or adolescence, sometimes following an upsetting or humiliating experience. Certain vulnerable children who have had unpleasant social experiences (such as being rejected) or who have poor social skills may develop social phobias. The condition also may be related to low self-esteem, unassertive personality, and feelings of inferiority.

A person with agoraphobia may have a panic attack at any time, for no apparent reason. While the attack may last only a minute or so, the person remembers the feelings of panic so strongly that the possibility of another attack becomes terrifying. For this reason, people with agoraphobia avoid places where they might not be able to escape if a panic attack occurs. As the fear of an attack escalates, the person's world narrows.

While the specific trigger may differ, the symptoms of different phobias are remarkably similar: e.g., feelings of terror and impending doom, rapid heartbeat and breathing, sweaty palms, and other features of a panic attack. Patients may experience severe anxiety symptoms in anticipating a phobic trigger. For example, someone who is afraid to fly may begin having episodes of pounding heart and sweating palms at the mere thought of getting on a plane in two weeks.

Diagnosis

A mental health professional can diagnose phobias after a detailed interview and discussion of both mental and physical symptoms. Social phobia is often associated with other anxiety disorders, depression, or substance abuse.

Treatment

People who have a specific phobia that is easy to avoid (such as snakes) and that doesn't interfere with their lives may not need to get help. When phobias do interfere with a person's daily life, a combination of psychotherapy and medication can be quite effective. While most health insurance covers some form of mental health care, most do not cover outpatient care completely, and most have a yearly or lifetime maximum.

Medication can block the feelings of panic, and when combined with cognitive-behavioral therapy, can be quite effective in reducing specific phobias and agoraphobia.

Cognitive-behavioral therapy adds a cognitive approach to more traditional behavioral therapy. It teaches patients how to change their thoughts, behavior, and attitudes, while providing techniques to lessen anxiety, such as deep breathing, muscle relaxation, and refocusing.

One cognitive-behavioral therapy is desensitization (also known as exposure therapy), in which people are gradually exposed to the frightening object or event until they become used to it and their physical symptoms decrease. For example, someone who is afraid of snakes might first be shown a photo of a snake. Once the person can look at a photo without anxiety, he might then be shown a video of a snake. Each step is repeated until the symptoms of fear (such as pounding heart and sweating palms) disappear. Eventually, the person might reach the point where he can actually touch a live snake. Three fourths of patients are significantly improved with this type of treatment.

Another more dramatic cognitive-behavioral approach is called flooding. It exposes the person immediately to the feared object or situation. The person remains in the situation until the anxiety lessens.

Several drugs are used to treat specific phobias by controlling symptoms and helping to prevent panic attacks. These include anti-anxiety drugs (benzodiazepines ) such as alprazolam (Xanax) or diazepam (Valium). Blood pressure medications called beta blockers, such as propranolol (Inderal) and atenolol (Tenormin), appear to work well in the treatment of circumscribed social phobia, when anxiety gets in the way of performance, such as public speaking. These drugs reduce overstimulation, thereby controlling the physical symptoms of anxiety.

In addition, some antidepressants may be effective when used together with cognitive-behavioral therapy. These include the monoamine oxidase inhibitors (MAO inhibitors) phenelzine (Nardil) and tranylcypromine (Parnate), as well as selective serotonin reuptake inhibitors (SSRIs) like fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft) and fluvoxamine (Luvox).

A medication that shows promise as a treatment for social phobia is valproic acid (Depakene or Depakote), which is usually prescribed to treat seizures or to prevent migraine headaches. Researchers conducting a twelve-week trial with 17 patients found that about half the patients experienced a significant improvement in their social anxiety symptoms while taking the medication. Further studies are underway.

In all types of phobias, symptoms may be eased by lifestyle changes, such as:

• eliminating caffeine
• cutting down on alcohol
• eating a good diet
• getting plenty of exercise
• reducing stress

Treating agoraphobia is more difficult than other phobias because there are often so many fears involved, such as open spaces, traffic, elevators, and escalators. Treatment includes cognitive-behavioral therapy with antidepressants or anti-anxiety drugs. Paxil and Zoloft are used to treat panic disorders with or without agoraphobia.

Prognosis

Phobias are among the most treatable mental health problems; depending on the severity of the condition and the type of phobia, most properly treated patients can go on to lead normal lives. Research suggests that once a person overcomes the phobia, the problem may not return for many years—if at all.

Untreated phobias are another matter. Only about 20% of specific phobias will go away without treatment, and agoraphobia will get worse with time if untreated. Social phobias tend to be chronic, and will not likely go away without treatment. Moreover, untreated phobias can lead to other problems, including depression, alcoholism, and feelings of shame and low self-esteem.

A group of researchers in Boston reported in 2003 that phobic anxiety appears to be a risk factor for Parkinson's disease (PD) in males, although it is not yet known whether phobias cause PD or simply share an underlying biological cause.

While most specific phobias appear in childhood and subsequently fade away, those that remain in adulthood often need to be treated. Unfortunately, most people never get the help they need; only about 25% of people with phobias ever seek help to deal with their condition.

Prevention

There is no known way to prevent the development of phobias. Medication and cognitive-behavioral therapy may help prevent the recurrence of symptoms once they have been diagnosed.

Resources

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed., revised. Washington, DC: American Psychiatric Association, 2000.

Beers, Mark H., MD, and Robert Berkow, MD., editors. "Phobic Disorders." In The Merck Manual of Diagnosis and Therapy. Whitehouse Station, NJ: Merck Research Laboratories, 2004.

PERIODICALS

Kinrys, G., M. H. Pollack, N. M. Simon, et al. "Valproic Acid for the Treatment of Social Anxiety Disorder." International Clinical Psychopharmacology 18 (May 2003): 169-172.

Ploghaus, A., L. Becerra, C. Borras, and D. Borsook. "Neural Circuitry Underlying Pain Modulation: Expectation, Hypnosis, Placebo." Trends in Cognitive Science 7 (May 2003): 197-200.

Rauch, S. L., L. M. Shin, and C. I. Wright. "Neuroimaging Studies of Amygdala Function in Anxiety Disorders." Annals of the New York Academy of Sciences 985 (April 2003): 389-410.

Weisskopf, M. G., H. Chen, M. A. Schwarzschild, et al. "Prospective Study of Phobic Anxiety and Risk of Parkinson's Disease." Movement Disorders 18 (June 2003): 646-651.

ORGANIZATIONS

Agoraphobics Building Independent Lives. 1418 Lorraine Ave., Richmond, VA 23227.

Agoraphobics In Motion. 605 W. 11 Mile Rd., Royal Oak, MI 48067.

American Psychiatric Association (APA). 1400 K Street, NW, Washington, DC 20005. (888) 357-7924. 〈http://www.psych.org〉.

Anxiety Disorders Association of America. 11900 Parklawn Dr., Ste. 100, Rockville, MD 20852. (301) 231-9350.

National Anxiety Foundation. 3135 Custer Dr., Lexington, KY 40517. (606) 272-7166. 〈http://www.lexington-on-line.com/naf.html〉.

National Institute of Mental Health (NIMH) Office of Communications. 6001 Executive Boulevard, Room 8184, MSC 9663, Bethesda, MD 20892-9663. (866) 615-NIMH or (301) 443-4513. 〈http://www.nimh.nih.gov〉.

OTHER

Anxiety Network Homepage. 〈http://www.anxietynetwork.com〉.

National Institute of Mental Health (NIMH). Anxiety Disorders. NIH Publication No. 02-3879. Bethesda, MD: NIMH, 2002.

KEY TERMS

Agoraphobia— An intense fear of being trapped in a crowded, open, or public space where it may be hard to escape, combined with the dread of having a panic attack.

Benzodiazepine— A class of drugs that have a hypnotic and sedative action, used mainly as tranquilizers to control symptoms of anxiety.

Beta blockers— A group of drugs that are usually prescribed to treat heart conditions, but that also are used to reduce the physical symptoms of anxiety and phobias, such as sweating and palpitations.

Monoamine oxidase inhibitors (MAO inhibitors)— A class of antidepressants used to treat social phobia.

Neuroimaging— The use of x ray studies and magnetic resonance imaging (MRIs) to detect abnormalities or trace pathways of nerve activity in the central nervous system.

Selective serotonin reuptake inhibitors (SSRIs)— A class of antidepressants that work by blocking the reabsorption of serotonin in the brain, raising the levels of serotonin. SSRIs include Prozac, Zoloft, and Paxil.

Serotonin— One of three major types of neurotransmitters found in the brain that is linked to emotions.

Social phobia— Fear of being judged or ridiculed by others; fear of being embarrassed in public.