April 29, 2024

Phobias: What They Are and How to Treat Them

If you’ve been in our Brentwood office, chances are you’ve seen the big pop up book of phobias. It's a playful, 3 dimensional book that pulls no punches when offering up depictions of common phobias.  Check it out next time you’re there!  

Phobias mimic OCD in many ways, as do many anxiety disorders. They follow a similar cycle of triggers leading to an increase in emotion followed by some sort of behavior to reduce distress. Those behaviors are commonly called safety behaviors or compulsions depending on which mental health concern is being discussed.

Common Anxiety Cycle

As with OCD and other anxiety disorders, this cycle tends to be self perpetuating. Doing it once makes it more likely you’ll feel compelled to do it again. The relief that comes from avoiding a perceived threat is often quick, and it can be difficult to notice the negative outcomes from engaging in avoidance and other safety behaviors. No wonder, then, that breaking out of it can feel like a monumental task!  

Despite their overlap, phobias do differ from OCD and other anxiety disorders in some pretty important ways. OCD tends to involve more cognitive content, or what we may call “mental gymnastics”.  It is not uncommon for someone with OCD to make connections that, outside of their OCD symptoms, don’t make very much sense. There is often a flavor of magical thinking, where associations are made and rules are formed that leave clients saying “I know this doesn’t make sense, but...” A person may have a “rule” that they only apply in one setting, such as “I can look at the sky on Wednesday, but if I do on Friday, my loved one will suffer.” There may be more repetition, counting, or other seemingly unrelated behaviors designed to prevent obsessive thoughts.  

With phobias, there is much less of this. The primary cognitive components are focused more singularly on avoidance of the specific feared thing or experience. Think “I’m afraid of dogs, so I won’t go to the dog park”. Or, “I’m afraid of heights so I won’t go to the Grand Canyon”. In people with a phobia, a major symptom we see is avoidance. This is in contrast to OCD, where avoidance is almost always present, but there are often other safety behaviors. To be clear, a person with a phobia may feel compelled to go to great lengths to avoid their feared experience, so the list of “dos and don'ts” will often be extensive. Not only would a person not go to the dog park, they may not go to the grocery store next to the pet store, just in case there is a dog in the parking lot. However, behaviors are usually obviously related to the fear.  

A person with a phobia often is driven by a singular emotional experience- FEAR. While fear is a primary emotion involved in other anxiety disorders, there are often other emotions at play. It is common for guilt, shame, or regret to be driving emotional experiences for individuals with OCD or generalized anxiety disorder. This is much more rare for a person who is dealing with a phobia. Again, don’t misinterpret this as evidence that phobias are less distressing or less serious. When a phobia is severe, it can significantly affect a person’s life.  For someone who is claustrophobic, they may feel compelled to quit a job out of fear of being asked to ride in an elevator with a colleague. Emetophobia, or the fear of vomiting, could lead a child to school refusal, resulting in significant academic and social consequences. Fear of heights may lead someone to skipping a family vacation, or spending excessive time driving inconvenient (but flat!) routes.  

While a person may become phobic of almost anything, the most commonly seen are fear of heights, fear of animals, and fear of public speaking. Phobias are a common anxiety disorder, with a 7.4% lifetime prevalence rate for adults. There is not one known cause of developing a phobia, but as with most psychological disorders, there are a combination of biological and environmental factors that lead toward it. Without treatment they do not usually improve on their own, as avoidance of the fear maintains the fear. Often, an underlying fear of the physical sensations of panic maintains the phobia by strengthening overall avoidance of the phobic fear as well as avoidance of anything that may trigger panic feelings. This “fear of fear” or “fear of sensations” keeps individuals stuck, even as they may see the ways that their avoidance is negatively affecting their life.  

Treatment of a phobia will often look similar to other anxiety disorders. We may use ACT (Acceptance and Commitment Therapy) to help clarify the values that would make it worth risking contact with the feared experience. We would practice being open to emotional experiences rather than preventing or avoiding them, in order for our body and brain to learn that while anxiety is uncomfortable, it is not dangerous. This may be done in a planned, hierarchical way with a focus on getting more comfortable with low levels of distress before moving gradually to increasingly difficult triggers.

A big part of the work is to practice finding willingness to stay in it rather than to end it. This involves working to maintain an attitude of “I am open to this experience, I can observe my thoughts, feelings, and urges, and I’m in no rush to get away.” If you are struggling with a phobic fear, please know that you CAN become more able to live life without the pressure to stay “safe” from your fear.  It will take time and effort, but it is so very possible!

Specific phobias - ScienceDirect

Specific Phobia - National Institute of Mental Health (NIMH) (nih.gov)

Recent developments in the intervention of specific phobia among adults: a rapid review - PMC (nih.gov)