Phobias – causes, types and treatment options
This month we discussed phobias with Dr Audrey Ng at Priory Hospital Roehampton. She offers useful advice to GPs and explores the different treatment options for this mental health challenge. She also provides information on the different types of phobias there are and what causes them.
What is a phobia?
A phobia is characterised by an overwhelming and debilitating fear of objects, situations, places, feelings or animals. It is not necessary for the affected individual to recognise that their anxiety is excessive or unreasonable although often they acknowledge that it may be an irrational response.
This is associated with a sense of uncontrollable anxiety and avoidance behaviours. There is an inability to function normally when exposed to the trigger.
Whilst it is normal for all of us to have ‘fears’ of particular objects or situations, these fears reach the threshold of becoming a phobia when:
- The imagined threat is out of proportion to the actual danger, accompanied by loss of control when exposed to the source of the fear
- The behaviour lasts for more than 6 months
- It affects the ability to function ‘normally’, impacting significantly on the life of the individual
- It is not directly caused by another disorder
What to look out for
The following physical symptoms may be experienced by those affected, when in contact with the source of their fears:
- Dizziness and /or light-headedness
- Sweating or hot flushes
- Palpitations or an increased heart rate
- Chest pains
- Shortness of breath
- Pins and needles in peripheries of fingers and toes
- Nausea, churning in stomach, stomach ache, diarrhoea
- Dry mouth
The different types of phobias to be aware of
Phobias can be broadly classified into specific phobias – simple or complex:
These are phobias which cause intense and persistent fear which is restricted to specific situations or objects. In general, these tend to arise during childhood or adolescence and over time tend to become less severe.
Specific phobias can occur concurrently with other anxiety disorders and some people can suffer with more than one specific phobia.
Below are the broad categories under which most can be classified:
- Animals or insects – for example, the fear of dogs (cynophobia), spiders (arachnophobia), birds (ornithophobia), snakes (ophidiophobia)
- Nature or environment – thunderstorms (astraphobia), heights (acrophobia), water (hydrophobia) for example
- Blood/injections/injury – fear of the sight of blood, injury or needles and/or of having medical procedures, for example going to the dentist
- Situations – fear of flying, enclosed spaces, elevators or going to school are some examples
- Others – fear of situations that may lead to choking, vomiting or fainting, loud noises, characters in costumes, or dolls
These generally develop in adulthood and they tend to be more disabling compared to specific phobias due to the more extensive nature of the fears. The two main ones are:
- Social anxiety disorder (social phobia)
Social anxiety disorder
It is normal for most people to feel shy or sometimes nervous in some social situations, for example when giving a presentation. Social anxiety disorder however is an intense and persistent fear, or anxiety of being in situations where the individual may be scrutinised by others. There is a fear of being embarrassed and a fear that others may notice the individual blushing, trembling or sweating.
Social situations are actively avoided or endured with great distress and can lead to the feeling of dread towards many day-to-day activities.
Individuals affected may have problems with:
- Talking to unfamiliar people or to groups of people
- Eating and drinking in front of others
- Speaking or performing in public
- Direct eye contact
- Attending school, work or university leading to absences
- Worrying about an event even weeks after it has occurred
In younger children, social anxiety can be expressed by crying, clinging, fear of speaking, avoidance of performances, not asking for help at school, avoiding other children and more frequent tantrums.
This is a complex phobia that is characterised by marked fear or anxiety of places or situations where it is perceived escaping may be difficult, should they suffer with symptoms akin to panic or other ‘embarrassing’ symptoms.
In DSM-V this fear/anxiety should prevail in two out the following five situations:
- Using public transportation (automobiles, buses, trains, ships, planes)
- Being in open spaces (parking lots, marketplaces, bridges)
- Being in enclosed spaces (shops, theatres, cinemas)
- Standing in line or being in a crowd
- Being outside the home alone
The situations are actively avoided, require the presence of a companion or are tolerated with intense fear or anxiety.
What causes a phobia?
Research has found a number of factors may be responsible for the formation of phobic disorders.
Genetics and environment
If a family member is affected, then there is more of a chance of developing a phobia both via the inherited genes but also the learned behaviour that may have been observed.
Traumatic experiences like being trapped in a lift or being chased by an animal may also result in the development of a phobia. Seeing traumatic incidents like plane crashes on the television may also trigger them.
Long-term stress or other mental health problems may also increase the chance of someone developing anxiety disorders.
Brain chemistry has also been researched and there have been links made between phobias and the amygdala, which releases ‘fight or flight’ hormones, putting the body into a high alert state.
What can GPs do to help a patient with a phobia?
It is important to recognise if a patient has a phobia, as left untreated can cause considerable impairment to the individual. Most phobias are treatable so early diagnosis can help improve the chances of a full recovery. In your GP surgery start by:
- Taking a detailed and full history of the patient, excluding other physical issues that may mimic some of the reported symptoms, for example having an overactive thyroid
- Checking for other co-morbid problems like substance misuse (which can often be used as a psychological crutch) and depression
- Asking about self-harm and suicide thoughts, as anxiety disorders are often associated with affective conditions
- Remembering that treatment of phobias is easier when the problem is addressed early on and expediently
What treatments are available?
There are various types of psychological therapies depending on the phobias.
Desensitisation and graded exposure therapy
This can be utilised in ‘specific phobias’ successfully. Exposure therapy is an effective intervention that aims to gradually reintroduce individuals to the objects or situations that cause them anxiety, in a carefully controlled way.
Cognitive behavioural therapy
Treatment for ‘complex phobias’ may take longer and cognitive behavioural therapy is mainstay of treatment at present. It aims to address the dysfunctional thought processes that underpin the person’s anxiety and evaluate more realistic ways of viewing situations and developing healthier thinking processes.
Medications may be useful in helping manage phobias particularly in more complex phobias as well as those complicated with co-morbid mental illness. These include antidepressants such as SSRIs, beta-blockers and anxiolytics.
How can Priory help?
Priory’s consultant psychiatrists and therapists are able to deliver a comprehensive and collaborative approach to achieve patient-centred care, taking into account:
- Other possible factors such as co-morbidities of drugs and alcohol substance misuse
- Complicating co-morbid mental health disorders
- A bio-psycho-social approach for an inclusive understanding of the individual’s issues, appropriate risk management and the appropriate treatment required