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Understanding phobias
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What are phobias?
What are the common phobias?
What are the effects of having a phobia?
Where do phobias come from?
What can I do about it?
What help can I get in the community?
What can I do to help myself?
What can partners, friends and relatives do to help?
Useful organisations
Further reading
'I have not been out of the house for six months. I did go to see my doctor at Christmas, but I got into such a state that I nearly collapsed, and now I get him to see me here. I feel safe here and I don't get the awful feelings, but I'm not even relaxed at home if I know a stranger is visiting. I often have a drink to calm me if the paperboy is coming to collect the paper money or the gas man is coming to read the meter. Sometimes, though, I just refuse to answer the door.'
'I was always a bit nervous about going out and about and, gradually, I went to fewer and fewer places on my own, and I began to rely more and more on a glass or two of sherry to give me Dutch courage. A year ago, I was able to use the corner shop and to get round the block to see my sister, but I can't do that now – even with the sherry. Just talking about it makes me feel wobbly and breathless. I try not to think about the awful feelings I get – thinking about them makes me feel almost as bad as going out does. Sometimes, I wonder whether I'm going mad.'
Overcoming anxiety Helen Kennerley (Robinson 1997)
This booklet provides a brief introduction to phobias. It explains what they are, why they start, and what sort of treatment and support is available. It also suggests how people can learn to manage and overcome them, and where to get help.
What are phobias?
A phobia is an intense fear of a situation or an object that wouldn't normally worry other people (unless they, too, suffered from the same phobia). It severely restricts your life, and may force you to take extreme measures to avoid whatever triggers it. A phobia is known as an anxiety disorder (like obsessive-compulsive disorder and panic attacks), which means it centres on our natural reaction to fear. Anxiety is about fear, and we all get anxious at some time. It's a natural reaction in all of us, and keeps us safe.
As we grow up, we learn what is dangerous, and how to avoid it. We know what it's like to be afraid in certain situations, and many of us have particular fears, whether it's of going up ladders, of water or of dogs, for instance. These are understandable responses to something that might do us harm.
Almost all phobias feature places, situations, animals or objects that aren't necessarily at all threatening, but which people react to, out of all proportion. Those who suffer from phobias aren't really frightened of particular situations or places, but of the feelings of terror they experience when in them. While they know they are not in real physical danger, they can't convince themselves this is the case.
A phobia is not a psychosis. When someone is diagnosed with a psychosis, such as schizophrenia, they may have hallucinations and delusions, which are experiences that other people don't share because they can't hear or see them. They may feel as if thoughts are being placed in their heads by an external source. But someone with a phobia knows that it's their own thoughts troubling them.
A phobia is not described as an illness. However, when confronted by the object of your phobia, you are likely to panic, and panic produces very severe physical symptoms, which can make you believe that you are seriously ill. Your heart may beat very fast, your stomach may be churning, you may feel dizzy, sick and short of breath, be sweating and trembling, have a dry mouth, feel confused, disorientated and full of dread. The fear of being ill can become part of the problem. (See Panic attacks, further down.)
Although these feelings pass, you may feel istressed and frightened by them, and this can make you feel out of control and overwhelmed. Afterwards, you may feel depressed and embarrassed about it. All this may make you nervous about being on your own and having to cope with such an experience.
Panic attacks
When someone is frightened by something, the chemical adrenalin floods the body, to prepare it for 'fight or flight' in the face of danger. The adrenalin causes the physical sensations of panic. These symptoms and sensations can themselves make people very anxious, and this releases more adrenalin. This vicious circle can lead to a full-blown attack. Panic attacks are very common and many people experience something of this description during their lives. (For more information, see Mind's booklets, How to cope with panic attacks, and Mind troubleshooters: panic attacks) If they happen very frequently, you may be described as having a panic disorder.
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What are the common phobias?
People can develop a phobia about any object, whether animate or inanimate, and about any situation. They can be roughly divided into different types: specific phobias (about any animal, bird or insect, or something like flying in an aircraft or germs); specific situations (about being away from home, the dark, heights, enclosed spaces, being alone or falling); social phobia (about meeting, speaking to or eating in front of other people), and illness (about heart trouble, cancer or losing a limb). Most people with phobias suffer from one or other of those mentioned. Agoraphobia (a fear of being away from home) is probably the most common phobia, and particularly affects women.
Many people suffer from more than one phobia at a time. Agoraphobia is often one of a complex mixture of problems that may include monophobia (fear of being alone) and a form of claustrophobia (a fear of being trapped or enclosed).
Current estimates are that there are 10 million sufferers in the UK. Unfortunately, people who have a phobia often feel unable to talk about it, and this makes it difficult to say exactly what numbers are involved. It's clear, though, that phobias are common and widespread.
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What are the effects of having a phobia?
People will try to avoid the situation or object that triggers their phobia, as far as possible. This is easier for some than for others. To what extent their life is affected will depend on the nature and severity of the phobia.
Someone with a phobia of cats might not want to touch one; another might not tolerate being in the same room, a third might be unwilling to see a picture of the animal. It's even possible for just the mental image of a cat to cause terror, in severe cases. This presents huge difficulties.
A social phobia can range from not wanting to eat meals in front of other people, being unwilling to speak in public, to withdrawing completely from social life. Agoraphobia can mean a mild fear of going out, being able to travel from one 'safe' place to another by car, or being unwilling to set foot outside the house. It's no wonder that problems of this kind can lead to even greater anxiety and depression.
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Where do phobias come from?
Some people can trace their phobia back to their childhood and to a certain frightening event, which may have caused a panic attack at the time. But it's not always so clear to someone where their phobia comes from.
It can result from long-term stress and anxiety. Bad relationships, poor housing, poverty and other social factors often undermine people, making them more vulnerable to problems such as phobias. It's possible that people who have less well-developed strategies for coping with life's difficulties may be more prone to phobias or other anxiety disorders. Early experiences and family background can play a part in this. Someone brought up by anxious parents may be more inclined to see the world as a dangerous place and to become anxious themselves. Being anxious makes it more likely that they will react to events more negatively.
At the start of a phobia, people feel frightened in a particular situation or place – but don't know why. Each time they are in the same situation or place, they have an overwhelming sense of impending disaster and an intense desire to escape. The extreme sense of fear is very real and spirals, so that the person comes to believe these feelings will be provoked wherever they go. In the end, avoiding the situation seems like the safest option – by steering clear of all lifts, for instance, or by walking everywhere, by staying at home or keeping themselves to themselves.
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What can I do about it?
Many people don't seek professional help for phobias, but develop coping strategies and self-help techniques themselves. (See What can I do to help myself? further down.) Alternatively, you could visit your GP, who can also refer you to a psychiatrist or psychologist, so you can find out what treatment might work for you. Or you might prefer to find your own therapist or source of help. There is no right or wrong way to feel or thing to do. Different things work for different people.
Talking treatments
There are different kinds of talking treatments, including counselling, psychotherapy, and cognitive behaviour therapy. Getting these treatments on the NHS may depend on where you live. It might be available through your GP surgery, or he or she may be able to refer you for treatment.
You could also find your own therapist or source of help. (For more information, see Useful organisations, further down.)
Counselling provides support, usually on a once-a-week basis, helping people deal with specific problems. Psychotherapy tends to be quite a long-term and in-depth talking treatment, with the focus on helping people find and deal with the causes of their distress, as well as developing their own coping strategies.Cognitive behaviour therapy (CBT) identifies connections between people's thoughts, feelings and behaviour, and develops practical skills to manage them. This has proved very useful to those who experience the symptoms associated with phobias.
Behaviour therapy
Psychologists can offer behaviour therapy, which is a practical form of treatment that gives you practice in facing your fears. It's also known as exposure therapy or desensitisation, because it involves being exposed to whatever you most fear, very gradually, in order to reduce your anxiety. There is a suggestion that a combination of behaviour therapy and appropriate medication can be beneficial.
Medication
It's generally recommended that you don't use medication as a substitute for talking treatments or other therapy, but short-term drug therapy can be useful in dealing with the effects of a phobia. Currently, there are three classes of drugs considered useful in managing anxiety. These are antidepressants, tranquillisers (benzodiazepines) and beta-blockers.
Antidepressants are often prescribed to lessen anxiety (anxiety and depression are often linked). Of the SSRI antidepressants, paroxetine (Seroxat) is licensed for the treatment of social phobia, and citalopram (Cipramil) and escitalopram (Cipralex) are both licensed for panic disorder. Venlafaxine (Efexor), which is chemically very similar to the SSRIs, is licensed for generalised anxiety disorder. The commonest side effects of these drugs include nausea, headaches, sleep disturbances and, initially, anxiety.
Drugs from the tricyclic antidepressant group may be given, especially clomipramine (Anafranil), which is licensed for phobic and obsessional states. Side effects of this group include a dry mouth, drowsiness, blurred vision, palpitations and tremors, as well as constipation and difficulty urinating.
The reversible MAOI antidepressant, moclobemide (Manerix) is also licensed for social phobia. MAOI antidepressants interact dangerously with certain foods, and a warning about which foods to avoid is given with the drugs. Other side effects include sleep disturbances, dizziness, stomach problems, headaches, restlessness and agitation.
Withdrawal problems may occur with all antidepressants, and you should come off them slowly, gradually lowering the dose over a period. Withdrawal effects are most problematic with paroxetine and venlafaxine. (For more information about all of these drugs, see Mind's booklet, Making sense of antidepressants)
Benzodiazepine drugs, also known as minor tranquillisers, are licensed for anxiety, but as these also cause well-known problems of dependence and withdrawal, doctors are advised to prescribe them only for severe anxiety, and to use the lowest possible dose, for the shortest possible time. They should not be used for more than four weeks and, preferably, should not be taken every day. As with the antidepressants, they should be withdrawn gradually. Of the drugs in this group, diazepam (Valium) is used most commonly; others are alprazolam (Xanax), chlordiazepoxide, clorazepate (Tranzene), lorazepam (Ativan) and oxazepam. The side effects of these drugs include drowsiness, tiredness and confusion.
Two non-benzodiazepine drugs licensed for anxiety are buspirone and meprobamate. These are also for short-term use in severe cases. The side effects of meprobamate are similar to those of the benzodiazepines. Side effects for buspirone include nausea, dizziness, headache, nervousness and lightheadedness. (For more information about all of these drugs, see Mind's booklet, Making sense of minor tranquillisers)
Beta-blockers are drugs that act on the cardiovascular system (heart and blood pressure), and may be given to people with anxiety to reduce physical symptoms, such as palpitations. They don't treat the anxiety itself, but slow the heart and reduce blood pressure. Their names all end with '-olol', and the one most commonly used for anxiety is propranolol (Inderal). The main side effects include effects on the heart, stomach troubles, cold fingers, tiredness and upset sleep.
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What help can I get in the community?
If your GP refers you to psychiatric services in England and Wales, you should have your needs assessed and care planned within the Care Programme Approach (CPA), or its equivalent. This should provide you with an assessment of your social and health care needs, a care plan, a care coordinator and a regular review. You are entitled to say what your needs are and to have an advocate to speak for you, if you want one. This assessment might also include the needs of carers and relatives.
Community Mental Health Teams
You might be referred to a local Community Mental Health Team (CMHT), which also makes community care assessments (see Community care services, below). They consist of a multidisciplinary team that might include a psychiatrist, a psychologist, a social worker, care workers and community psychiatric nurses (CPNs). Their aim is to enable you to live independently. They can help with practical tasks, such as sorting out welfare benefits and housing, as well as day centres or drop-in centres. The CPN can visit you and help you with your medication, if necessary.
Community care services
Social services can make an assessment, either separately or as part of the CPA, for providing community care services. These would cover all your needs from day-care to housing, with the aim of providing services in supported accommodation or in your own home. You might need careworkers, and, since many areas have introduced charges for services, this cost may have to be included in the assessment.
Direct payments
Once your community care assessment has confirmed your need for services, you may be eligible to claim direct payments to enable you to purchase the care yourself, rather than having it provided by social services. Direct payments cover such things as employing your own careworker and day-centre charges. Your local social services or the National Centre for Independent Living (NCIL) should be able to help you. (See Useful organisations, further down.)
You can get information about local mental health services from your GP, the social services department of your local council, your local Mind association, your CMHT, Patient Advice and Liaison Services (PALS) or Council for Voluntary Services (CVS). This includes details of local projects that provide services to particular communities, such as Black and minority ethnic communities, women, disabled people and lesbians and gay men. You may also find details in your local telephone directory.
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What can I do to help myself?
There is no one way of coping with phobias that is guaranteed to work. Different strategies work for different people. Some people might prefer to work on their own self-help programme, while others prefer to get involved in self-help groups or to work with a psychologist, psychiatrist or therapist within an agreed treatment plan – or to do a combination.
Self-help programmes
You can choose to work to your own programme, which could includes cognitive behaviour therapy techniques. The organisations and the books listed below should be able to help you devise one to suit. You could work the programme on your own, with someone close to you or with a careworker, if appropriate, or you could involve a therapist.
For example, someone with agoraphobia might find it useful to plan a programme that involves making a very short trip outside to begin with, gradually increasing the length of time spent outside and the distance away from home. Similarly, a planned programme to reduce claustrophobia might start with approaching an enclosed space, such as a lift, watching others using it, then opening the doors. The next stage could include stepping inside, going up one floor, and so on.
The same applies to monophobia (fear of being alone) where the person might try being alone for a very short period of time, and then gradually increasing it. With space phobia (a fear of falling), which affects balance, there is a suggestion that people may have a physical difficulty with walking. The techniques described above, known as self-exposure therapy, can also be applied here – taking a small number of steps, while coping with the anxiety, and gradually increasing the number attempted.
Relaxation techniques
Some people find relaxation techniques helpful. Printed or taped guides or classes can teach you how to improve your breathing to lessen tension. They may feature physical exercises to relax your muscles and action plans to help you progress from coping with non-stressful situations to those you find difficult. (See Useful organisations and Further reading below.)
Visualisation
This is another technique that some people have found helpful in dealing with a phobia. It combines relaxation and, in particular, breathing techniques with mentally planning and carrying out a task, such as making a trip to the shops.
Self-help groups
It can be useful to share common experiences and methods of coping with others. You could contact the local Mind association in your area or the organisations listed below. Social services may also be able to tell you if there is a group local to you.
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What can partners, friends and relatives do to help?
It can help a great deal if you can accept the feelings your partner, friend or relative is having, and recognise how difficult it is for them to cope. It can increase someone's isolation, distress and anxiety if their feelings are not accepted, and they come to believe they are being treated as though they were over-reacting.
If the person is working to a self-help programme, either on their own or with a therapist, you could ask them how you can help them with it. Perhaps you could accompany them to treatment sessions, if they want you to.
Make sure that you get enough support for yourself. It's important, while supporting someone, to try to avoid them becoming dependent on you so that their phobia also becomes the focus of your life.
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Useful organisations
British Association for Behavioural and Cognitive Psychotherapies (BABCP)
tel. 0161 797 4484
web: www.babcp.com
Full directory of psychotherapists available online
British Association for Counselling and Psychotherapy (BACP)
BACP House, 35–37 Albert Street, Rugby CV21 2SG
tel. 0870 443 5252
web: www.bacp.co.uk
See website or send an A5 SAE for details of local practitioners
First Steps to Freedom
1 Taylor Close, Kenilworth, Warwickshire CV8 2LW
helpline: 01926 851 608 or 0845 120 2916,
email: first.steps@btconnect.com
web: www.first-steps.org
Offers help to those who suffer from phobias
International Stress Management Association (ISMA)
PO Box 348, Waltham Cross EN8 8ZL
tel. 07000 780 430
web: www.isma.org.uk
Information about preventing and reducing stress
National Centre for Independent Living (NCIL)
250 Kennington Lane, London SE11 5RD
tel. 020 7587 1663
email: ncil@ncil.org.uk
Information about independent living and direct payments
National Phobics Society
Zion CRC, 339 Stretford Road, Hulme, Manchester M15 4ZY
tel. 0870 770 0456
email: nationalphobic@btconnect.com
web: www.phobics-society.org.uk
Counselling and helpline about all anxiety disorders
No Panic
93 Brands Farm Way, Randlay, Telford, Shropshire TF3 2JQ
helpline: 0808 808 0545
tel. 01952 590 005
email: ceo@nopanic.org.uk
web: www.nopanic.org.uk
For people experiencing anxiety disorders, such as phobias
Supportline
PO Box 1596, Ilford, Essex IG1 3FW
helpline: 020 8554 9004
email: info@supportline.org.uk
web: www.supportline.org.uk
Confidential helpline on a variety of problems
TOP UK (Triumph over Phobia)
PO Box 3760, Bath, BA2 3WY
tel. 0845 600 9601
email: info@topuk.org
web: www.topuk.org
Helps sufferers of phobia or obsessive-compulsive disorder
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Further reading
Anxiety and tension: symptoms, causes, orthodox treatment – and how herbal medicine will help J. Wright (How To Books 2002)
The BMA family doctor guide to stress (Dorling Kindersley 1999)
Confidence works: learn to be your own life coach G. McMahon (Sheldon Press 2001)
Conquering fear D. Rowe (Mind 2003)
How to assert yourself (Mind 2003)
How to cope with panic attacks (Mind 2004)
How to improve your mental wellbeing (Mind 2004)
How to increase your self-esteem (Mind 2003)
How to look after yourself (Mind 2004)
How to stop worrying F. Tallis (Sheldon 2001)
How to stop worrying (Mind 2004)
Making sense of antidepressants (Mind 2004)
Making sense of cognitive behaviour therapy (Mind 2004)
Making sense of herbal remedies (Mind 2000)
Making sense of homeopathy (Mind 2001)
Making sense of minor tranquillisers (Mind 2003)
Manage your mind: the mental health fitness guide G. Butler, T. Hope (Oxford University Press 1995)
The Mind guide to managing stress (Mind 2003)
The Mind guide to massage (Mind 2004)
The Mind guide to relaxation (Mind 2004)
The Mind guide to yoga (Mind 2001)
Mind troubleshooters: panic attacks (Mind 2004)
Overcoming anxiety H. Kennerley (Robinson 1997)
Overcoming panic: a self-help guide using cognitive-behavioural techniques D. Silove, V. Manicavasagar (Robinson 1997)
Relaxation: exercises and inspirations for wellbeing Dr S. Brewer (DBP 2003)
Understanding anxiety (Mind 2003)
Understanding depression (Mind 2004)
Understanding obsessive-compulsive disorder (Mind 2004)
Understanding talking treatments (Mind 2002)
When panic attacks A. Tubridy (Newleaf 2003)
For a catalogue of publications from Mind, send an A4 SAE to:
Mind Publications
15 19 Broadway
London E15 4BQ
tel. 0844 448 4448
fax: 020 8534 6399
email: publications@mind.org.uk
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This booklet was written by Fiona Hill
First published by Mind 2000
Revised edition © Mind 2004
ISBN 1-974690-99-5
No reproduction without permission
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