Phobias

About phobias

What are phobias?

Fear is a form of anxiety triggered by a situation or an object. We know what it’s like to be afraid in certain situations and change our behaviour accordingly – avoiding dark alleys and standing back from the edge of a cliff. These are understandable responses to situations where we might be harmed. When there is a real threat, for example if you are about to be attacked, fear is a sensible and realistic response, and your body will release adrenaline and prepare for ‘fight or flight’.

A fear becomes a phobia when you have an exaggerated or unrealistic sense of danger about a situation (eg. going outside) or object (eg. buttons). You will often begin to organise your life around avoiding the thing that is causing you anxiety.

What are the symptoms?

If you have a phobia, you usually won’t have any symptoms until you face the situation or object that you fear. If your phobia is very severe, then even thinking about the object of your phobia can provoke anxiety. Some of the most common signs and symptoms of phobia are in the diagram below.

These symptoms can make you feel more anxious, which releases more adrenaline (see above), and this vicious circle can lead to a full-blown panic attack. Although these feelings will pass, you may feel stressed 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 and anxious about being on your own and having to cope with such an experience.

Types of phobias

What types of phobias are there?

It is impossible to list every phobia because they can develop around any object or situation: from fear of cotton wool to a fear of vomiting. In practice they can be roughly categorised into two groups:

• specific (simple) phobias
• complex phobias

Specific (simple) phobias

These are phobias about one thing; for example, spiders or flying. They often develop in childhood or adolescence, and for many people they will lessen as they get older. It is difficult to group specific phobias into categories; this list shows some of the more common ones, but there are many more:

• animal phobias, e.g. dogs, insects, snakes, rodents
• natural environment, e.g. heights, water, darkness
• situational, e.g. flying, going to the dentist, tunnels
• body-based phobias, e.g. blood, vomit, injections
• sexual phobias.

If you have a specific phobia about something which you do not come into contact with in everyday life then it might be easier to cope with than a phobia about something which you have to face often. However, this is not always the case. If you have a very severe phobia it can cause fear and anxiety even when the object or situation is not present.

Complex phobias

Complex phobias tend to be more disruptive and disabling than specific phobias and often develop after adolescence. Two of the most common complex phobias are social phobia and agoraphobia.

Social phobia
If you have social phobia (sometimes called social anxiety) then you will feel very anxious when you have to be around people. You might worry that they are going to be critical of you, and that you will do something embarrassing. For some people, social phobia can be connected to one specific activity, such as public speaking, but it can be much more severe. It can become incredibly debilitating and a seemingly impossible challenge to engage in everyday activities, like shopping, eating out or meeting friends.

Most people call me SHY but I always knew that what I was suffering was much more than this. I can’t even go out of the front door for fear that somebody may see me.
– Anxiety UK

Agoraphobia
Agoraphobia is widely thought to be a fear of open spaces, but it is more complex than this. The essential feature of agoraphobia is that you will feel anxious about being in places or situations from which escape might be difficult, embarrassing, or in which help may not be available in the event of having a panic attack. This anxiety will then result in you avoiding of a variety of situations that may include: being alone, inside or outside the home; being in a crowd of people; travelling by car, bus or plane; or being on a bridge or in a lift.

Leaving my home is frightening, I am constantly petrified something terrible is going to happen, and the fear triggers panic attacks. I am reliant on my mother, having lost my confidence and independence.

You may find that if you experience agoraphobia you also dislike being alone (monophobia), and may also become anxious in small confined spaces (claustrophobia).

What causes phobias?

What causes phobias?

There doesn’t seem to be one particular cause of phobias, but there are several factors that might play a role.

• For some people the phobia can be linked to a particular incident or trauma; for example, a child who experiences a lot of turbulence on a plane might develop a phobia about flying.

• Phobias can be learned responses, picked up in early life – you might develop the same specific phobia as a parent or older sibling. It has also been shown that factors in the family environment, such as parents who are very worried or anxious, can have an effect on the way you cope with anxiety in later life.

• There does seem to be some evidence that genetics can play a role – some people appear to be born with a tendency to be more anxious than others.

You might find that it is helpful to try and work out a specific cause for your own phobia, but you might equally feel that there is not a simple explanation; either way, avoiding the object or situation that is making you phobic, will make your fear worse.

What help is available?

What help is available?

Different options are available to help you, and there is no right or wrong way to approach treatment. Many people who experience phobias use self-help techniques, including relaxation, for example, to manage and overcome the symptoms. Self-help options can also be used at the same time as accessing professional support.

If you want support from a healthcare professional, then the first place to go would normally be your GP. Your GP should explain all of your options to you, and your views should be taken into account before any treatment is started. There are three main types of treatment recommended by the National Institute for Health and Care Excellence (NICE) for anxiety and panic disorders (there are no guidelines specifically written about phobia):

• talking treatments
• medication
• advice and information about self-help – bibliotherapy, support groups, exercise etc.

Talking treatments

There are different types of talking treatments, such as counselling and psychotherapy (see Talking treatments for more information).

Cognitive Behaviour Therapy (CBT) is a form of counselling. It aims to identify connections between thoughts, feelings and behaviour, and to help develop practical skills to manage them. There is considerable evidence to suggest that CBT is especially effective in dealing with phobias. (See Cognitive behaviour therapy)

The behavioural element of CBT (also known as exposure therapy or desensitisation) is recommended to give you practice in facing your fears. This involves gradually exposing you, in a safe and controlled way, to the object or situation that you fear. The most commonly used exposure therapy involves gradual exposure in your imagination at first, and then in reality. For example, if you had a phobia about going to the dentist, you might read about the dentist; then look at a picture of a dentist’s chair; then sit in the waiting room; then talk to the dentist; and then, finally, sit in a dental chair.

Through repeated experiences of facing your fear, you feel an increasing sense of control over your phobia. This sense of control over the situation and yourself is the most important benefit of exposure therapy, you will feel less anxious and the phobia begins to lose its power.

Exposure therapy can cause distress if it is not carefully managed, so it is important that you understand the treatment fully and feel comfortable with the additional support you have; for example, from your therapist.

NICE endorses computerised CBT to treat panic and phobia. You can access it on a home computer, using a programme called ‘Fearfighter’. Research has shown computerised CBT can be particularly helpful if you experience social phobia or agoraphobia as it can be delivered in your own home.

Some phobias, such as fear of flying or driving, are so common that there are therapists who specialise in their treatment. The number of treatments you will need depends on the severity of your phobia, but exposure-based therapy is usually brief. Some phobias can often be treated in as little as two to four sessions. Sometimes a single, long session is all that is needed.

Medication

Medication is not usually recommended for treating phobias because talking therapies are often successful and do not have the same side-effects. However, short-term drug therapy can be useful in dealing with the effects of a phobia, such as anxiety. Currently, there are three classes of drugs considered useful in managing anxiety. These are:

• antidepressants
• tranquillisers (benzodiazepines)
• beta-blockers.

Antidepressants
The drugs prescribed most commonly are SSRI antidepressants, such as paroxetine (trade name Seroxat), citalopram (Cipramil) and escitalopram (Cipralex). These drugs may have side effects, including nausea, headache, sleep disturbance, stomach upsets and increased anxiety. They may also cause sexual problems.

The reversible MAOI antidepressant, moclobemide (Manerix), is also licensed as a treatment for social phobia. MAOI antidepressants interact dangerously with certain foods, and a warning about which foods to avoid is given with the drugs in the Patient Information Leaflet (PIL). Other side effects include sleep disturbances, dizziness, stomach problems, headaches, restlessness and agitation.

The tricyclic antidepressant clomipramine (Anafranil) may also be given to treat phobias. The side effects can include a dry mouth, blurred vision, constipation, drowsiness and dizziness. For more information, see Antidepressants.

Tranquillisers
In the past, people may have been given tranquillising drugs from the benzodiazepine group, such as diazepam (Valium), to reduce anxiety. This should now be limited to short periods of treatment for those people who are experiencing very severe anxiety. See Sleeping pills and minor tranquillisers for more information on benzodiazepine medicines.

Beta-blockers
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.

Self-help

Relaxation techniques
Following a relaxation technique can help you to reverse the effects of anxiety. Rather than preparing your body for ‘fight or flight’ you can help it to slow down, lower blood pressure and limit the amount of adrenaline that is released. There are many different relaxation techniques available, ranging from meditation to breathing control to stretching. See managing stress for more information.

Self-help groups
Joining a self-help group allows you to share common experiences and methods of coping with others who are facing similar challenges. It is sometimes very comforting to know that you are not alone, and other people may be able to suggest different ways of coping. Your local Mind or No Panic can help you to identify a suitable group.

Bibliotherapy (using self-help books)
There is evidence to suggest that using a self-help book can be very helpful for people coping with phobias. Many are based on the principles of CBT and will help you to develop your own program to reduce anxiety and make it easier to face your fear.

Hypnotherapy
Hypnotherapy is often cited by people who have phobias as a helpful technique for relieving the symptoms. The Complementary and Natural Healthcare council maintains a register of hypnotherapists who have trained to national standard level.

Accessing help

NHS

GPs are the first access point to health care on the NHS. They can provide an assessment and diagnosis, and help you access appropriate treatment. If your symptoms are mild then you might be referred to your local IAPT (Improving Access to Psychological Treatments) programme to access CBT. Unfortunately waiting times for psychological treatment on the NHS are often very long.

If your symptoms are moderate, or if you have not found low-intensity CBT helpful, your GP is likely to refer you to a Community Mental Health Team (CMHT). The CMHT should give you a more thorough assessment which will look at your health and social care needs. The CMHT will bring together a range of professionals such as psychiatrists, psychologists, social workers and occupational therapists.

You are entitled to say what your needs are and have a right to have an advocate – someone who can listen to you and speak for you. A member of your family may act as an advocate, or you can ask about an advocacy service (see Advocacy and mental health).

The assessment can also include the needs of carers and relatives. The CMHT will use your assessment to develop a care plan which should name your care co-ordinator and outline the kinds of treatment and support that are available to you. Your care plan should be regularly reviewed and your care co-ordinator should be in regular contact with you. For more information on assessments and support, see Community-based mental health and social care.

Private counselling and therapy

You are entitled to receive free CBT on the NHS but you may feel that you don’t want to wait or that you would like more support than is being offered. In this case, you can choose to see a therapist privately. If you see a private therapist then they should be aware of the NICE guidelines for treatment (see the NICE website), and be appropriately qualified to offer you the support you need. See Talking treatments for more information about choosing at therapist. Some of the organisations listed below can also help you find a therapist.

Useful contacts

Anxiety UK
tel. 08444 775 774
web: anxietyuk.org.uk
Support, help and information for those with anxiety disorders.

British Association for Behavioural and Cognitive Psychotherapies (BABCP)
tel. 0161 705 4304
web: babcp.com
Can provide details of accredited therapists.

British Association for Counselling and Psychotherapy (BACP)
tel. 01455 883 300
web: bacp.co.uk
For Information about counselling and therapy. See website or sister website, itsgoodtotalk, for details of local practitioners.

Complementary and Natural Healthcare Council
tel: 020 3178 2199
web: cnhc.org.uk
Maintains a register of complementary healthcare practitioners.

NICE (The National Institute for Health and Care Excellence)
web: http://guidance.nice.org.uk/CG113
Guidance on anxiety and panic disorders

No Panic
helpline: 0800 138 8889
web: nopanic.org.uk
Provides a helpline, step-by-step programmes, and support for those with anxiety disorders.

TOP UK (Triumph over Phobia)
tel. 0845 600 9601
web: topuk.org
Helps people experiencing phobias or obsessive-compulsive disorder.

Published 2012
To be revised 2014
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