Definition
A phobia is an intense and unrealistic fear brought on by an object, event, or situation, which can interfere with the ability to socialize, work, or go about everyday life.
Description
Almost all children develop specific fears at some age. Sometimes the fear is a result of a particular event, but some fears arise on their own. Many fears are associated with certain age groups. Very young children (through age two) tend to fear loud noises, strangers, large objects, and being away from their parents. Preschoolers often have imaginary fears, such as monsters who might eat them, strange noises, being alone in the dark, or thunder. School-age children have concrete fears, such being hurt, doing badly in school, dying, or natural disasters. When the child is afraid of something past the age at which it is normal, when the fear interferes with the child's ability to function normally, then the fear ranks as a phobia.
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, most common in children)
- social phobia
- agoraphobia (not common in children)
Specific Phobias
As its name suggests, a specific phobia is the fear of a particular situation or object, for example, flying on an airplane or going to the dentist. 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 the person's everyday life. Common examples of specific phobias, which can begin at any age, include fear of insects, snakes, and dogs; escalators, elevators, and bridges; high places; and open spaces. Children often have specific phobias that they outgrow over time, and they can learn specific fears from adults or other children around them, or even from television.
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. They may 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. Young children often have a fear of strangers that is quite normal; social phobia is not usually diagnosed until a child reaches adolescence and has crippling fears that interfere with normal function.
Social phobia is not the same as shyness. Shy people may feel uncomfortable with others, but they do not experience severe anxiety, they do not worry excessively about social situations beforehand, and they do not 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 being 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 or approximately 3 percent 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. People are literally fearful of fear. They 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.
Demographics
Approximately one person in five (18 percent) of all Americans experience phobias that interfere with their daily lives. Almost all children experience some specific fears at some point, but not many rise to the level of phobia or require professional treatment.
Causes and Symptoms
Experts do not 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 was as of 2004 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 do not 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: feelings of terror and impending doom, rapid heartbeat and breathing, sweaty palms, and other features of a panic attack. People 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.
When to Call the Doctor
A doctor, mental health professional, or counselor should be consulted when irrational fears interfere with a child's normal functioning.
Diagnosis
A mental health professional can diagnose phobias after a detailed interview and discussion of both mental and physical symptoms. Children are often less able to accurately describe their symptoms or discuss their fears, and so should be encouraged to talk about them with parents. 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 does not 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. Medication is used less often in young children, but more frequently in older children or adolescents with severe phobias and associated depression. 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 individuals how to change their thoughts, behaviors, 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 affected people 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 over-stimulation, 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).
In all types of phobias, symptoms may be eased by lifestyle changes, such as the following:
- 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 fear of 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 people 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 it returns at all. Children most often outgrow their specific phobias, with or without treatment.
Untreated phobias are another matter. In adults, only about 20 percent of specific phobias go away without treatment, and agoraphobia gets worse with time if untreated. Social phobias tend to be chronic and are 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. Therefore, specific phobias that persist into adolescence should receive professional treatment.
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 as of 2004 it is not 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 percent of people with phobias ever seek help for their condition.
Prevention
There was, as of 2004, 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.
Nutritional Concerns
Unless a phobia involves fear of eating a needed food, there are no nutritional concerns associated with phobias.
Parental Concerns
Parents should be observant to ensure that unusual fears or phobias do not interfere in the lives of their children. Parents should recognize that a child's fears are real, and encourage the child to talk about his or her feelings, without trivializing the fear. Parents should be sympathetic, but not allow the child to avoid situations in which the child must encounter the feared object or events. If a school-age child has fears that interfere with the child's education, ability to make friends, or participate in other normal activities, a professional should be consulted.
Resources
Books
Diagnostic and Statistical Manual of Mental Disorders,4th edition. Washington, DC: American Psychiatric Association, 2000.
"Phobic Disorders." Section 15, chapter 187 in The MerckManual of Diagnosis and Therapy. Edited by Mark H. Beers, and Robert Berkow. Whitehouse Station, NJ: Merck Research Laboratories, 2002.
Stafford, Brian, et al. "Anxiety Disorders." In Nelson Textbook of Pediatrics, 17th ed. Edited by Richard E. Behrman, et al. Philadelphia: Saunders, 2003, pp. 81–3.
Periodicals
Birk, L. "Pharmacotherapy for performance anxiety disorders: occasionally useful but typically contraindicated." Journal of Clinical Psychology 60, no. 8 (2004): 867–79.
Hofmann, S. G. "Cognitive mediation of treatment change in social phobia." Journal of Consulting and Clinical Psychology 72, no. 3 (2004): 393–9.
Ilomaki, R., et al. "Temporal relationship between the age of onset of phobic disorders and development of substance dependence in adolescent psychiatric patients." Drug and Alcohol Dependence 75, no. 3 (2004): 327–30.
Izquierdo, I., et al. "The inhibition of acquired fear." Neurotoxicity Research 6, no. 3 (2004): 175–88.
Krijn, M., et al. "Virtual reality exposure therapy of anxiety disorders: a review." Clinical Psychology Review 24, no. 3 (2004): 259–81.
Organizations
ABIL Incorporated. 400 West 32nd Street, Richmond, Virginia 23225. Web site: www.anxietysupport.org/b001menu.htm.
Agoraphobics in Motion. 1719 Crooks, Royal Oak, MI 48067. Web site: www.aim-hq.org/.
American Academy of Family Physicians. 11400 Tomahawk Creek Parkway, Leawood, KS 66211–2672. Web site: www.aafp.org/.
American Academy of Pediatrics. 141 Northwest Point Boulevard, Elk Grove Village, IL 60007–1098. Web site: www.aap.org/.
American Psychiatric Association. 1400 K Street NW, Washington, DC 20005. Web site: www.psych.org/.
American Psychological Association. 750 First Street NW, Washington, DC, 20002–4242. Web site: www.apa.org/.
Anxiety Disorders Association of America.8730 Georgia Avenue, Suite 600, Silver Spring, MD 20910. Web site: www.adaa.org/.
National Anxiety Foundation.3135 Custer Dr., Lexington, KY 40517. Web site: www.lexington-on-line.com/naf.html.
National Institute of Mental Health. 6001 Executive Boulevard, Rm. 8184, MSC 9663, Bethesda, MD 20892–9663. Web site: www.nimh.nih.gov/home.cfm.
Web Sites
"Anxiety Disorders (Phobias)." National Mental HealthAssociation. Available online at www.nmha.org/infoctr/factsheets/35.cfm (accessed November 2, 2004).
"Coping with Anxiety, Fears, and Phobias." Kids Health forParents. Available online at (accessed November 2, 2004).
"Phobias." American Psychiatric Association. Available online at www.psych.org/public_info/phobias.cfm (accessed November 2, 2004).
"Phobias." National Library of Medicine. Available online at www.nlm.nih.gov/medlineplus/phobias.html (accessed November 2, 2004).
[Article by: L. Fleming Fallon, Jr., MD, DrPH]
