If you have an intense fear of snakes, dogs, heights or tight spaces, you are not alone. An estimated 10% to 15% of people have at least one phobia—a persistent anxious response that causes them to go out of their way to avoid a particular thing or situation, even though they know their fear is out of proportion to any actual danger.
Arranging your life around a phobia might not be a big problem if the thing you’re afraid of is easy to dodge. But avoidance can sap confidence, limit opportunities and reduce life satisfaction. Examples: Someone with a fear of heights might turn down a promotion because it would require relocating from a second-floor office to one on the thirty-second floor…someone with a fear of flying may not apply for desirable jobs that involve frequent travel…someone who fears dogs may avoid working in the yard because the neighbor’s dog often is outside.
Good news: Most phobias—even ones you’ve had your entire life—are treatable. Bottom Line Personal asked cognitive therapy expert Michael A. Tompkins, PhD, to explain how you can get over your deepest fears.
The most common type of phobia is specific phobia—fear of a particular animal, object or situation, such as spiders or flying. This type of phobia may develop after a traumatic experience—this is called traumatic conditioning. Example: Someone who gets bitten by a dog may be conditioned to fear all dogs.
Some people become phobic as a result of observing other people’s traumatic experience—this is called vicarious learning. Examples: Seeing someone else get bitten… watching a terrifying movie…having a phobic parent who often talks about his/her own fear.
Of course, not everyone who has a traumatic experience develops a phobia. Psychologists believe that people who are prone to phobias have high emotional reactivity, a quality that may be genetic. They react to stressful events more intensely and for longer periods of time. As a result, they experience intense anxiety and quickly learn to avoid whatever triggered those highly unpleasant emotions.
Treatment: Specific phobias often can be treated in as few as one to three sessions with exposure therapy.
How it works: The therapist and the patient together identify situations that evoke the fear, then develop a ladder, or hierarchy, of anxiety-triggering situations ranging from the least to the most fear-inducing. With the therapist present to offer support, the patient confronts each step on the ladder, beginning with the one that is least anxiety-provoking. Each situation in the hierarchy is faced repeatedly until the patient’s anxiety recedes. Then he confronts the next situation in the hierarchy. Example: Someone who is afraid of dogs might first look at a photograph of a dog…then sit in the therapist’s office knowing that a dog is just outside in the waiting room…then look at the dog through the waiting-room door…sit in the same room with the dog…reach out a hand toward the dog…pet the dog…let the dog sit on his lap…let the dog jump on and off his lap.
You can try exposure therapy on your own, but persisting through the discomfort at each phase can be difficult without professional support.
To find a therapist who specializes in treating phobias: Consult the Association for Behavioral and Cognitive Therapies website (ABCT.org).
Specific phobias are different in some ways from another common phobia—agoraphobia. In popular culture, agoraphobia is oversimplified and defined as fear of leaving the house. But agoraphobia can be a form of specific phobia (situational specific phobia) or a feature of panic disorder with agoraphobia. A diagnosis of panic disorder with agoraphobia must include a panic attack. People can develop agoraphobia, however, as a specific situational phobia through traumatic conditioning. Example: Someone who is actually trapped in an environment for a period of time.
The initial panic attack usually isn’t caused by the environment itself. Typically, the first panic attack is a bit of a perfect storm scenario. First, the person tends to be a bit of a worrier…second, the person is experiencing a period of chronic stress…third, the person is in a situation and becomes aware of intense body sensations associated with high physiologic arousal and then makes a catastrophic misappraisal of physical symptoms, such as I’m dying or I’m going crazy…and then the person has the panic attack, a sudden rush of fear or terror. The cause may be unknown, or the incident could stem from other stressors going on in the person’s life. But after the attack, the feeling of panic is connected to the site of the attack. The fear may then spread to similar environments—from shopping malls to any atrium-like space…or from bridges to freeways to even neighborhood streets. The person’s zone of comfort becomes smaller and smaller, and in extreme cases, she may fear going any distance from home.
Treatment: Exposure therapy helps a client deal with the environmental triggers, but the panic attacks need to be addressed as well. Cognitive behavioral therapy (CBT) has an excellent success rate in treating panic disorder. CBT for agoraphobia includes the important element of interoceptive exposure—a series of exercises that trigger the physical sensations that the patient fears and that were associated with the panic attack so the patient can learn to tolerate those sensations in a safe environment. Example: The therapist might ask the client to spin in a circle to create the sensation of dizziness…breathe through a straw to create shortness of breath. As the client gets better at accepting these uncomfortable sensations, she learns that these feared physical sensations aren’t dangerous and becomes increasingly confident when approaching situations she used to avoid.
Along with interoceptive exposure, the individual and therapist build a situational hierarchy of situations or activities that evoke the feared physical response. Example: Someone who fears feelings of suffocation might have a ladder that includes wearing a mask, sitting in a hot room, etc.
Benzodiazepines such as alprazolam (Xanax) and clonazepam (Klonopin) are not recommended for the treatment of a phobia or any anxiety disorder. They may help people who are experiencing high levels of stress and anxiety due to a stressor or perhaps even a panic attack, but the use of this type of medication is temporary until the stressor subsides. Example: A doctor might prescribe a benzodiazepine to someone who has lost his job and is stressed and overwhelmed and experiencing occasional panic attacks. However, ongoing prescription of benzodiazepines for anxiety disorders is not recommended. Long-term use can lead to dependence, and recent research suggests that benzodiazepines negatively influence the brain centers where learning occurs, which could potentially interfere with the effectiveness of exposure therapy. Benzodiazepines are not recommended for people over 60, because the drugs can impair balance and memory.
Safer: Antidepressants in the SSRI category, such as fluoxetine (Prozac), may be helpful in reducing emotional reactivity and don’t interfere with learning.