Phobias
Phobias are intense, persistent and exaggerated fears of particular objects or situations.
Phobia sufferers typically feel panic or a sense of dread when they’re in the feared situation, or in anticipation of it. They typically aim to escape from or avoid the phobic situation where they can. We only describe a fear as a phobia if it has a significant negative impact on the person’s life as a result of the distress it causes or its interference in the person’s work, social or leisure activities.
This article focuses on general principles and strategies for helping overcome or reduce phobic anxiety in a range of specific situations.
Understanding these principles and strategies can help deal with other conditions involving phobic anxiety, including obsessive-compulsive disorders, eating disorders and post-traumatic stress disorder where exaggerated fears might relate to concerns about contamination, putting on weight or exposure to traumatic memories.
Social phobia, also known as social anxiety disorder, is the most common phobia, afflicting approximately 5% of people at any point in time.
Social phobia involves an intense fear of coming under other people’s scrutiny in such situations as speaking in front of a group or eating or writing in front of others. In such situations the person is fearful of doing something embarrassing or humiliating such as blushing, saying something silly, or shaking visibly.
Another common phobia is agoraphobia, often described as a fear of open spaces.
However, it can present in a range of guises, usually associated with a fear of having a panic attack in a situation from which escape might be difficult, such as whilst driving in traffic over a bridge or in a supermarket queue. The fear might relate to then experiencing physical harm or suffering embarrassment in front of others.
Approximately 10% of people experience exaggerated fears for other specific situations, known as specific phobias.
The most common types are of particular animals (such as spiders or snakes), the natural environment (such as heights or thunderstorms), blood-injury-injection phobia or other situations (such as flying or being in enclosed spaces). People can also be phobic about a wide range of other circumstances or objects, such as of choking, vomiting, falling asleep, loud noises or clowns.
Phobic reactions relate to our instinctual survival mechanisms such as the fight-flight-freeze response in the face of perceived threat and danger.
Such anxiety-based reactions have three main components, somatic, cognitive and behavioural. The somatic or physical component typically involves feelings of panic such as heart palpitations and shortness of breath. The cognitive aspect involves catastrophic beliefs about being unsafe. The behavioural reaction often involves attempts to escape or avoid the situation.
Fleeing from a feared situation leads to a sudden reduction of anxiety with two unfortunate consequences.
The feeling of immediate relief from escaping or avoiding the situation will typically strengthen or reinforce the urge to escape the same situation in future. Secondly, escaping the situation prevents the possibility of disconfirming the catastrophic beliefs by seeing that the feared outcome does not occur.
Treatment Principles
The key to overcoming phobias is to repeatedly face the feared situation and to stay there until the anxiety settles, usually from recognizing that the feared harm does not result.
Such “exposure therapy” is one of the most well-established and effective psychological interventions for phobic anxiety.
Naturally, this will often be a very uncomfortable process, especially initially. A number of strategies can help manage with the associated discomfort, addressing the various dimensions of phobic reactions. They include arousal reducing techniques to help manage somatic symptoms, cognitive strategies to assist with catastrophic thinking and behavioural strategies to help plan once exposure to the feed situation so that it is not too overwhelming.
Managing with physical arousal
Typical strategies for reducing arousal include muscle relaxation and breathing techniques.
Reducing the level of anxiety in the feared situation by even a small amount can lead to a feeling of partial control. Staying in the phobic situation for an extended period is almost guaranteed to cause the anxiety to level off and come down. This is a result of both physiological mechanisms as well as seeing that the feared harm has not occurred.
Managing catastrophic thoughts
Initial psychoeducation can help reduce the subjective sense of danger.
For example, most people with a flying phobia would be surprised to hear that most people involved in plane crashes survive. Agoraphobics who are fearful of fainting in a public place are often reassured by learning that the physiology of panic reactions prevents fainting. The one exception is blood and injury phobias when a person is at extra risk of fainting as a result of lowered blood pressure. However, this can be prevented by repeatedly squeezing one’s hands. Panic attacks are uncomfortable but not dangerous. They involve exactly the same physiological mechanisms as child’s excitement on a carnival ride. It’s our perception of heightened arousal that can lead to it being distressing as opposed to fun.
It also helps to develop coping self-statements, or a calming mantra, that can help to counter catastrophic thoughts in the feared situation.
Such self-statements as “I’ll be OK”, “just breathe” or “let time pass” can be deceptively powerful in encountering anxiety, especially with practice. They help keep our frontal lobes switched on and not just react to the activation of the limbic system, the body’s natural reaction in dangerous situations to trigger fight-flight-freeze survival responses.
When facing a feared situation, it can help to estimate the likelihood that some specific harm will occur, and then to re-rate the perceived likelihood after being in the situation for a time. This helps recognise that our perception of danger in a phobic situation will likely reduce over time. Expressing aloud one’s catastrophic beliefs at the time can enable an objective test to see if that happens. This can help to more actively disconfirm the beliefs.
Behavioural strategies
A core treatment intervention is exposure to the feared situation, often in graded steps.
This preferably involves facing a phobic situation until one’s anxiety comes down to no more than 50% of its original level, and preferably much less. Each time that occurs, the person has undone some of the phobic reaction. This increases once sense of “self-efficacy”, or confidence that you can manage in the situation without unduly disruptive distress.
It is important to plan such exposure in a way that makes it more manageable.
This often involves “graded exposure”, meaning facing one’s fears in a step-by-step fashion from less challenging to more challenging situations. A therapist experienced in treating phobias can help do this in an optimal way.
Practising graded exposure typically involves developing a fear hierarchy, or exposure hierarchy.
It helps to draw up a list of situations which trigger the phobic reaction, from less challenging to more challenging. You can rate each situation according to your “subjective units of distress”, or SUDS level, on a 0 to 10 scale. A SUDS level of 0/10 would represent no distress, whilst a 10/10 would represent the highest level of distress you could experience. For example, someone with a phobia of spiders might initially anticipate experiencing a 2/10 if they looked at a photograph of a small spider through to a 10/10 of having a large spider moving on their hand.
There are no strict guidelines as to what level of challenge to aim for.
However, it helps to start by facing some situations at lower levels of your exposure hierarchy to gain confidence that you can face certain phobic situations and that your anxiety will come down. That usually bolsters confidence to tackle the next step.
You might unexpectedly encounter more challenging phobic situations in the course of your everyday life.
Managing through such situations can provide a boost of confidence if you find yourself getting through them, even with difficulty. To make the most predictable and efficient progress it can help to plan to face situations at intermediate levels of your exposure hierarchy, perhaps at a 7/10 or 8/10 level. Facing such situations is clearly a significant achievement, but more manageable than the most extreme situations.
You will typically make the most progress with situations you have actually faced.
For example, when people have tackled situations at higher levels of their exposure hierarchy their anticipated fear in again facing that situation will typically reduce more than other phobic situations that they haven’t faced yet. However, managing through any phobic situation will typically lead to reduced distress in other phobic situations as well.
As well as SUDS ratings, it is worth rating situations in your exposure hierarchy according to your self-efficacy, or your perceived likelihood of being able to face that situation and to manage with any associated distress.
You can rate your self-efficacy on a 0 to 100% scale, where 0% means that you believe there is no chance at all that you could face the situation even if you wanted to and 100% means that you definitely believe you would. A 50% self-efficacy rating means that you only think there’s a 50-50 chance that you would face the situation and stay there, managing to deal with your discomfort. When engaging in regular practice, such ratings become fairly accurate in predicting your likelihood of being able to manage. In practice, it is often helpful to plan to face situations where you have at least 70% to 80% self-efficacy as you are more likely to have successful experiences that further reduce your phobic anxiety. This will more predictably give ongoing encouragement. However, it is sometimes worth tackling situations you are less confident in as you can pleasantly surprise yourself with your progress.
People who planfully expose themselves to situations in their fear hierarchy often experience great encouragement when they see their SUDS and self-efficacy ratings improve following such practice.
It soon becomes clear that the more frequently you face situations, the longer you stay in them and the more your anxiety reduces at the time, the more rapid progress you’ll make in dealing with your phobia. The key is to keep persisting with this process. Not every situation you face will be a successful experience, but they can all be a learning experience.
When going through an exposure exercise it is important to be mindfully present and to allow yourself to experience your feelings “within your own skin”, without tuning out or dissociating.
The challenge is to deal with the fear of distressing feelings. Ultimately, they are just bad feelings. They are not dangerous. They will pass. If people dissociate when facing a feared situation, they will not have the same opportunity to properly observe this and to learn from the experience. The exposure might then provide little benefit. Exposure won’t help much if people then flee a phobic situation or tell themselves straight afterwards how desperately glad they are to no longer be there. Such reactions can unwittingly reinforce the fear.
It is possible to gain significant benefit from facing a feared situation in one’s imagination.
This can be enhanced using additional therapy modalities, including hypnosis and EMDR (Eye Movement Desensitization and Reprogramming). However, ultimately, facing the situation in vivo, or in real life, is typically the most helpful when people have the opportunity to do so.
Conclusions
These principles and strategies are hopefully a helpful guide, but they are not intended to play down the challenge of facing a phobia.
The fight-flight-freeze survival mechanisms that are triggered when we face sudden threat or danger are very powerful indeed. They need to be very powerful and immediate to prompt us to respond to threat or danger without having to think too much. Otherwise, we might not have enough time to escape from a predator or avoid an imminent accident. These mechanisms support not only our own survival, but the evolution of the species.
The problem with phobias is that these mechanisms are triggered when they are not necessary, leading to markedly exaggerated fear reactions.
When suffering a phobia our brain is overreacting to certain situations that otherwise might be dangerous, such as heights, potentially poisonous animals and insects or not getting enough air.
The heartening news is that we can reprogram ourselves to no longer perceive phobic situations as catastrophic or life-threatening.
However, this is difficult to achieve without being prepared to manage with the repeated discomfort of planned exposure.
As with other situations when we are working to change habitual reactions, it’s important to show self-compassion and give ourselves active encouragement.
This includes giving oneself a genuine pat on the back, truly appreciating one’s worthwhile attempts and achievements and being forgiving toward oneself when lapses occur. Occasional lapses are normal, even with very successful progress. The goal is not to completely eliminate discomfort, although this may occur in some instances. The more realistic goal is often to reduce restrictions in one’s life and for the discomfort to become manageable.
When people face their phobias using strategies described here, they typically gain considerably more freedom in those parts of their lives that used to be most affected by the anxiety.
They also often gain an additional boost in confidence in their coping skills more generally, bolstering their resilience in the face of other challenges.
Episode 16, Facing Phobias, of the practice’s podcast, covers this topic. Please listen below.
For more episodes of Psych Spiels & Silver Linings