Guest blog: Phobias Featured Image

Over the years we have helped many clients who have various problems. One of them has been phobias.  Whether it be a phobia of the gym or even related to nutrition, it’s an interesting and often overlooked area.

This topic has come up recently because although i’ve flown many times, it’s always made me uneasy, so I decided to jump out of a plane and it worked for me. Many people have since asked me about phobias and whether we could do a blog.

You can watch me take the leap here

Here’s is Alex with an explanation on why you have phobias and what to do about it:

Fear is our body’s ‘in-the-moment’ response to danger or a threat, and purely functions to protect us. But why is it that sometimes fear can cause us way more problems that it solves? This usually happens when the level of fear that we experience is disproportionate to the situation we find ourselves in and can lead to embarrassment, public ridicule and a life limited by avoidance of various objects and scenarios. But before we think about disproportionate fear, it’s useful to consider why we have anxiety in the first place, particularly when it feels so awful!

As you might remember from a previous blog posting co-authored with Nick, I wrote about how, in the context of evolution, our body’s natural fear response (the Sympathetic Nervous System, or SNS for short) kicks in when we’re faced with a stimulus that we unconsciously recognise as being a significant threat. The SNS is our body’s automatic and unconscious response that keeps us safe. So, when faced with a wooly mammoth lumbering forwards at full throttle, our caveman ancestor didn’t have to think about running or hiding; physiologically his body took over as adrenaline was released and activated all the necessary SNS ‘fight-or-flight’ systems needed to keep him safe (heart pumping, rapid breathing, leg muscles ready etc). Faced with a contemporary version of this threat – e.g. a ruckus in the pub, a dog barking nearby, or the sound of breaking glass in the middle of the night – our physiology kicks in in pretty much the same way. Nothing much has changed, largely because it works! Our species has survived thanks to our fear!

However, let’s consider a more irrational experience of fear. Why is it that some people are terrified of tarantulas? Or scared stiff of snakes? Or petrified of public speaking?

If you find yourself regularly having an overwhelming fear response to a certain situation or object, you might be one of the 10-12% of the general population who experience a mild phobia. They’re relatively common, and usually 90% of sufferers go through life without ever seeking help, most likely as it doesn’t stop them from living the life they want to live despite having their fear. This is particularly true if they rarely come into contact with the feared object or situation (e.g. a fear of open water if you live in Birmingham!).

Diagnostically-speaking, specific phobias are persistent fears that are excessive or unreasonable, and are cued by a specific object or situation. Finding yourself exposed to the feared stimulus almost always provides immediate and intense anxiety that can even result in a panic attack. Typically, the person recognises that the fear is excessive (most likely after the event….), and the usual coping strategies that are implemented to manage the fear are either through avoidance of the object/situation, or endurance of the situation despite extreme distress. At a clinically significant level, phobias can interfere with daily functioning and almost always causes marked distress.

From a clinical perspective, specific phobias (often unfairly labelled as “simple phobias”) fall into five subtypes:
Animal (e.g. spiders, frogs, butterflies)
Situational (e.g. enclosed spaces, driving, big shopping centres)
Natural environment (e.g. heights, open water)
Other uncommon (e.g. choking, germs, buttons, dolls)
Blood-injection-injury type phobia.

The last subtype probably warrants a blog posting all of its own due its unusual and distinctive vasovagal response. Briefly, however, with blood-injection-injury phobias, the heart rate briefly accelerates before it decelerates, leading to a significant drop in blood pressure that can result in fainting. Most other fears and phobias are characterised by an increase in heart rate, meaning fainting is physiologically impossible.
Origins of Phobias:
Psychologists are yet to agree on a single model to explain the development of phobias. One view is that some phobias are evolutionary ‘hangovers’, whereby we are scared of things that once may have been potentially dangerous to humans. This might explain why it is that we continue to be scared of snakes and spiders, yet rarely do we hear of a phobia of flowers!

Another view is that phobias develop as a result of Classical Conditioning (remember Pavlov and his dogs?). In an example of a phobia developing as a result of this, former colleague of mine was left terrified of horses as the result of a childhood trauma where he was bitten by a horse whilst petting one in a field. His SNS still kicks in as strongly as ever when he sees a horse, even when he’s sat safely in a car and the horse is in a field behind a fence. In this case his mind has generalised his fear from a single traumatic incident to all horses. This is a great example of a phobia developing through Classical Conditioning, and being maintained by Operant Conditioning (negative reinforcement of avoidance behaviour); avoiding or escaping from horses is a negative reinforcement as it results in a removal of an unpleasant experience (fear), and so the fear continues.

Yet anther view is that some phobias develop through vicarious conditions, such as observing the fear of others, or the transmission of information. Indeed, some phobias are thought to develop as a result of intergenerational transmission of fear. As children we tend to learn what to avoid by copying the behaviours of our parents and as such if we observe family members getting afraid in specific situations then we are likely to learn to feel afraid in the same circumstances. So if a mother demonstrates fear around rats, it’s likely that her child will display the same behaviour, even if there is no reasonably fear cognition underlying the experience of seeing a rat.

Whereas some phobias are classically conditioned fear responses, or following observed fear responses in others, other phobic responses are less-easily explained. For instance, I’ve had conversations with a number of people with the same rather unconventional fear of ‘things with holes in’ that seemingly defies a clear explanation, yet is generalised to similar-looking objects such as sponges, seed pods and even crumpets! The common link with these appears to be something along the lines of a fear of ‘what might be in there’ and the people I’ve spoken with tend to be those people who like to know what’s going on and are self-confessed perfectionists. In the research literature, similarly unexplained phobias are described, most famously by Rachman and Seligman (1976) who described a client who reported an intense fear of chocolate. The researchers were unconvinced by the client’s idea that the fear developed when she observed a bar of chocolate that was present in the room where her mother’s dark brown coffin lay.

Knowing the cause is not essential for treatment. Nevertheless, from a cognitive-behavioural perspective it is often useful to at least try to understand any thought processes that may lie behind the fear. Indeed, I often find myself describing the cognitive model to clients, that is, that it’s not what happens to us that generates distress, but rather it’s the sense we make of it. As such, it’s not the standing up in front of a crowd of people to speak that generates the fear per se, but rather the ideas that go through your mind, such as “They’re all going to laugh at me” and “What if I dry up? They’ll all think I’m incompetent”. It might be possible to identify the thought, particularly if your phobia is rooted in a specific trauma; however, if it’s fear that has built over time and seems relatively ‘automatic’, or if it is as a result of observing fear in our parents it might be harder to identify the specify fear thought. This is particularly true if you’ve coped by avoiding your feared stimuli. As such, exposure to the feared object might help trigger the underlying thought processes and help you out that way, particularly if they turn out to be unreasonably or unrealistic (as most tend to be!).
Treatment of phobias:
One of the most effective treatments for phobias is exposure. Understanding your anxiety, reading about it, talking to friends, family members or even a therapist can be helpful, but nothing can beat exposure in terms of overcoming a phobia. However, this inevitably comes with a certain degree of discomfort, particularly as any therapist worth their salt will encourage you to face the situation or object that you fear. Doing this suddenly and dramatically (‘flooding’) is generally unhelpful, and instead psychologists have long advocated for a graded exposure approach to overcoming a phobia, which means repeated and prolonger exposure to the feared stimulus to promote psychological habituation (to the fear response) and extinction (when you stop having the fear triggered in response to that specific stimulus). This goes as far back as the 1950s, when Joseph Wolpe developed his treatment methodology which we still refer to today – Systematic Desensitization.

Graded Exposure, such as Systematic Desensitization, typically involves developing a fear hierarchy, or a continuum of feared situations that produce a range of anxiety from 0 (no discomfort fear) to 10 (maximum fear). The phobic client then works through the hierarchy from the least to the most feared situation, but only moving onto the next stage when the current stage elicits no fear at all. This can be a slow process, and there are few quick fixes in psychotherapy, so rush this at your peril!!

Generalisation using exposure is vital to truly eliminate the phobia, so I always encourage my clients to keep on practicing exposure to the point of over-practicing – e.g. if you’re scared of heights, keep hanging out in the food terrace at the top of a shopping centre; if you’re terrified of dogs, keep going to the park; scared of the Tube? Keep on getting on the underground! Of course if can be helpful to do this with someone you trust and care about, but be careful not to become too reliant on a companion as they may become another maintaining factor (i.e. “The birds didn’t attack me because I was with my Mum!”)

Being exposed to the feared stimulus (spiders, buttons, clowns) rather than avoiding increases the likelihood of you learning that the predicted feared outcome is wildly different from the actual outcome. This helps you to become more grounded about the anticipated fears and you’re able to reassure yourself that the worst fears are highly unlikely. If these unhelpful thought process are corrected, the physiological arousal should decrease. After all, who ever had a panic attack in response to the thought “That dog isn’t going to bite me”?

Eliminating safety behaviours can be an incredibly powerful but difficult strategy and takes a LOT of willpower. This essentially means dropping all of the things that you normally do to try to ‘protect’ yourself during exposure to the thing that triggers your phobia (e.g. prayers, holding you breath, Prozac, alcohol). Only by eliminating these can exposure be effective.

Relaxation training using progressive muscle relaxation, breathing relaxation, guided imagery, meditation, yoga, mindfulness and breath awareness are all helpful ways of reducing the fear stimulus. This is where YouTube can be your best friend!

Treatment for any excessive or unwarranted fear is paradoxical: it’s easy to explain and extremely tough to put into practice. In the real world, it’s only really necessary to tackle those fears that really get in the way of you living the life you want to live, and as such you only need to reduce them to a level that makes feared situations manageable. I don’t like heights and as such I don’t enjoy flying. I don’t need to work on my fear to the point where it generates no fear at all – unless I wanted to become a pilot! I just need to be able to tolerate my fear so that I can go on holiday.

For more information, check out the website for MoodJuice (www.moodjuice.scot.nhs.uk/phobias.asp), No Panic (www.nopanic.org.uk) and Get Self Help (www.getselfhelp.co.uk/phobias.htm).

Happy New Year!

Alex

Dr Alex Fowke CPsychol is a Clinical Psychologist and accredited Cognitive Behavioural Therapist working in the NHS and private practice. See his website at www.alexfowke.co.uk for more information, or email equiries@alexfowke.co.uk

 

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