Phobias (phobic disorder)

Panicked fear of spiders, fear of flying or fear of heights? Then you probably have a phobia, a form of anxiety disorder. You can find out more about causes, symptoms and therapy here

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Phobias - briefly explained

Phobias is an exaggerated fear of certain objects or situations. They belong to the category of anxiety disorders, which in addition to phobias also include panic disorder and generalized anxiety disorder.

Common to the phobias is an inappropriately great fear, which manifests itself in physical complaints such as palpitations, dizziness or nausea. If the phobic reactions are triggered by clearly definable situations or objects, one speaks of an isolated or specific phobia. The generalized anxiety disorder, on the other hand, manifests itself more through an undirected fear and "permanent worry". In the case of social phobia, which, like isolated phobias, is classified as a phobic disorder, it is very difficult for those affected to be the center of attention and, for example, to talk in front of others. A phobia is treated with psychotherapy, possibly accompanied by drug therapy.

What is a phobia?

Anyone who suffers from a phobia has a strong and long-lasting fear of a certain object or a certain situation - for example, a spider or a visit to the dentist. A phobia is characterized by inappropriate fear and a physical response triggered by the situation or just imagining the situation.

Anxiety disorders are among the most common mental disorders in Germany. The most common among them is the specific phobia. Almost every tenth person suffers from it at least once in a lifetime. A specific phobia often begins in childhood, sometimes it only develops between the ages of 30 and 40.

Typical characteristics of the phobia

Fear is an important sensation. It serves as an internal hazard detector. However, certain characteristics indicate a pathological fear, an anxiety disorder:

  • Physical reaction: The fear is very pronounced and leads to unpleasant physical symptoms for which no organic causes can be found - such as palpitations, tremors, shortness of breath, nausea, gastrointestinal complaints or sweating. Even at the thought of the cause of fear, those affected get intense feelings of fear that they can hardly control. The fear sometimes escalates into a panic attack.
  • Inappropriate Fear: Objectively speaking, the fear is inappropriate - there is no objective reason to be so afraid. Those affected often know this, but still cannot keep the fear under control.
  • Avoidance strategy: After all, many fear fearful moments so much, are so "afraid of their fear", that they try to avoid fear-inducing situations and objects as much as possible. This flight from fear usually leads to an intensification of the fear. It spreads easily to other areas of life and can ultimately massively restrict everyday life.

How are phobias classified and what phobias are there?

The anxiety disorders are divided into four groups, whereby there can be smooth transitions.

  • specific phobia
  • Panic disorder / agoraphobia
  • generalized anxiety disorder
  • social phobia

The individual groups are listed and described in more detail in our picture gallery (see separate box below).

What phobias are there?

Isolated (specific) phobia

The range of possible fear triggers is almost infinite. A number of fears have their own medical terms - from acrophobia (fear of heights), aviophobia (fear of flying), ceraunophobia (fear of thunderstorms) and claustrophobia (fear of confined spaces) to vaccinophobia (fear of vaccinations). Animal phobias are widespread, such as the fear of spiders. It is medically called arachnophobia. There is also nomophobia (fear of being without a cell phone).

Typical characteristics of the phobia are that the fear specifically refers to a very specific object, such as an animal or a syringe, or to a very specific situation, such as a place at high altitude. Those affected can therefore name and narrow down very precisely what they are afraid of.

Fear of animals

The fear of spiders in particular is widespread. But other animals can also be frightening for some people, such as bees, snakes or dogs.

Nomophobia

With nomophobia (from English: no mobile), those affected are afraid as soon as their cell phone is out of range. They fear, for example, that they will miss an important phone call that could be a matter of life or death.

Agoraphobia - fear of crowds, squares, or elevators

Agoraphobia often begins between the ages of 20 and 30, and women are more often affected than men. Experts describe the fear of situations and places as agoraphobia that one could only leave with greater care or in which one would only get limited support should it become necessary. For example, the intense fear of certain places or situations in which it would be difficult or embarrassing to escape. Typical triggers are crowds, public transport or elevators. The fear can become so strong that it can lead to panic attacks. But fear of being alone is also part of agoraphobia; an accompanying person can give the person concerned security. Agoraphobia can occur alone or in combination with a panic disorder.

Agoraphobia is not "claustrophobia"

The term agoraphobia contains the Greek word "agora" = "marketplace". This is why this phobia is often called "claustrophobia". However, this is misleading. Because most people understand claustrophobia to mean the fear of tight, small, enclosed spaces. This claustrophy (fear of space) is one of the specific phobias (see below).

Agoraphobia - two examples:

1) Mr. Y is afraid of standing in a large crowd. He imagines that he might suddenly need help - for example because he is dizzy or because his heart is out of rhythm. In such an emergency, he would have difficulty leaving the crowd, and helpers could only reach him with difficulty. He fears that he will then become the center of attention in an embarrassing way.

2) Ms. X is tormented by feelings of fear as soon as she is on public transport - takes a long train or plane trip. Because she cannot leave a train or an airplane immediately in an emergency or receive help from outside. Thinking about your own safety is of course not pathological. In agoraphobia, however, the fear is exaggerated and cannot be logically justified. A person affected can be twenty years young and proven to be in good health - and still have a pronounced fear of an impending heart attack.

Many of those affected avoid more and more places and opportunities that could trigger fear - they no longer go shopping in the department store, forego going to the cinema, only sit down on the subway when accompanied. In extreme cases, those affected do not leave their home at all. Your life shrinks to a minimal radius of action.

Social phobia

The social phobia usually arises in childhood and adolescence. Sufferers fear situations in which they are the focus of attention. A characteristic symptom is an exaggerated fear of being judged, criticized or rejected, of attracting negative attention, of being somehow embarrassing and of being the center of attention inadvertently. In addition, many fear that their fear will become apparent to others: that their cheeks will blush with excitement, that their hands will tremble, that beads of sweat will appear on their foreheads - and that others will interpret this as weakness. Patients with social phobia usually try to take precautions to appear as inconspicuous and "normal" as possible. They control their behavior very closely: for example, they sit in the back row, they avoid eye contact, they only speak when it is inevitable. Some drink alcohol to "loosen up". Others try to hide their red cheeks under thick makeup.

Social phobia - part 2

Distorted self-awareness

Patients' self-perception is usually severely distorted. Often others do not even notice your supposedly bad mistakes. Even the excessive fear is usually not recognizable for the environment.

Social phobia is also not synonymous with shyness. Those affected do not have to appear overly cautious about their surroundings - while they can be under great stress internally.

In severe cases, the anxiety disorder can be so pronounced that it makes normal togetherness impossible and leads to loneliness and complete withdrawal. The social phobia is often linked to other psychological problems, for example depression or alcohol abuse and addiction. Both diseases may also reinforce each other.

Social phobia - an example

16-year-old Monika (name changed) reports that she suffers from anxiety in various situations. For example, it is very difficult for her to address people she does not know, especially people of the same age. In the school class she was afraid that the teacher would call her and ask her questions, especially if she had to give a presentation. She also doesn't like talking on the phone in front of others and has to ask her parents when it comes to making appointments, for example with a doctor. She is very afraid if she has to give a presentation. She feared she might stall, or have a total blackout, or say something stupid. In such situations, she is also afraid of blushing and being laughed at by others. In such situations, she sweats more or shakes, feels a lump in her throat and blushes. She prefers to avoid such situations completely, but if that is not possible, speak softly and quickly and do not look at her classmates.

She has always been a shy child. It was stressful that the parents had often moved with the whole family, so that it was difficult for them to get used to again and again. After the last move, she hardly made any friends in her current school. She was also bullied by students and felt like an outsider. After a few days off, she stopped going to school and once she was invited, she turned it down and used a stomachache and headache as an excuse. She is often very sad and alone and is at home in the room most of the time.

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Passed out from fear?

Many also know the fear of blood ("cannot see blood"), of injections, needles or injuries. This form of phobia has a peculiarity: in fearful situations, the affected person's blood pressure often drops for a moment and their heart beats slower. This can cause a brief faint. At the sight of a wound or when blood is drawn, the patient simply falls over and is briefly passed out.

In contrast, the other phobias tend to increase blood pressure and pulse at the moment of fear.

Cause: What causes a phobia?

A phobia usually does not arise from a single cause. Different triggers work together with different weightings.

Some triggers pave the way, generally make you more susceptible to anxiety disorders - such as a certain upbringing, personal disposition, individual peculiarities in the area of ​​brain metabolism. Bad experiences can play a role, and circumstances such as overly concerned family members may perpetuate fear.

experience

Fear can be learned to a certain extent. An example: a small child is afraid. Coincidentally, at that moment, there is a dog nearby. Although the animal has nothing to do with the child's fear, the child unconsciously connects the animal with his feelings of fear. From now on every dog ​​suddenly triggers feelings of fear without there being any understandable reason for it.

education

Parents and other caregivers exemplify certain behavior patterns. If, for example, they react excessively excited at the sight of a spider, the children can take over the behavior. This mechanism seems to be important, especially in the case of specific phobias - such as a spider phobia.

Human history

Scientists also observe that some objects trigger phobias more easily than others. Significantly more people are afraid of a snake than of a television set - probably because the fear of snakes has been learned over generations in the course of human history - in other words, warning of a real danger.

adventures

Very specific situations can, under unfavorable circumstances, become the starting point of a phobic disorder.

An example (experiences)

Ms. X doesn't like to remember her first flight on vacation. Because of all the stress in the office, she barely had time to pack her bags, got caught in a traffic jam on the way to the airport and barely reached the plane. The start was delayed by a thunderstorm. During the flight, the machine got into turbulence and was shaken vigorously - pure stress.Ms. X experienced the whole day as a roller coaster of negative emotions, from tension to anger to sheer fear.

When Ms. X booked a bus trip a year later, she felt anxious at the thought of the journey and the cramped sitting in the means of transport. They increase until the day of departure. Finally, Ms. X cancels the vacation. This increases the fear of the next similar event. After all, she even avoids trips by car.

Disposition

Anxiety disorders are sometimes more common in families. There seems to be a certain willingness for it that is inherited, so to speak. However, this does not mean that relatives of anxious patients will always fall ill.

Brain metabolism

Our brain cells communicate via messenger substances. Scientists assume that a disturbed balance of certain messenger substances in the brain can be the starting point for the development of phobias. Doctors sometimes prescribe drugs to treat severe anxiety disorders that affect the brain's metabolism and thus relieve symptoms.

Inner conflicts

Depth psychology interprets pathological fear as an expression of an internal, insoluble conflict. According to the theory, there are actually unconscious, repressed feelings behind the symptom of fear.

An example (internal conflicts)

XY`s parents split up when she was little. The girl grows up with her mother, there is no contact with her father. XY lives in the strong fear that the mother could suddenly disappear too. The child is overwhelmed with this fear. The deep fears do not penetrate XY`s consciousness, but are suppressed and redirected. Fear is looking for a "simpler" goal: XY is suddenly afraid of crowds. XY can deal with this fear and avoid dreaded situations. The fear of the crowd serves as a placeholder for a deeper fear. The fear could also fulfill a further function: XY unconsciously binds her mother to herself through the fear. Because the mother has to accompany her over-anxious daughter on many occasions. The risk of being abandoned decreases.

Diagnosis: how is a phobia diagnosed?

Medical history and physical examination

Many patients first turn to their family doctor. Sometimes when taking the medical history (discussing the medical history), general complaints such as difficulty sleeping or pain are reported without the person concerned being aware of an anxiety disorder. Above all, they feel physical symptoms of anxiety such as palpitations, dizziness or nausea. Therefore, at the beginning it is necessary to ask the doctor specifically about fear. He asks about the symptoms and the circumstances in which symptoms of anxiety occur.

Further diagnostics and laboratory tests

In any case, it must first be clarified whether a physical cause could be behind the symptoms - for example a heart disease, a respiratory disease, a neurological disease such as a migraine or a metabolic disorder such as an overactive thyroid or diabetes mellitus. In addition to a physical examination, electrocardiography or blood tests can also be used.

The doctor will also check what medications the patient is taking. Sometimes they can trigger or intensify fears.

Interview and questionnaires

If there is a suspicion of a pronounced anxiety disorder that requires treatment, the doctor will usually refer to a specialist - a psychiatrist or psychotherapist.

The specialist will talk to the patient in detail. He asks in which situations the fears arise, whether the patient consciously avoids certain opportunities or objects, or whether the fear arises "out of the blue". With the help of standardized questionnaires, the psychiatrist or psychotherapist can assess more precisely which anxiety disorder is present and how much the fears hinder the patient's everyday life.

Anxiety can also be a symptom of another mental illness, such as depression, obsessive-compulsive disorder, alcohol addiction, or drug addiction. It is not uncommon for several diseases to be present at the same time.

Therapy: How is a phobia treated?

There are different ways to treat a phobia: Psychotherapeutic methods, especially behavior therapy, have proven their worth. Medicines can also be useful in certain cases. A combination of different methods is also conceivable. The therapy can take place individually or in groups, on an outpatient basis or in a clinic.

Patients have to discuss the best therapy in each individual case with their treating specialist. Usually phobias can be treated well. Anxiety disorders rarely improve without therapy. In addition to the patient's personal level of suffering, the psychosocial limitations resulting from the anxiety disorder are decisive for starting treatment.

psychotherapy

Cognitive behavioral therapy is not just about behavior change, as many believe. At the beginning there are detailed discussions. The patient and therapist try to clarify in which situations the fear arises, what function it has in the patient's life, and which factors maintain it. The aim is to get to the bottom of some of the underlying problems.

The therapist works with the patient to develop an explanatory model for the phobia and derives possible therapeutic steps from this. These are discussed with the patient and common goals are worked out. It is important that the patient actively cooperates, knows how the treatment is going and makes free decisions.

Confrontational exercises often help with specific phobias. The patient consciously exposes himself to his fear-inducing objects and situations (exposure). There are different variants:

  • The exposure can take place in sensu (i.e. imagining) or in vivo (in reality).
  • Exposure in sensu can be graded with relaxation (= systematic desensitization) or massaged without relaxation (= implosion).
  • The implementation of an exposure in vivo can also either be graded (= step-by-step procedure) or massaged (= flooding - a quick, intense experience of fear).

Through exposure therapy, those affected learn to return to avoided objects and situations and to face their fear step by step. In addition to the experience that the fear does not increase immeasurably, but usually subsides on its own after a certain time, the main thing is that the patients have positive new experiences. These new experiences, such as "I can cope with the situation, my fears have not materialized, I am competent, I have / I am learning new skills" contribute significantly to a new self-confidence and experiences of self-efficacy. To enable these new experiences to be transferred to as many situations as possible, it is important to repeat the exposures and to carry them out in different contexts (for example, when treating altitude phobia: different buildings, times of day, personal sensitivities and with and without therapeutic support). Positive memories (such as photos of successful expositions) can promote positive storage of the sense of achievement.

Group therapy for social phobia

In the treatment of social phobia, group therapy has proven to be helpful in addition to individual therapy. Patients have the opportunity to check their actual effect on others in a protected setting and to test situations in role plays. As a further exercise, you could, for example, ask strangers on the street for something specific (for example, route, time).

As part of the treatment, those affected should be taught the ability to unconditionally accept the fear that arises and to recognize which options for action still exist for those affected despite the fear. The focus here is on the experience of an expectation violation, to recognize that the expected fears have not materialized, as well as new experiences of self-confidence or self-efficacy to be able to cope with difficult situations for those affected.

Further procedures

Relaxation techniques such as progressive muscle relaxation according to Jacobson or autogenic training can support the therapy.

Depth psychological methods get to the bottom of the underlying causes of an anxiety disorder more intensively. Your goal is to uncover the inner conflicts that could be the real cause of the phobia (see chapter causes). In detailed discussions, the patient and the specialist look for possible solutions. Such therapies can last from months to years.

Recently, so-called mindfulness and acceptance-based therapy methods have also been used for anxiety disorders in addition to cognitive behavioral therapy. With MBSR (Mindfulness-Based Stress Reduction), those affected learn, among other things, to adopt a mindful attitude, to accept thoughts and events without evaluating them. Put simply, this can be helpful to live more in the here and now, to develop more acceptance of feelings and thoughts, to reduce avoidance behavior and to cope with fears.

Endurance sports, such as running three times a week, can be recommended in addition to other therapy methods for panic disorders / agoraphobia. Sports beginners and people over 35 years of age should seek medical advice on the appropriate amount of training.

In the case of exposure methods, in addition to exposure in vivo and in sensu, exposures in the virtual world are also increasingly used (exposure in virtuo). These are mainly used to treat specific phobias (e.g. fear of heights, fear of flying).

Medication

If the phobia severely limits the person's life and hinders therapy, or if there is another mental illness, the specialist may be able to prescribe medication. Above all, antidepressants such as selective serotonin reuptake inhibitors (SSRI) and selective serotonin norepinephrine reuptake inhibitors (SNRI) are used. These substances influence the metabolism of the brain messenger substances serotonin or serotonin and noradrenaline. In some cases, tricyclic antidepressants or MAOIs can also help. However, it usually takes a few weeks for the drugs mentioned to take full effect.

In exceptional cases, the doctor can also prescribe calming medication. It should be noted that the drugs that are still most frequently used - the so-called benzodiazepines - can quickly become addictive. They should really only be prescribed in an emergency. There are also sedative drugs that do not pose a risk of addiction.

Certain so-called atypical neuroleptics can also have a positive effect on those affected with anxiety disorders without there being a risk of addiction.

Patients should seek detailed advice from their doctor about the medication - about possible side effects and benefits.

Prof. Dr. Ulrich Voderholzer

© W & B / private

Our advisory expert:

Professor Dr. Ulrich Voderholzer is the medical director and chief physician of the Medical-Psychosomatic Clinic Roseneck in Prien am Chiemsee and an expert on obsessive-compulsive disorders, sleep disorders and depression. He is a member of the German Society for Psychiatry and Psychotherapy, Psychosomatics and Neurology (DGPPN), board member of the Scientific Advisory Board of the German Society for Obsessive Compulsive Diseases (DGZ) and has published numerous publications.

Swell:

  • German Society for Psychiatry and Psychotherapy, Psychosomatics and Neurology (DGPPN), S3 guidelines for the treatment of anxiety disorders. Online: https://www.dgppn.de/_Resources/Persistent/0c2fc607fa678377a9efb4f13d5ce7007f2c43d0/S3-LL_Lang_Angstören_2014.pdf (accessed October 29, 2019)

Warning: This article contains general information only and should not be used for self-diagnosis or self-treatment. He can not substitute a visit at the doctor. Unfortunately, our experts cannot answer individual questions.

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