Phobias, Part 2: Causes and Treatments

Simply put, a phobia is a fear of something specific, such as fear of spiders in arachnophobia, or something more general in nature, such as a type of social phobia in which one fears giving a performance. According to the National Institute of Mental Health, phobias are the most common form of anxiety disorder, affecting as many as one in five people, but patients who haven't been able to cope with a phobia by avoiding the "trigger" can take heart in knowing that treatment is successful in a very high percentage of cases.

A variety of techniques have proved effective in helping people "face their fears" and overcome them, including basic relaxation methods, gradual exposure to the cause of the fear, or more total "immersion" in whatever it is that brings on phobia-based panic. And medications, including certain antidepressants, are often used in conjunction with other therapies to very good effect.

"Specific phobias are eminently treatable," said Carlyle H. Chan, MD, Medical College Professor of Psychiatry. "The need for treatment and the treatment itself vary from case to case." Dr. Chan, who practices at the Medical College's Behavioral Health Center, is also Vice Chair for Professional Development in Educational Outreach and Associate Director of the Columbia St. Mary's Center for Psychotherapies.

"If you have a spider phobia, which is fairly common, it's not an issue unless you see a spider. Paradoxically, if you regularly see spiders you probably would desensitize to it and it wouldn't be an issue. For most people with simple phobias it's more of an annoyance and a distraction than it is something that's disruptive in their lives. You may have a fear of heights (acrophobia), but you can still go up on a fire tower during a vacation without having a panic attack. You can do it. It's just that you don't enjoy it.

"For some people, though, it can be incapacitating. They can't work in tall buildings, for example. The key is to know when the symptoms become disruptive in their lives to the degree that they can't do the things they normally need to do or want to do. Then it presents itself as a condition requiring treatment."

Reactions to Danger
Hundreds of specific phobias have been identified, although it is not yet well understood why one person may have astraphobia (fear of thunder and lightning) when most others do not. The same is true for all phobias. Internal workings of the body that come into play when danger is perceived are increasingly well known, though, helping to move forward treatment for anxiety disorders including phobias.

"The anxiety disorders are really part of the fight-or-flight phenomenon," said Dr. Chan. "Our bodies, genetically, are geared up to sense danger. When you sense danger, your brain releases certain hormones that go to the adrenal glands, releasing epinephrine and cortisone. The body is then ready to either fight or run away because it senses danger.

"That danger reaction is adaptive, which is part of the reason it's so common: it's a survival tool. In a dangerous situation you're either going to run and get out of there or you're going to fight for your life. The epinephrine keys your body up. For example, when you start pumping epinephrine it constricts the peripheral blood vessels in the skin so when you get cut you're not going to bleed as much, and it stops digestion and other processes so that you're ready to 'grab' all the energy you need to start running if you need to.

"Things go amok when the danger reaction keeps happening. If the stressor is continuous, this can contribute to anxiety. In an oversimplified fashion, that fight-or-flight phenomenon is just not working correctly in people with anxiety disorders. In those people it is triggered unnecessarily, or excessively, or more constantly. If it's triggered unnecessarily, that's when anxiety panic starts developing."

Dr. Chan added that some people are more sensitized to certain stimuli if they have had earlier experiences that were traumatizing in ways that somehow set them up to overreact with more extreme "fight-or-flight" responses.

Drug and Behavioral Treatments
"Specific to phobias, treatment may depend on the severity of the symptoms," said Dr. Chan. "SSRI antidepressants are among the first-line drugs for panic disorders, and by correlation for phobias." SSRI stands for "selective serotonin reuptake inhibitor." Serotonin is a neurotransmitter, a chemical that brain cells use to communicate with one another. In depressed and anxious individuals, this chemical may be in short supply. SSRIs make sure that more serotonin is available in the brain. The SSRIs include brand names such as Zoloft, Prozac, Luvox, Celexa, Lexapro, and Paxil.

"If it's a severe phobia we'll sometimes start out with an SSRI antidepressant before starting other treatments," said Dr. Chan. "Almost all other antidepressants can also be effective. Antidepressants can decrease the intensity of the panic reaction, reduce the frequency of attacks, and protect against it happening in the future. Medications are often the first approach for more severe cases. The other treatment is psychotherapy, more specifically cognitive-behavioral approaches such as exposure. By actually exposing yourself to the thing that makes you anxious you 'wear down' the body's reaction.

"Through exposure, the body essentially learns that the reaction will go away and 'everything is going to be OK'. For example, I knew a psychiatrist with a fear of flying. He had a PhD in psychology in addition to his MD, and as well as a psychiatry residency, so he certainly understood himself and understood that this was an irrational fear. What he decided to do was reward himself during a semester break with a trip to Europe. He put himself on a plane for eight hours and sat through the anxiety, 'imploded' if you will. The implosion method involves thoroughly exposing yourself to the situation that triggers anxiety and staying with it. That was his approach, and he's been flying ever since."

A more gradual exposure approach is called systematic desensitization, said Dr. Chan. With systematic desensitization, a person with a fear of heights may practice breathing and relaxation techniques, then imagine going up a ladder. "You go up one step, pairing it with the breathing, then come back down. The next time you might imagine yourself going up two steps. As you begin to increase your comfort level through imaginary, then you may do it for real." This type of desensitization can be used with variations and other cognitive behavioral techniques for many different phobias.

There is evidence that anxiety disorders tend to run in families, but testing and treatment at the genetic level are still in the future, said Dr. Chan. "As the study of the human genome continues we may locate indicators for predisposition to anxiety disorder," he said, "but right now all we know is that it can be familial without having identified a gene or genes. And it could be multi-determined, involving more than one gene."

Dr. Chan offered some general advice for those fearful of something specific who may be considering seeking treatment. "It's important to recognize that you're not 'going crazy'," he said. "It's essentially an intense physiological reaction to certain stimuli. And again, the severity of the problem will influence whether a person with a phobia seeks treatment. If you see a spider every few months and get a little anxious about it, there's no reason that you have to go get psychiatric help. But if a phobia has gotten to the point where you can't function or are becoming housebound, or are so troubled by it that you can't do something that you want to do, that may be the time to come in and get some treatment."

Dan Ullrich
HealthLink Contributing Writer

This article includes information from the National Institute of Mental Health.

For more information on this topic, see the first part of Dr. Chan's article, Facing Fears: Most Patients Can Overcome Phobias.

MCW Health News presents up-to-date information on patient care and medical research by the physicians of the Medical College of Wisconsin.