The Truth About Phobias

Phobias may be irrational but they are real medical conditions that can be treated.

Medically Reviewed by Michael W. Smith, MD

Weddings are generally joyous occasions, but not so for Marissa Wolicki, 25, of Toronto, Canada, who reluctantly attended one recently with her boyfriend.

"All of a sudden, the room started to spin. I started to feel really nauseated. My heart went pound-pound-pound-pound. I grabbed my boyfriend's hand and said we had to go. He said, 'We can't go. We're in the middle of a wedding!' He started getting mad at me. People who don't have these attacks don't understand. My legs started to shake. I had a fear of fainting and embarrassing everyone -- a fear I was going to die."

For Wolicki, this was another in a series of attacks brought on by a social phobia, a form of anxiety disorder marked by irrational fears so terrifying they can sometimes lead a person to avoid everyday situations. How many people suffer from phobias? About 8% of American adults, according to the American Psychiatric Association.

"Phobias are real," says Jerilyn Ross, who is a licensed clinical social worker, president of the Anxiety Disorders Association of America, and director of the Ross Center for Anxiety and Related Disorders Inc. in Washington, D.C. "People should not feel ashamed. For some reason, their bodies do this. Phobias are serious -- and can be treated."

Ross is familiar with phobias from two vantage points: as a medical expert and as a patient. She overcame a serious phobia of being trapped in tall buildings.

"The experience of phobia is so unlike what most people know as fear and anxiety. If you try to tell them there's nothing to be afraid of, that just makes the person feel more alone and distant," Ross tells WebMD. "People with phobias are always aware that their fear doesn't make any sense. But they cannot face it."

"An adult with phobia does indeed recognize the fear response is exaggerated," says Richard McNally, PhD, a Harvard psychology professor. For example, "they recognize that this is not a poisonous spider but can't help but react with disgust and aversion to any spider they see. So these people cannot go into their backyard for fear of spiders."

And if the backyard isn't safe, maybe crossing the street isn't, either. "This is where phobic people's worlds start getting smaller and smaller," Ross says.

Which is what happened to Wolicki, who has agoraphobia, a fear of open spaces. When she was in high school, she could rarely leave her house. In fact, on many days she rarely left her bed. "I thought that if I slept all day, the hours would pass faster and I would not have to experience panic attacks," she says.

Most people think fear has a primal source. If you're afraid of dogs, the thinking goes, a dog must have bitten you. But very few people with phobias recall these kinds of "conditioning events," says McNally. To explain this, psychologists developed the notion that we are hardwired to fear certain things. Fear of snakes, for example, helped our ancestors avoid poisonous bites. Scared but safe, they passed on their snake-fear genes.

But this theory doesn't come close to explaining most phobias.

"Why," McNally asks, "would we have an evolutionary fear of spiders if the vast majority are not poisonous to humans?" His answer? "Spiders and snakes move quickly and unpredictably. They are highly discrepant from human form. It may not be so much that we are biologically prepared to fear spiders because they threatened our early ancestors but that certain things related to spiders happen to elicit fear."

Certain things trip wires in our brains. As we get older, most of us outgrow these fears. Some of us don't. And some of us apparently have extraordinarily sensitive fear alarms.

Which is why, in the future, McNally says, phobias may be referred to as a kind of "fear circuitry disorder."

Not everyone who is scared by a spider or who feels anxious in a crowded elevator or airplane has a phobia. Phobias are learned behaviors. And while they can't be unlearned, it's possible to override them with new learning.

"The goal of treatment is not to disconnect the fear but to overcome it with new learning that overrides the underlying fear," McNally says. The technique is called exposure therapy. Here's how it works:

Evaluation: A professional therapist first assesses a patient and asks what he or she is afraid of, and what has happened in the past that may contribute to these fears.

Feedback: The therapist conducts a detailed assessment and offers a treatment plan.

Fear hierarchy: The therapist creates a list of fearful situations, increasing in order of intensity.

Exposure: The patient is exposed to the feared situations -- starting with the least scary. Patients learn that panic decreases after a few minutes.

Building: The patient moves up the list to confront increasingly difficult situations.

Take, for example, a person with a snake phobia who decides to try exposure therapy. Barbara Olasov Rothbaum, PhD, director of the Trauma and Anxiety Recovery Program at Atlanta's Emory University, starts with pictures of snakes. Then she and her patient handle rubber snakes. Then they go to the zoo. Then comes the ultimate test.

"We have a photo taken with a snake around the patient's neck -- with the patient not experiencing any anxiety," says Ross. "In the future, when that person starts to get scared, the picture serves as a reminder."

Does treatment work forever? Not without constant practice, Rothbaum says. "It's like losing weight. You have to stick with diet and exercise to stay thin."

And Wolicki? With exposure therapy, her world slowly is getting larger.

"I got over some of my phobias," she says. "Now I can get into an elevator and not think it is going to stall and I am going to die. And I can take the subway. I am still a little hesitant, but I can do that."

Published August 16, 2006.

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SOURCES: Jerilyn Ross, LICSW, director, Ross Center for Anxiety & Related Disorders; president, Anxiety Disorders Association of America, Washington, D.C. Richard J. McNally, PhD, professor of psychology, Harvard University; member, specific phobia and posttraumatic stress disorder committees, American Psychiatric Association DSM-IV and DSM-V Task Force; member, National Institute of Mental Health consensus panels for the assessment of panic disorder and posttraumatic stress disorder. Barbara Olasov Rothbaum, PhD, professor of psychiatry and director, trauma and anxiety recovery program, Emory University School of Medicine, Atlanta. Ellyn Geller, EdD, Kingston, N.J. Marissa Wolicki, Toronto, Ontario, Canada.

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