Phobias are often dismissed as exaggerated fears, yet for millions of people they are serious psychological disorders that can shape daily life and remain widely misunderstood. Photo credit: Vadim Bogulov on Unsplash
Recently, I completed a survey about my health as part of a longitudinal study in which I have participated for several years. One question presented a long list of mental illnesses and requested that I tick a box to indicate which, if any, I suffer from. I selected no box and progressed through the survey as, for all the researchers knew, a perfectly mentally healthy individual, with no diagnoses or treatment to report. I do not have anxiety, depression, OCD, schizophrenia, or any of the psychological disorders listed. I do, however, have a specific phobia.
We all have an everyday understanding of phobias, which are simply big fears. But phobias, when defined and diagnosed according to certain criteria, can also be severe psychological disorders. In the Diagnostic and Statistical Manual of Mental Disorders (DSM), a specific phobia is defined as a ‘[m]arked fear or anxiety about a specific object or situation’. Crucially, the fear or anxiety is disproportionate to the actual danger posed.
To receive a diagnosis, symptoms of the phobia must cause ‘clinically significant distress’, or significantly disrupt a person’s life, for example preventing work or socialising. Most people who would casually mention a snake phobia do fear snakes, but this has a limited impact on their daily functioning beyond avoiding the reptile section of a zoo. Someone with a clinically significant snake phobia might refuse to walk in grassy areas and suffer extreme social isolation as a result. (There is, of course, a complex spectrum between these two extremes.)
…almost everyone I know can report at least one excessive or unusual fear which could reasonably be called a phobia.
Phobias are some of the most common mental health disorders. This is unsurprising: almost everyone I know can report at least one excessive or unusual fear which could reasonably be called a phobia. The lifetime prevalence of phobias, diagnosed in accordance with the DSM, is estimated at 7.4%. This result means that, for every one-hundred people, at least seven will experience a clinically significant phobia during their lifetime. I expect that a much larger proportion of people would report some sort of phobia that would not meet clinical thresholds. Phobias are more common in women and typically start young, with a median age of onset of eight. For comparison, lifetime prevalence of depression is estimated to be 10.8%. The lifetime prevalence of schizophrenia, which made it onto the list of options for the survey I recently completed, is less than 1%.
In both research and healthcare settings, phobias are often shoehorned into the umbrella of “anxiety disorders”. This categorisation is reasonable; phobia symptoms resemble those of Generalised Anxiety Disorder (GAD). Nevertheless, there are several important distinctions between phobias and other anxiety disorders. Most obviously, specific phobias are, in both nature and name, not “generalised”. Furthermore, a crucial symptom used to diagnose a specific phobia is extreme avoidance of the phobic object, which does not appear in diagnostic criteria for anxiety. Avoidance can become ritualistic or compulsive; anecdotally, some phobia sufferers find more shared experiences among sufferers of OCD. Indeed, the gold-standard treatment for specific phobias, exposure therapy, is very similar to exposure-response prevention (ERP) therapy, which is recommended for OCD. Generalised anxiety disorders are typically treated with cognitive behavioural therapy, which may involve exposure, but generally overlaps less with exposure therapy than ERP does.
It may be surprising to learn that people receive treatment for a specific phobia. Most people who identify as having a phobia manage extremely well, largely by taking measures to avoid uncomfortable confrontations. Nonetheless, between a tenth and a quarter of people with a specific phobia receive treatment during their lifetime, and very severe phobias can be treated in mental health hospitals. Exposure therapy for a specific phobia is as unpleasant as it sounds: patients repeatedly expose themselves to things they fear, until the anxiety dwindles. It is extremely effective, with some studies reporting up to a 90% success rate. Unfortunately, it has a high dropout rate, which is concerning: it may be those suffering most who resist and discontinue exposure treatment.
…between a tenth and a quarter of people with a specific phobia receive treatment during their lifetime, and very severe phobias can be treated in mental health hospitals.
I have myself received exposure therapy and have experienced firsthand its transformative benefits. During my treatment, I met phobia sufferers for whom exposure therapy is ineffective, or feels too terrifying to even consider. Nevertheless, I strongly advocate for phobic individuals to seek out treatment, if they are experiencing significant distress or avoiding things that they would otherwise want to do. Phobia sufferers are unlikely to find the right treatment, or realise that phobia-specific treatments exist, if their disorder is often sidelined into an umbrella that does not represent them.
As is common in mental health disorders, lines may blur between phobias and other diagnostic categories. For example, a person with a severe germ phobia might equally be said to suffer from contamination-related OCD. Confusion also arises from the difference between the everyday use of the word “phobia”, and its clinical profile. Researchers perhaps exclude phobias when studying psychological disorders to avoid inadvertently including participants with mild phobias that are not relevant to research. This can be solved with some extra clarity in the wording of survey questions, or a shift in public perception, much as we can distinguish clinical anxiety from a sporadic, normal anxious feeling.
Phobias are hugely under-researched, and vast amounts of data are lost due to categorisation with other disorders.
My phobia has, at times in my life, been extremely debilitating, and is without a doubt relevant to any research concerning health and wellbeing in which I participate. I believe phobias can affect a person just as much as other common mental health disorders. Phobias are hugely under-researched, and vast amounts of data are lost due to categorisation with other disorders. There is even less research separating individual phobias to explore if we can tailor treatment more effectively for specific phobic objects. To do justice to the experience of people with severe specific phobias, we need a shift in both research settings and in everyday discussions around phobias, to avoid mistaking debilitating disorders for manageable fears.
