Specific phobias: when you know the fear is excessive and it doesn't help

“I know it can’t hurt me. It’s smaller than my fingernail. And I still slept on the sofa last night, because there was a spider on the bedroom ceiling.”

A sentence like that almost always comes with a laugh that isn’t quite a laugh. The person saying it is usually perfectly sensible: they run a department, drive on the motorway, raise children, pay the bills. And then there is this one thing — a spider, a needle, a lift, a dog, the edge of a balcony — where all that good sense gives way. The worst part is not the fear itself. The worst part is that you know it is out of proportion, and knowing doesn’t help in the slightest.

In this post I would like to explain what a phobia is, why you cannot talk yourself out of it, how avoidance quietly feeds it, and why exposure is the first-choice treatment. I will also say who carries that treatment out — and where my own place in it is.

Fear that is useful, and a phobia that is more than fear

Fear is a useful emotion. If a rustle in the leaves stops you on a forest path, that is exactly what it is for. Professionals speak of a specific phobia only when several things come together: the fear is tied to one particular object or situation, it appears almost every time and almost immediately, it is clearly out of proportion to the real danger, it has lasted at least six months and — this is decisive — it gets in the person’s way or causes real distress. That is how the American diagnostic manual, the DSM-5, describes it.

The last condition matters more than it seems. A great many people are afraid of snakes, but someone who lives in the centre of Ljubljana and feels uneasy at the thought of a viper does not have a phobia because of it. A phobia begins where the fear starts deciding for you: where you go on holiday, which floor you move to, whether you turn up for a blood test, whether you accept a job that can only be reached by lift.

The word “specific” tells you the fear is narrow. This sets a phobia apart from anxiety that spreads across the whole of life, and from panic attacks that seem to come out of nowhere. A person with a phobia can be entirely calm for months — until they meet their one thing.

How common it is

More common than you would guess from how little it is talked about. In 2017 Klaas Wardenaar and colleagues analysed World Health Organization surveys from 22 countries and estimated that roughly 7.4 per cent of people meet the criteria for a specific phobia at some point in their lives. It is more common in women than in men, and it typically starts early, often in childhood.

Two things about that figure seem important to me. First, this is one of the most common anxiety disorders, so you are certainly not the only one on your street. Second, people with a phobia seek help relatively rarely. The reason is understandable. As long as the thing can be avoided the price looks small, and the shame of being afraid of “something so silly” is often greater than the fear itself.

The five groups they are sorted into

There are as many phobias as there are things in the world, but professionals sort them into five groups. The sorting is not an end in itself: the groups differ in when they usually begin, how the body responds and what needs care during treatment.

The third group deserves a note of its own. In most phobias the heart speeds up and blood pressure rises. In the fear of blood, needles and injury, pressure often drops sharply after the initial jump, which is why the person goes pale and may faint. That is not weakness and not exaggeration; it is a different bodily response, and it calls for a slightly different approach. With this group a professional usually adds a muscle-tensing technique to exposure, described by the Swedish psychologist Lars-Göran Öst.

Two phobias from the fourth and fifth groups have their own posts on this blog, because they raise further questions: Fear of flying: what is going on and what helps and Emetophobia: the fear of vomiting that is rarely talked about.

Where it comes from

The first question is almost always: “What happened to me to make me like this?” Sometimes there is an answer. A dog knocked you over when you were five, you went through severe turbulence on a flight, you felt faint during a blood test. Back in the 1970s the psychologist Stanley Rachman described three routes by which we learn fear: through a bad experience of our own, by watching others, and through information. The second route is very common in families. A child who watches their mother freeze at the sight of a wasp and run out of the kitchen learns nothing about wasps, but a great deal about how dangerous they are.

A great many people, though, remember no such event — and that is entirely ordinary. Fears are not distributed at random. In 1971 Martin Seligman pointed out that humans learn to fear snakes, spiders, heights and the dark far more easily than sockets or cars, even though the latter are a good deal more dangerous today. He concluded that we are evolutionarily “prepared” for some fears. Temperament comes into it as well: some children are born with a more sensitive alarm, and phobias appear in families more often than chance would predict.

The good news is that the cause does not have to be found for treatment to work. A phobia is kept going not by how it began, but by what you do with it today.

Why your reason doesn’t help

This is the heart of that unpleasant feeling of being “stupid”. You aren’t. Fear and knowledge about fear arise in different parts of the brain and travel along routes of different speeds. The amygdala, which sets off the alarm, receives a rough picture of the stimulus before the cortex has had time to examine it properly. By the time you realise you are looking at a rubber snake, your heart has already sped up.

That is why persuasion doesn’t work — neither your own nor anyone else’s. Sentences such as “it can’t hurt you”, “it’s more scared of you than you are of it” or “statistically it’s safe” address the part of you that already agrees. The part that sets off the alarm does not learn from words. It learns from experience: from what happened the last time you were near that thing. And if you fled every time, it has only one piece of data to go on — that you survived because you fled.

This is exactly why people with a phobia often know the facts about their fear very well. They know how many dangerous spider species live in their country, how a lift’s braking system works, how many times they have given blood without any trouble. The knowledge piles up and the fear stays the same, because the knowledge never reaches the address where the fear lives.

Avoidance: the solution that becomes the problem

A phobia is kept alive by one very understandable mechanism. When you withdraw, the fear drops within seconds. That relief is so strong and so immediate that the brain files it as the solution. Avoidance is therefore not a sign of weak will; it is a behaviour that has been rewarded a hundred times over.

Avoidance also has a quieter form that people rarely recognise in themselves: safety behaviours. You go down to the cellar, but only with the torch on your phone switched on and someone on the line. You step into the lift, but only if nobody else is in it and the ride is shorter than three floors. You turn up for the blood test, but you look away, clench your fists and count in your head. From the outside you “did it”. Your brain, however, noted that you survived because of the torch, because of the counting, because the lift was empty — not because the situation was safe.

A similar loop drives panic attacks and agoraphobia, except that there the person fears their own bodily sensations above all, not an outside object. I have written about that in Fear of fear: how panic learns to return and Agoraphobia: how life quietly narrows to safe routes, so I won’t repeat it here.

A phobia is never yours alone

This part is barely mentioned in the manuals, and it is the part that interests me most. A phobia rarely stays with one person. Over time a whole family rearranges itself around it: someone checks the rooms, someone does the driving, someone fetches things from the cellar, the children know that dogs are not a topic at dinner. An evening might sound like this (a composed example, not a real person):

“Did you look in the bathroom?”
“I did. Nothing there.”
“Behind the washing machine too?”
“There too. … Maja, I’ve been doing this every evening for three years.”
“I know. I’m sorry. Just tonight.”
“That’s what you said yesterday.”

Nobody in this scene is doing anything wrong. He helps because he loves her and because checking the bathroom is quicker than an argument. She asks because she cannot fall asleep otherwise. And yet his help works in precisely the same way as her escape: it brings relief tonight and confirms that the bathroom is a place that has to be checked. Professionals call this family accommodation. It is almost always well meant, and it almost always prolongs the fear.

Something else comes with it that is harder to talk about. The one who is afraid carries shame and the sense of being a burden. The one who helps carries tiredness and sometimes an anger they don’t allow themselves, because “it’s not her fault”. In this way the phobia slowly becomes a third member of the relationship — one that decisions are made about, but that nobody talks to. How to stand by someone close without wearing yourself out is the subject of How to help someone you love with anxiety — without burning out.

What helps: exposure — and who carries it out

With specific phobias the research picture is unusually clear. The first-choice treatment is exposure: gradual, planned and repeated approach to the thing you fear, without escaping and without safety behaviours. In a 2008 meta-analysis Kate Wolitzky-Taylor and colleagues compared different psychological approaches and found that those based on exposure were more effective than the others, with the strongest effect from exposure in real life — to a real dog, a real lift, a real needle. Medication is not the first choice for specific phobias; that is a matter for a doctor to judge.

It is also striking how short this treatment can be. At the end of the 1980s Öst described treatment in a single extended session lasting up to three hours, in which the person and the therapist walk the whole path from a first look to contact. Later research showed that this approach works for many phobias. That does not mean it is easy, but it does mean that years of suffering are not inevitable.

How exposure works is understood somewhat differently today than it once was. Michelle Craske and her colleagues stress that the old fear does not disappear; a new experience forms alongside it and competes with it: “I was there, I was afraid, and what I expected did not happen.” The aim, then, is not to feel no fear during the exercise, but to stay long enough for the prediction to prove wrong. Something practical follows from this: fear can return after a break, and that is not a sign the treatment failed. I write more about the principles in Exposure: why panic has to be approached, not avoided.

Here I need to be clear about myself. I do not carry out exposure. It is a method of behavioural and cognitive therapy, led by a professional trained in it — a cognitive behavioural therapist or a clinical psychologist — and the dose, the order of steps and knowledge of particular features, such as fainting in the fear of blood, all matter. In Slovenia the route to that kind of treatment usually goes through your GP, who can refer you on.

As a therapist in training under supervision in relational family therapy, I work with something else: with what happens between people around the fear. Who in the family is carrying whose fear. How partners talk about the thing they have not talked about for years. What it means that the fear appeared just when a great deal was changing at home. This is not a substitute for exposure. But it is often what makes the decision to try it easier — or what helps a family stop quietly serving the fear. I also work with English-speaking clients, in person in Ljubljana.

An exercise: a map of your fear

This exercise is not yet exposure. It is preparation for it and, at the same time, a way of looking at your fear — perhaps for the first time in years — as something with a shape and edges. You need a sheet of paper and twenty minutes.

1. Write down what you are really afraid of. Not “dogs”, but what you expect: “it will jump at me”, “I’ll faint in front of everyone”, “I won’t be able to bear the feeling”. Fear is almost always a prediction, and a prediction can be tested.
2. List what you avoid because of it — and beside each item, what it costs you. A walk by the river, a visit to friends who have a dog, a check-up you have been putting off for two years.
3. List your safety behaviours and the people who help you. Who checks the room, who goes instead of you, what you must have with you. This is the part of the map that is hardest to see for yourself.
4. Arrange five to eight situations from easiest to hardest and rate each from 0 to 10 on a distress scale. A drawing of a spider might be a 2, a spider in a jar on the far side of the room a 5, a spider on your hand a 10. You now have a draft of what is called an exposure ladder.
5. Choose the lowest rung and stay on it. Look at the drawing or photograph and don’t put it down straight away. Watch what happens to the fear if you do nothing, and how much of what you predicted actually happens.

If even the lowest rung overwhelms you, or if this is a fear of blood and needles that makes you feel faint, stop at step four. The map you have drawn is exactly what a professional needs at a first appointment.

Where this explanation does not apply

Everything I have written holds for a specific phobia. But not every strong fear is a phobia, and not every phobia needs treating.

Sometimes the fear is proportionate. If a dog bit you badly a month ago, caution around dogs is not a disorder. If you fear driving after a road accident and images, jolts in the body and nightmares keep coming back, this may be a response to a traumatic event, which calls for different treatment from a phobia.

Sometimes the same name hides something else. Fear of lifts can be a phobia, but it can also be fear of having a panic attack in a space with no exit, which I describe in Panic at the wheel, in the lift, in the shop: why there. Fear of dirt or illness can be part of obsessive-compulsive disorder. Fainting, a pounding heart and dizziness should be looked at by a doctor first. Telling these apart is not your job, nor mine; the assessment is made by a clinical psychologist or psychiatrist.

Not everything has to be treated. If you are afraid of snakes and never meet them in your life, the fear may be taking nothing from you. The measure is not whether the fear is “normal”, but whether it narrows your life — whether because of it you skip a check-up, don’t visit people you love, don’t accept something you want.

Exposure is not being thrown in at the deep end. A neighbour who holds a spider in front of your face “for your own good” is not doing therapy. Exposure without your consent, without gradual steps and without the chance to stay long enough generally deepens the fear. The same goes for parents: children’s fears are largely developmental and most pass by themselves, and forcing does not speed them up.

And a limit to the family explanation. The fact that those close to you serve the fear does not mean they caused it. A phobia is not proof that something is wrong with the relationship. But the relationship is often the place where something can shift for the first time.

What to remember

• A phobia is not an exaggerated character trait but a learned alarm tied to one particular thing; we speak of a disorder when it lasts for months and narrows your life.
• Knowing the fear is out of proportion doesn’t help, because the part of the brain that sets off the alarm learns from experience, not from words.
• Avoidance and safety behaviours bring immediate relief, and that is exactly why they keep the fear going.
• Well-meant help from those close to you can work as avoidance too — which is why a phobia is often a whole family’s business.
• The first-choice treatment is gradual exposure led by a professional trained in it; it is often shorter than people imagine.