Phobias: types, symptoms and treatment

Key points

• A phobia is an anxiety disorder: fear of an object or situation, out of proportion to the danger, that leads to avoidance [1][7].
• What marks it out is the level of avoidance and impairment, not the fear itself, and it lasts six months or more [7].
• In England, 2.6% of adults met the criteria for a phobia in the week before the 2023/4 Adult Psychiatric Morbidity Survey [4].
• Specific phobias fall into five categories: animal, natural environment, blood-injection-injury, situational and other [7].
• Blood-injection-injury phobia is the type that commonly causes fainting, and treatment is adapted for that [7].
• Exposure-based cognitive behavioural therapy is the main treatment, and NICE has no guideline devoted to specific phobia [2][5].

What phobias are

A phobia is an intense fear of a particular object, situation or activity that is far greater than the danger it poses, and that leads a person to avoid it [1][7]. The fear is persistent, usually lasting six months or more, and it causes distress or disrupts ordinary activities such as work, travel or medical care [7]. Phobias are anxiety disorders [1].

If you need help now. Samaritans: call 116 123, free, 24/7. Shout: text SHOUT to 85258. NHS 111, then choose the mental health option. Call 999 if anyone is in immediate danger.

The difference from a strong dislike is not the strength of the feeling but the impairment: turning down a job that involves flying, skipping a blood test, or routing around a park with dogs [1][7].

Symptoms

Symptoms appear on contact with the trigger, and often when a person expects it.

Physical: - Racing heart, palpitations and chest tightness [1] - Dizziness, trembling, sweating, breathlessness and nausea [1]

Thoughts and feelings: - Severe anxiety out of proportion to the risk [1] - Fear of fainting, losing control or dying [1]

Behaviour: - Avoiding the trigger and anywhere it might appear [1] - Needing someone else present in order to face it [1] - Using distraction, alcohol or reassurance to get through it [9]

Phobias are commonly confused with panic disorder, where attacks have no predictable trigger, and with agoraphobia and social anxiety disorder, where the fear is broader [1]. Fear of vomiting is often mistaken for an eating disorder [8].

Types

Phobias are usually divided into specific phobias with a single trigger and the broader conditions agoraphobia and social anxiety disorder, which the NHS describes as more life-affecting [1]. Specific phobias fall into five categories, from the DSM-5-TR classification [7].

• Animal. Spiders, known as arachnophobia, plus dogs, insects and snakes [1][7].
• Natural environment. Heights, deep water, storms and the dark [1][7].
• Blood-injection-injury. Blood, needles, known as trypanophobia, and medical or dental procedures [7].
• Situational. Flying, known as aviophobia, and enclosed spaces, known as claustrophobia, covering lifts, tunnels and MRI scanners [1][7].
• Other. Vomiting, known as emetophobia, plus choking and loud sounds [7].

Emetophobia, a phobia of being sick or seeing others be sick, may affect up to 8% of people, more often women, and usually starts in childhood [8]. Checking food dates, avoiding foods and reassurance-seeking are common in it, which is why it is often misdiagnosed [8].

Blood-injection-injury phobia stands apart. In other categories heart rate and blood pressure rise and stay raised. Here they rise and then drop sharply, which is why fainting is common in it and rare elsewhere [7]. Treatment is adapted: people stay seated and tense their muscles during exposure [7].

Causes and risk factors

There is no single cause. The NHS lists frightening direct experiences, learned behaviour within a family, a family history of anxiety and negative reactions from others, using cautious wording because the evidence points to no single route [1].

• Phobias usually begin in childhood, the teenage years or early adulthood [1].
• They are more common in women than in men [1][7].
• Reported prevalence falls with age [7].
• A frightening event can start a phobia, but not everyone can identify one [1].

Explanations that blame weak character are not supported: the response is an automatic physical reaction, not a choice [1][7].

How it is diagnosed

In the UK a phobia is usually identified by a GP, or at an NHS Talking Therapies for anxiety and depression assessment. The assessment is a structured conversation covering the trigger, what happens in the body, how long it has gone on and what is being avoided [1][7].

The usual threshold is fear out of proportion to the danger, lasting six months or more, with distress or disruption [7]. Clinicians also check for panic disorder, agoraphobia, social anxiety disorder and obsessive compulsive disorder, which overlap.

Referral does not have to go through a GP, as people can self-refer to these services [2]. The national standard is a first appointment within six weeks for 75% of people and within 18 weeks for 95%, though waits differ between services [3]. A diagnosis describes a pattern, and that pattern is not fixed.

Treatment

Exposure-based cognitive behavioural therapy is the main treatment, and the NHS lists CBT first among talking therapies for phobias [2]. Exposure means staying in contact with the feared thing until anxiety falls by itself, called habituation [9].

A graded exposure hierarchy is the practical form this takes:

• List situations involving the trigger and rank them from least to most frightening, each rated 0 to 100 [9].
• Start near the bottom of the list rather than the top [9].
• Stay in the situation until anxiety drops, which can take five minutes to two hours [9].
• Repeat a step four or five times in a week before moving up [9].
• Drop distraction and safety behaviours, which keep the fear going [9].

For blood-injection-injury phobia, exposure is combined with muscle tensing and staying seated, to reduce the blood pressure drop that causes fainting [7].

A meta-analysis of nine randomised trials compared virtual reality exposure with real-world exposure in 371 participants. It found no significant difference for specific phobia, and an advantage for real-world exposure in social phobia [10]. The trials were small, so the evidence is promising rather than settled [10].

The NHS lists antidepressants, beta blockers and sedatives among treatment options, and any decision is made with a prescriber [2]. No medication is approved specifically for specific phobia in the United States, and none is licensed for it in the UK [7]. Hypnotherapy is also listed, and has been studied far less than CBT [2].

NICE has no guideline devoted to specific phobia. Its guideline on common mental health problems, CG123, has been stood down, NICE stating that its recommendations are now covered elsewhere or out of date [5]. Related conditions have their own guidance, including social anxiety disorder [6].

Living with phobias

Plan ahead for encounters you cannot avoid, such as a blood test, a scan or a flight. Telling the nurse or radiographer beforehand lets them adjust what happens, and if needles are the trigger you can ask to lie down [7].

Keep track of what you turn down. Avoidance grows quietly, and each avoided situation makes the next harder [9].

At work or university you do not have to disclose a diagnosis, but explaining the practical effect makes adjustments easier to arrange, for example around travel, lifts or first aid duties. The NHS lists breathing exercises and support groups as self-help, and some airlines and zoos run sessions for fear of flying and spiders [1].

When to speak to a professional

Speak to your GP if a phobia is affecting your daily life [1]. You can also refer yourself to an NHS Talking Therapies service [2].

Contact someone sooner if you are:

• Avoiding or postponing medical care, vaccinations or blood tests
• Turning down work, study or travel because of the trigger
• Planning your day around avoidance
• Drinking alcohol or using medication to get through encounters
• Having panic attacks, or noticing the fear spread further

If you feel unable to keep yourself safe, contact Samaritans on 116 123, text SHOUT to 85258, or call NHS 111 and choose the mental health option. Call 999 if anyone is in immediate danger.

Common questions

Why do some people faint at the sight of blood or needles?

Blood-injection-injury phobia produces a different physical response: blood pressure and heart rate rise and then fall sharply, and that drop causes fainting [7]. Tensing the muscles and staying seated during exposure counters it [7].

Is emetophobia an eating disorder?

No. Emetophobia is a specific phobia of vomiting, often confused with an eating disorder because people avoid foods to prevent sickness [8]. It is also mistaken for obsessive compulsive disorder and health anxiety [8].

Can a phobia go away without treatment?

Some fears fade, and reported rates of specific phobia fall with age [7]. Avoidance works against this, because it prevents anxiety settling on its own [9]. Where a phobia affects daily life, the NHS points to treatment rather than waiting [1][2].

Clinical review pending

References

1. NHS. Overview: Phobias. NHS. https://www.nhs.uk/mental-health/conditions/phobias/overview/
2. NHS. Treatment: Phobias. NHS. https://www.nhs.uk/mental-health/conditions/phobias/treatment/
3. NHS England. Mental health access and waiting time standards. NHS England. https://www.england.nhs.uk/mental-health/resources/access-waiting-time/
4. NHS England Digital. Adult Psychiatric Morbidity Survey: Survey of Mental Health and Wellbeing, England, 2023/4. Chapter 1: Common mental health conditions. https://digital.nhs.uk/data-and-information/publications/statistical/adult-psychiatric-morbidity-survey/survey-of-mental-health-and-wellbeing-england-2023-24/common-mental-health-conditions
5. NICE. Common mental health problems: identification and pathways to care (CG123). National Institute for Health and Care Excellence. https://www.nice.org.uk/guidance/cg123
6. NICE. Social anxiety disorder: recognition, assessment and treatment (CG159). National Institute for Health and Care Excellence. https://www.nice.org.uk/guidance/cg159/resources/social-anxiety-disorder-recognition-assessment-and-treatment-pdf-35109639699397
7. Specific Phobia. StatPearls, NCBI Bookshelf. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK499923/
8. Oxford Health NHS Foundation Trust. Emetophobia. Oxford Health Specialist Psychological Intervention Centre. https://www.oxfordhealth.nhs.uk/ohspic/problems/emetophobia/
9. TalkPlus NHS Talking Therapies. Graded Exposure. TalkPlus, 2023. https://www.talkplus.org.uk/wp-content/uploads/2023/12/Graded-Exposure.pdf
10. Wechsler TF, Kümpers F, Mühlberger A. Inferiority or Even Superiority of Virtual Reality Exposure Therapy in Phobias? A Systematic Review and Quantitative Meta-Analysis on Randomized Controlled Trials. Frontiers in Psychology, 2019;10:1758. https://www.frontiersin.org/journals/psychology/articles/10.3389/fpsyg.2019.01758/full