Causes and symptoms

Experts don't really know why phobias develop, although research suggests the tendency to develop phobias may be a complex interaction between heredity and environment. Some hypersensitive people have unique chemical reactions in the brain that cause them to respond much more strongly to stress. These people also may be especially sensitive to caffeine, which triggers certain brain chemical responses.

Advances in neuroimaging have also led researchers to identify certain parts of the brain and specific neural pathways that are associated with phobias. One part of the brain that is currently being studied is the amygdala, an almond-shaped body of nerve cells involved in normal fear conditioning. Another area of the brain that appears to be linked to phobias is the posterior cerebellum.

While experts believe the tendency to develop phobias runs in families and may be hereditary, a specific stressful event usually triggers the development of a specific phobia or agoraphobia. For example, someone predisposed to develop phobias who experiences severe turbulence during a flight might go on to develop a phobia about flying. What scientists don't understand is why some people who experience a frightening or stressful event develop a phobia and others do not.

Social phobia typically appears in childhood or adolescence, sometimes following an upsetting or humiliating experience. Certain vulnerable children who have had unpleasant social experiences (such as being rejected) or who have poor social skills may develop social phobias. The condition also may be related to low self-esteem, unassertive personality, and feelings of inferiority.

A person with agoraphobia may have a panic attack at any time, for no apparent reason. While the attack may last only a minute or so, the person remembers the feelings of panic so strongly that the possibility of another attack becomes terrifying. For this reason, people with agoraphobia avoid places where they might not be able to escape if a panic attack occurs. As the fear of an attack escalates, the person's world narrows.

While the specific trigger may differ, the symptoms of different phobias are remarkably similar: e.g., feelings of terror and impending doom, rapid heartbeat and breathing, sweaty palms, and other features of a panic attack. Patients may experience severe anxiety symptoms in anticipating a phobic trigger. For example, someone who is afraid to fly may begin having episodes of pounding heart and sweating palms at the mere thought of getting on a plane in two weeks.

Diagnosis

A mental health professional can diagnose phobias after a detailed interview and discussion of both mental and physical symptoms. Social phobia is often associated with other anxiety disorders, depression, or substance abuse.

Treatment

People who have a specific phobia that is easy to avoid (such as snakes) and that doesn't interfere with their lives may not need to get help. When phobias do interfere with a person's daily life, a combination of psychotherapy and medication can be quite effective. While most health insurance covers some form of mental health care, most do not cover outpatient care completely, and most have a yearly or lifetime maximum.

Medication can block the feelings of panic, and when combined with cognitive-behavioral therapy, can be quite effective in reducing specific phobias and agoraphobia.

Cognitive-behavioral therapy adds a cognitive approach to more traditional behavioral therapy. It teaches patients how to change their thoughts, behavior, and attitudes, while providing techniques to lessen anxiety, such as deep breathing, muscle relaxation, and refocusing.

One cognitive-behavioral therapy is desensitization (also known as exposure therapy), in which people are gradually exposed to the frightening object or event until they become used to it and their physical symptoms decrease. For example, someone who is afraid of snakes might first be shown a photo of a snake. Once the person can look at a photo without anxiety, he might then be shown a video of a snake. Each step is repeated until the symptoms of fear (such as pounding heart and sweating palms) disappear. Eventually, the person might reach the point where he can actually touch a live snake. Three fourths of patients are significantly improved with this type of treatment.

Another more dramatic cognitive-behavioral approach is called flooding. It exposes the person immediately to the feared object or situation. The person remains in the situation until the anxiety lessens.

Several drugs are used to treat specific phobias by controlling symptoms and helping to prevent panic attacks. These include anti-anxiety drugs (benzodiazepines) such as alprazolam (Xanax) or diazepam (Valium). Blood pressure medications called beta blockers, such as propranolol (Inderal) and atenolol (Tenormin), appear to work well in the treatment of circumscribed social phobia, when anxiety gets in the way of performance, such as public speaking. These drugs reduce overstimulation, thereby controlling the physical symptoms of anxiety.

In addition, some antidepressants may be effective when used together with cognitive-behavioral therapy. These include the monoamine oxidase inhibitors (MAO inhibitors) phenelzine (Nardil) and tranylcypromine (Parnate), as well as selective serotonin reuptake inhibitors (SSRIs) like fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft) and fluvoxamine (Luvox).

A medication that shows promise as a treatment for social phobia is valproic acid (Depakene or Depakote), which is usually prescribed to treat seizures or to prevent migraine headaches. Researchers conducting a twelve-week trial with 17 patients found that about half the patients experienced a significant improvement in their social anxiety symptoms while taking the medication. Further studies are underway.

In all types of phobias, symptoms may be eased by lifestyle changes, such as:

• eliminating caffeine
• cutting down on alcohol
• eating a good diet
• getting plenty of exercise
• reducing stress

Treating agoraphobia is more difficult than other phobias because there are often so many fears involved, such as open spaces, traffic, elevators, and escalators. Treatment includes cognitive-behavioral therapy with antidepressants or anti-anxiety drugs. Paxil and Zoloft are used to treat panic disorders with or without agoraphobia.

Prognosis

Phobias are among the most treatable mental health problems; depending on the severity of the condition and the type of phobia, most properly treated patients can go on to lead normal lives. Research suggests that once a person overcomes the phobia, the problem may not return for many years--if at all.

Untreated phobias are another matter. Only about 20% of specific phobias will go away without treatment, and agoraphobia will get worse with time if untreated. Social phobias tend to be chronic, and will not likely go away without treatment. Moreover, untreated phobias can lead to other problems, including depression, alcoholism, and feelings of shame and low self-esteem.

A group of researchers in Boston reported in 2003 that phobic anxiety appears to be a risk factor for Parkinson's disease (PD) in males, although it is not yet known whether phobias cause PD or simply share an underlying biological cause.

While most specific phobias appear in childhood and subsequently fade away, those that remain in adulthood often need to be treated. Unfortunately, most people never get the help they need; only about 25% of people with phobias ever seek help to deal with their condition.

Prevention

There is no known way to prevent the development of phobias. Medication and cognitive-behavioral therapy may help prevent the recurrence of symptoms once they have been diagnosed.

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