Things That Go Bump in the Night: Specific Phobias
Specific phobias are fears of things or events such as dogs, thunderstorms, and closed spaces (e.g., closets). These fears, while quite common (7% to 13% of us will develop one or more specific phobias in our lifetime), are not likely to be seen by psycholgists or psychiatists. Only 12% to 30% of people with specific phobias seek professsional help. Because the objects or events causing the fears are often easily avoided, are not encountered on a regular basis, or the fears only occur infrequently. Usually when people with specific phobias are not in the presence of the feared object or event, they experience little fear. However, for some people their fears can have a marked effect on their lives. For example, people with fears of flying may be restricted in the types of jobs they have. Similarly, people with fears of enclosed spaces, such as elevators, may not be able to attend appointments or would have to climb long flights of stairs to attend appointments. This can be problematic for people who have physical problems.
The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) lists five sub-types of specific phobia disorders: animal fears (e.g., fear of snakes), fear of natural environment events (e.g., fear of thunderstorms), fear of blood/injection (e.g., fear of seeing blood), fear of specific situations (e.g., fear of elevators), and “other” fears (e.g., fear of vomiting).
Most adults with specific phobias recognize that that their fears are out of proportion to the actual danger of the situation. But knowing this usually does not lessen the fear they experience when in the presence of the feared object or event. However, young children often do not have this recognition and believe the feared “thing” to be dangerous.
Symptoms of specific phobias, which can include severe anxiety, dread, and panic attack, usually begins in childhood or early adolescence and may occur earlier for girls than boys. There is evidence that twice as many elderly females have specific phobias compared to elderly males. However, the ratio of females to males is dependent on the type of phobia experienced. Approximately 80% of those who have animal phobias and 55% to 75% of those with blood/injury phobias are female.
Some of the factors that lead to the development of specific phobias include traumatic events, such as being attacked by an animal or experiencing panic attacks when in the presence of the object or event. If a panic attack occurs, it is often associated with objects or events occurring at the time of the attack. Additionally, children can develop specific phobias if their parents have similar fears. If young children see a parent (who is supposed to be big and brave) become fearful, that thing may become dangerous in the childs's mind. If parents or other respected adults repeatedly tell children that something is dangerous, they can become afraid of the object or event.
Some phobias do develop in adulthood following traumatic events, even if the event happens to someone else, because it can be assumed that it could also happen to you. Some fears can be transitory and others persisitent. For example, fears of animals and boogey men are common during childhood, but can be transitory. However, other fears such as blood and injury fears are quite persistent.
The type of phobia a person develops is also affected by culture and ethnicity. For example, people in some cultures have strong beliefs in magic or spirits. In these cultures people are more likely to develop fears related to objects or events associated with these beliefs. The beliefs, which are common, are not the cause of the phobia. A phobia would only be diagnosed if the person's fear was out of proportion and/or caused significant distress or impairment.
Phobias are often associated with other psychological problems. It is estimated that 50% to 80% of those meeting the diagnostic criteria for a specific phobia will also meet criteria for at least one other mental disorder. In addition, the likelihood of having another mental disorder may be much higher for those whose phobias developed at a very early age.
One of the most effective treatments for phobias, either in childhood or adulthood, is Cognitive Behaviour Therapy (CBT). The specifics of CBT often vary when working with children compared to adults. As stated earlier most adults recognize that their fears are out of proportion to the actual danger presented by the phobic object or event. As a result of this, the adult client can be challenged to evaluate his or her fearful thoughts and, through graded exposure, change his or her thoughts to more realistic thoughts about the feared object or event. With many children, however, they truly feel the object or events is real (the monster in the closet is very real to a young child). Exposure, or having the child approach fearful objects or events, is also difficult. Young children when asked to approach a feared object, such as a closet or dog, will often resist and may have tantrums. Often a non-fearful child can be used as a companion to the fearful child in early stages of exposure. Parents, because they are often seen as protectors, can also be useful if they are gentle and not too demanding.
When using exposure with children, as with adults, the therapist should always try to recruit ideas from the client on how to do the exposure. Children, especially, are more willing to engage in exposure tasks if they suggest them. During the early stages of exposure, children should be verbally praised for small steps. This includes not only praising the child directly but also telling other important adults (e.g., grandparents) how brave the child is.
Two Case Examples of Specific Phobias
The two cases described below are good examples of specific phobias that have markedly affected each person's life. Names and details of the individuals described have been changed to protect their privacy. The first case is detailed, the second just provides the major features of the phobia
Dick was a 61 year old male who worked for in a provincial government office as an accountant. He enjoyed his work and the people he worked with. He had worked for the government in this position, or similar positions, for the last 25 years. His salary was quite good and he had excellent benefits. However, prior to making an appointment with me he was seriously considering retirement. His reason was that his office, in fact the whole accounting department, had recently been consolidated from several different locations. This was done to improve efficiency. For Dick the problem with the consolodation was that he had a marked fear of small, enclosed spaces such as elevators. When his office first was moved, Dick tried to use the stairs to get to his office. He found this very difficult because of an arthritic left knee. Because of his fear and his physical problem, he began to dislike going to work. A friend of his suggested that he get therapy for his elevator fears.
Dick recognized that his fear was out of proportion to the actual dangers involved in elevator travel. However, this did not keep him from avoiding travel on all elevators.
Dick's problems began when he was a young child and was locked in his bedroom closet by his older brother. It was done as a prank, but Dick became very panicked and pounded on the door, but only was relased an hour later. After that event he avoided enclosed spaces of all types. He even had to have a light on in his bedroom at night.
Because he recognized the irrationality of his fear (he did not know of anyone who had been harmed in an elevator) he willingly agreed to do exposure therapy. He suggested we start with him entering an elevator, but with the door remaining open and the elevator stationary. After doing this several times, he suggested letting the elevator door close, but not move. He knew that he could open the door at anytime, but I encouraged him to let his fear wane before opening the door. If he opened the door while he was very fearful, it could strengthen the fear. Because of his knowledge that he could let himself out, he was able to remain in the elevator with the door closed. After about two minutes I suggested he come out. He said that his fear was quite bad initially, but he said to himself, “The elevator is not moving and I can get out whenever I want.” These self-statements replaced his initial thoughts that he would be caught on the elevator and not be able to get out.
After doing this he suggested that we go down one floor on the elevator. We did this several times. During the next session he suggested going one floor by himself. He did this several times going both up and down one floor.
After the fourth session where he had been able to ride the elevator by himself up or down five floors he suggested he take the elevator up one floor at his work place and walk the remainder of the floors. Fortunately, as it turned out, a friend of his boarded the elevator at the same time he did. He felt that he could not explain why he was only going to ride one floor and went all the way to his office. He called to report what had happened , telling me that although initially very frightened, he calmed down when his friend started talking to him. I only saw Dick for one more session to provide him with relapse prevention information. This included telling him that he should talk to himself if he became fearful (realistic thoughts rather that fear thoughts), he should remain in the situation until his fear calmed down rather than bolting away, and and he should praise himself for seeing things through.
Lisa was a 26 year old female with a terrible fear of moths. Her fear was so bad she had difficulty visiting friends in the evening if they left their porch light on because moths would fly around the light. Before she would go for an evening visit, she would call her friends and ask them to turn their porch light off. Her fear and her need to have the light off brought ridicule from even her best friends. “What could a moth do to you?” was a common response when she told them of her fears.
Similar to Dick, she recognized her fears were excessive and was aware that the chance of being harmed by a moth was almost zero. Even so, her fears persisted.
Treatment consisted of helping her develop more appropriate thoughts (e.g., “I don't like moths buzzing around me, but they won't harm me.”)--and exposure therapy. Fortunately, the biology department at my university had an old collection of moths that we no longer used for teaching purposes. They readily gave me several. During our first session, Lisa looked at the mounted moths and described their colour, shape, and general appearance. However, she did not touch them. Over the next two sessions she began touching them and inspecting various parts of their bodies. At one of the last sessions she suggested that I put several of them on her hair and arms. It was obvious that she was initially uncomfortable, but, with encouragement, she let them remain on her until her fear abated.
During the last session, we visited a friend during the evening. The friend was asked to keep the outside light on. Lisa walked to the door and stood there while moths buzzed around the light. She waited for five minutes before knocking on her friend’s door. During all this I waited at the curb. She later told her friend that she was nervous as she walked to the door, but not frightened. As she watched the moths, her feelings of nervousness were replaced by an amusement over the moth’s antics. She actually thought them quite funny.
She later reported that she had had several moments when moths bothered her, but that she was able to calm herself. I did not hear from her again--a good sign.