Anxiety & Mood
Specific phobias: fear of heights, claustrophobia, emetophobia and treatment
Specific phobias explained: how common they are, fear of heights, claustrophobia, emetophobia and blood-injection-injury phobia, why avoidance keeps fear going, and what treatment studies show.
A specific phobia is an intense and persistent fear of something specific: heights, enclosed spaces, vomiting, an animal, blood or injections. The fear is greater than the real danger, and it makes you avoid things. It is very common and usually starts in childhood. The treatment of choice is gradual exposure to what you fear, and it can be short.
How common are phobias?
In the World Health Organization’s surveys in 22 countries, with 124,902 people:
7.4% had had a specific phobia at some point in their life, and 5.5% in the past year,
women had almost twice the rate of men (9.8% vs 4.9%),
the median age of onset was 8 years,
only 23.1% of those with a phobia in the past year had received any treatment.
A phobia rarely stood alone: 60.5% had another mental disorder at some point, and in most cases (72.6%) the phobia had started first. A review in Lancet Psychiatry notes that phobias strongly predict the onset of other anxiety disorders, depression and substance use, and that in 10% to 30% of cases they last for years or decades. The most common fears concern heights and animals.
Fear of heights (acrophobia)
In a representative sample of 2,012 people in Germany:
28.5% had at some point felt discomfort looking down from a height (“visual height intolerance”),
6.4% had a fear of heights (8.6% of women, 4.1% of men),
almost one in five of those with height intolerance (22.5%) had episodes as intense as a panic attack.
The first episodes appeared most often in the second decade of life. The fear quickly spreads to other heights and often lasts for years.
Claustrophobia
It is the fear of enclosed and narrow spaces, such as a lift or a small room. It often shows up during an MRI scan. In a study with 55,734 patients in Berlin, 2.1% had a claustrophobic reaction in a conventional scanner and 0.7% in a newer, quieter scanner with a shorter tunnel. Reactions were more common in women, in middle-aged people and in those who entered the scanner head first.
If you are afraid of MRI scans, tell the imaging centre when you book and ask what kind of scanner they have.
Emetophobia
It is the intense fear of vomiting, your own or other people’s. The first randomised study of its treatment was small: 24 people, 23 of them women. After 12 sessions of cognitive behavioural therapy, 50% showed clinically significant change, compared with 16% on the waiting list. The researchers concluded that emetophobia is treatable, but that treatment still needs improving.
Blood, injection and injury phobia
Here the reaction is unusual: blood pressure often drops and the heart beats very slowly, and fainting may follow. The recommended treatment is “applied tension”: tensing the muscles to raise blood pressure, together with exposure. However, a critical review found only five controlled studies, all from one research group, and little evidence that the tensing adds anything to exposure. If you have fainted during a blood test or a vaccination, say so before the procedure.
Why avoidance keeps a phobia going
A phobia has two parts: fear and avoidance. Avoidance reduces distress in the moment. The course of a phobia runs from fear to avoidance and then to the disorder. That is why researchers believe that early treatment may interrupt this course.
When avoidance keeps the problem going, the goal is gradual exposure, not waiting for the anxiety to go away first. And we count the steps fairly: if out of five times you take the lift twice, that is progress, not failure.
How it is treated
Exposure. A pooled analysis of 33 randomised studies found that exposure therapy had a large benefit and was better than placebo and other psychotherapies. Exposure to the real situation was better at the end of treatment, but not at follow-up. More sessions gave slightly better results. The benefit was similar across all types of phobia.
One-session treatment. It combines exposure and modelling by the therapist in one long session. In the first series of 20 patients, the session lasted 2.1 hours on average. About four years later, 90% were much improved or fully recovered. It was a small series without a comparison group.
Virtual reality. In an Oxford randomised study with 100 adults with a fear of heights, six sessions of about 30 minutes over two weeks, with a virtual coach, strongly reduced fear compared with usual care. The benefit remained at the four-week follow-up, and no adverse effects were reported.
One caveat: exposure remains the treatment of choice, but the authors of the Lancet Psychiatry review note that in the long term it may be less effective than we thought.
In the moment of intense fear, we accept the feeling, not the catastrophic content. “I feel a lot of fear” is true. “I will fall” or “something will happen to me” is a thought produced by anxiety, not a fact.
When to ask for help
Not every fear needs treatment. The criterion I use is how you function: when fear systematically gets in the way of your life, a trip, a medical test, a job or a relationship, then it is worth tackling.
You avoid travel, medical tests, jobs or places because of the fear.
The fear has lasted for months and is spreading to new situations.
You have panic attacks when you face what you fear.
It comes with low mood, or you drink alcohol to cope.
Safety: If fear makes you avoid a necessary test or treatment, such as a blood test, a vaccination or an MRI scan, tell your doctor beforehand. If you have thoughts of harming yourself, call 166 (ambulance, EKAV), 112 or the Suicide Prevention Line 1018.
How I can help
Book an assessment, at the practice in Trikala or online. See also the page on anxiety and panic attacks. If you are wondering which specialist to choose, read the article Psychiatrist or psychologist in Greece? The first conversation can also take place from your home: see how working with an online psychiatrist works, or book an appointment.
This article is educational and does not replace individual clinical assessment. Do not change or stop any treatment you are already taking without talking to your doctor.
Sources
Eaton WW, Bienvenu OJ, Miloyan B. Specific phobias. Lancet Psychiatry. 2018. https://doi.org/10.1016/S2215-0366%2818%2930169-X
Wardenaar KJ, et al. The cross-national epidemiology of specific phobia in the World Mental Health Surveys. Psychol Med. 2017. https://doi.org/10.1017/S0033291717000174
Kapfhammer HP, et al. Visual height intolerance and acrophobia: clinical characteristics and comorbidity patterns. Eur Arch Psychiatry Clin Neurosci. 2015. https://doi.org/10.1007/s00406-014-0548-y
Dewey M, Schink T, Dewey CF. Claustrophobia during magnetic resonance imaging: cohort study in over 55,000 patients. J Magn Reson Imaging. 2007. https://doi.org/10.1002/jmri.21147
Riddle-Walker L, et al. Cognitive behaviour therapy for specific phobia of vomiting (Emetophobia): A pilot randomized controlled trial. J Anxiety Disord. 2016. https://doi.org/10.1016/j.janxdis.2016.07.005
Ayala ES, Meuret AE, Ritz T. Treatments for blood-injury-injection phobia: a critical review of current evidence. J Psychiatr Res. 2009. https://doi.org/10.1016/j.jpsychires.2009.04.008
Wolitzky-Taylor KB, Horowitz JD, Powers MB, Telch MJ. Psychological approaches in the treatment of specific phobias: a meta-analysis. Clin Psychol Rev. 2008. https://doi.org/10.1016/j.cpr.2008.02.007
Öst LG. One-session treatment for specific phobias. Behav Res Ther. 1989. https://doi.org/10.1016/0005-7967%2889%2990113-7
Freeman D, et al. Automated psychological therapy using immersive virtual reality for treatment of fear of heights: a single-blind, parallel-group, randomised controlled trial. Lancet Psychiatry. 2018. https://doi.org/10.1016/S2215-0366%2818%2930226-8
