Conquer Anxiety: Transform Your Life with Angus Munro

Anxiety forms the basis of a vast range of mental health disorders, and is the most common psychological issue that people seek help about. Even so, anxiety remains a tricky thing to define. It is always challenging to try to define subjective emotions and feelings- we all experience anxiety in our inner world, but how do we define that experience and put it into words? (Taylor and Arnow, 1988).

We have a great many words for anxiety: fear, concern, anxiety, apprehension, terror, panic, fright, agitation, and many others, all with different nuances in meaning. The fact that we have so many words for anxiety highlights how important it is to our experience as humans (Marks, 1987), but it does also complicate and discussion of fear and anxiety on a more scientific level.

As a very basic definition, anxiety is a response to perceived harm. Our mental response to a sense of danger is extremely complex, involving a huge range of brain areas including the visual thalamus, amygdala and visual cortex. Anxiety is rooted in the body’s “fight or flight” response- in which the body and mind prepare to combat or escape from danger through a variety of changes.

The fight or flight response takes place on three separate levels. Physically, the body prepares for danger by raising the heart rate and breathing more deeply, increasing the levels of available oxygen in the bloodstream. Resources are diverted away from the rest and digestion systems- which are not needed to respond to danger. This can lead to the feelings of nausea often experienced when feeling anxious.

Secondly, when the fight or flight system is activated, our attention naturally turns towards the perceived source of danger. This can lead to “tunnel vision”, making it harder to concentrate on anything but the source of fear. Third, the individual is motivated to take action- to attempt to confront (fight) or avoid (flight) the source of their fear.

The fight or flight response has been essential to our survival throughout human history. Feeling no sense of peril and having no desire to avoid harm would make us far less likely to survive as a species. So while anxiety is never pleasant to experience, it’s important to remember that it serves a valuable function.

Abnormal Anxiety

While it has helped us survive for thousands of years, the fight or flight response is far from perfect. A system which was designed to help early humans outrun predators or avoid natural disasters isn’t always subtle or sensitive enough to meet the different kinds of anxiety we face today. The FF response can sometimes produce “false alarms” and activate when we are not actually in danger. At other times, it activates in a way that is out of proportion to the actual threat of a situation.

Having your mind and body respond to low-level threats as though you are in a life-or-death situation can be extremely unhelpful. For example, public speaking is a situation which produces anxiety for many people. Having your FF response activate as though you are getting ready to run away from danger by raising your heart rate, making you sweat, and focusing your attention on all sources of threat around you does very little to help you speak well!

Whenever anxiety could reasonably be considered disproportionate to the actual level of threat, we categorize it as some kind of anxiety disorder. There are a variety of anxiety disorders we recognise today, including phobias, social anxiety and general anxiety, and while the object of fear is very different in each of them, the underlying processes of anxiety are remarkably similar (Abramowitz & Deacon, 2005).

Anxiety disorders are grouped according to the source of the fear, but this doesn’t mean two people with the same disorder will necessarily fear exactly the same things. If you were to take, for example, two people with social anxiety, one may fear talking to members of the opposite sex for fear of humiliating themselves, while another may fear speaking up in front of large groups due to worries about saying something stupid. Both the fears, and the beliefs underlying them, are different.

How Does Anxiety Develop?

Fear can be learned in many different ways. Research has identified that there are four main pathways by which anxiety disorders tend to develop:

Classical Conditioning

The most direct and obvious means by which fear can be learned is through experience. Having a frightening experience with a dangerous situation or stimulus would understandably lead to a fear of the same thing happening again.

Learning to fear dangerous things in this way is perfectly natural. However, through the process of classical conditioning one can also develop a fear of harmless, non-threatening stimuli if they are encountered at the same time as something dangerous. For example, a person who encounters a deadly spider in their car glove box may develop a fear of getting into the car. Previously the idea of driving was not associated with any anxiety, but following the incident with the spider it has become mentally linked with the idea of danger. The car on its own is now enough to produce fear, even without any indication that there’s a spider in the glove box a second time.

Classical conditioning may account for how many fears are formed, but it can’t be the whole picture. Not all extreme fears are the result of direct experience after all- many people fear flying before they ever set foot on a plane. Equally, not all dangerous experiences lead to the formation of an anxiety disorder. So why do some people experience threatening or traumatic events without developing an anxiety disorder?

One possible explanation is a process called latent inhibition. This is where a prior positive experience can serve to “protect” you from developing fear as a result of negative experiences. Having many fond memories with dogs may protect you from becoming afraid of them after a single bad experience, such as getting bitten by a stray. Such danger is considered the exception, rather than the rule, and so fear and dogs do not become strongly linked in the mind (Poulton & Menzies, 2002).

Modelling

Modelling, or vicarious learning, is the process of learning by observation. Observing other people acting fearfully in certain situations can often lead to the belief that the situation must be dangerous, and to the development of fear.

Misinformation

Fears can be passed on without any direct contact through the spread of incorrect or exaggerated information. Examples of this include anxious parents warning their children of the dangers of climbing trees or playing outside after dark, TV adverts for antibacterial products warning about germ and bacteria, or sensationalist news reports about crime or natural disasters.

Evolutionary Preparedness

Some fears are more easily acquired than others. Certain fears, such as heights, spiders and snakes, are very common. While these stimuli are dangerous to some extent, they are far from the most dangerous thing people regularly come into contact with- far more people are killed in car accidents than by spiders, many more people are afraid of spiders than of driving.

The reason for this is evolutionary preparedness: the fact that humans are predisposed to fear stimuli and situations which posed a danger to our ancient ancestors. Stimuli such as spiders, snakes or heights were common threats earlier in human history, and this has made our minds more predisposed to fear them.

Why Doesn’t Anxiety Go Away?

Why do some people develop anxiety disorders while others don’t? Lots of people experience traumatic and frightening events such as accidents, injuries and so on. Some people who experience such trauma go on to develop anxiety disorders in one form or another, but by no means all. So what’s the difference

Often it comes down to the beliefs people hold. A person’s beliefs can help them recover from a traumatic event or they can lead to the fear from that trauma lingering in their daily lives. Research has identified several beliefs which can contribute to the development of anxiety disorders:

Probability Overestimation

Anxious individuals often overestimate the likelihood of something bad happening if they encounter their feared situation. Individuals with a snake phobia may overestimate the odds that a snake will attack them on sight, or overestimate how common deadly snakes are in their area, while individuals with a driving phobia might overestimate the odds of a car crash. While both snake bites and car crashes are of course possible, most people recognise that the odds of their occurrence are low, and as such do not get overly anxious about these possibilities.

Severity Overestimation

A similar belief is overestimating the consequences of something bad happening. People with anxiety disorders often believe that their feared situations will be unbearably awful, even if others would see them as unpleasant but by no means catastrophic (Gellatly & Beck, 2016). No one enjoys the idea of forgetting their lines when giving a speech, but most people would hardly see it as the end of the world. Yet someone with a social phobia around public speaking would believe that such an occurrence would be terrible beyond endurance, and this belief would greatly contribute to the anxious individual’s desire to avoid such situations.

Intolerance of Uncertainty

While most people recognise that some degree of risk and uncertainty is unavoidable in life, some anxious people hold the belief that any degree of uncertainty is unbearable. For such people, the fact that their feared situations are extremely unlikely is little comfort- as long as there is any doubt in their mind, there is still danger. This intolerance of uncertainty can cause people to avoid any and all situations in which there is even the slightest risk of something bad happening, and can be a major contributing factor to the development of anxiety disorders (Dugas, Buhr, & Ladouceur, 2004).

Low Coping Self-Belief

Another belief which can contribute to anxiety is one’s belief in how well you will cope with danger. Low estimates of your own coping ability could lead to anxiety in situations others would find non-threatening (Bandura, 1988). Most anxious individuals have low confidence in their own coping ability, which increases their desire to avoid any and all dangerous or difficult situations. Such avoidance unfortunately deprives them of the chance to learn good coping skills, or even to see that they in fact could cope much better than they expect.

Anxiety Sensitivity

Very anxious individuals may also fear anxiety itself. People may believe that anxiety is an unpleasant experience in itself, or may fear being seen to panic and thus make fools of themselves, or fear the idea of losing control and being unable to avoid harm (Cox et al, 1999). Even more severe beliefs around anxiety sensitivity could include believing that being frightened or surprised could lead to a heart attack, or that prolonged anxiety may lead to losing one’s mind.

Safety Behaviours

Safety behaviours are actions people take in frightening situations to try and reduce the anxiety they feel. Examples of safety behaviours vary greatly depending on the kind of anxiety in question, but could include avoiding eye contact when out in public to avoid the sense of judgement from others, remaining close to a handrail to mitigate the fear of being in a high place, or repeated phone calls to a doctor over health concerns. The exact nature of the behaviour is not important- it is the intention to reduce anxiety that makes an action into a safety behaviour.

On the surface, safety behaviours may seem like a good way to cope with anxiety. Unfortunately, they ultimately serve to reinforce anxiety by making a person dependant on them to function. A person who calls their doctor weekly to ask health-related questions may soon become dependent on this behaviour to feel safe. They come to believe that their frequent checks around their health are the only thing keeping them safe, when in fact their health would be just as good if they never called the doctor at all. Safety behaviours are therefore “false friends” to anxious people and can become highly restricting to their lives.

There are four main types of safety behaviour:

Passive Avoidance

The simplest safety behaviour is simply to avoid any contact with the source of anxiety. Avoidance can be specific or all-encompassing. A social phobia may, for example, lead to a person avoiding large social gatherings, or it may lead avoiding more specific situations, such as meetings, gatherings in pubs or groups over a certain number of people. Some anxious people may need others to engage in their avoidance as well in order to feel safe- for example a patient with OCD may ask their entire family to avoid contact with anything contaminated in order to satisfy their concerns.

Checking and Reassurance Seeking

Some people engage in excessive checking in order to reassure themselves they are safe. Patients with spider phobia may feel the need to repeatedly check for spiders around their car before getting in, or patients with health-related anxiety might repeatedly check themselves for symptoms of different illnesses.

Compulsive Rituals

Compulsive rituals are internal actions which people perform repeatedly in an attempt to reduce anxiety. Rituals are normally triggered by worries creating a sense of pressure or a need to act to reduce anxiety. Rituals can be overt, such as regular hand washing in response to concerns over cleanliness, or they can be internal, such as forcing yourself to think happy images when negative thoughts enter your mind.

People perform these rituals believing they will remove the source of danger and help them feel less anxious. Rituals do indeed reduce anxiety temporarily- a person who has just washed their hands feels relief at the fact they are definitely clean- but this short-term relief reinforces the ritual behaviour and makes the person more likely to turn to it in the future. In this way rituals quickly become habits that demand large amounts of time and effort.

Mental rituals such as “correcting” bad thoughts or analysing and attempting to “solve” worries can be hard to detect, but nevertheless create the illusion that they are necessary in order to feel safe. In this way they prevent a person truly overcoming their fears.

Safety Signals

Safety behaviours can also involve reliance on cues or signals in the environment which make one feel safe. Cues to safety can vary greatly depending on the nature of the fear- having medication to hand, remaining in a known environment or the presence of a trusted loved one are all possible examples.

Often it is the presence of these safety signals that makes the person feel safe- even if they are never actually used. Individuals who utilise safety signals often become highly anxious when they are not present, creating dependence.

What is a Phobia?

A phobia is defined as a persistent fear of a specific object or situation, causing significant impairment, distress or interference with daily life (APA, 1994). About 12.5% of the population will be diagnosed with a phobia at some point in their lives, making phobias the most common form of anxiety disorder (Kessler, Berglund, & Demler, 2005).

There are countless different specific situations or objects which a person may fear- anything could conceivably become the object of a phobia in the right circumstances. All these different possible phobias are normally categorised into one of four groups (Curtis, Magee, Eaton, Wittchen, & Kessler, 1998):

Situational Phobias (such as fear of flying or being in open spaces)
Natural Environment Phobias (such as fear of heights, storms or waves)
Animal Phobias (such as fear of arachnids, bees or snakes)
Blood, Infection and Injury Phobias (such as fear of medical procedures, injections or seeing blood)

Phobias and Other Disorders

Phobias often begin early in life (Craske et al, 1996). Research shows that developing a phobia can be a risk factor for the later development of other disorders, such as major depression (Kessler et al, 1996) and alcoholism (Kessler et al, 1997).

Phobias are very rarely experienced on their own. Only 24.2% of people with specific phobias reported just one fear- the majority reported two (26.4%), three (23.5%), four (10.4%) or even more than four (17.3%) specific phobias over the course of their lives. As with many anxiety disorders, specific phobias are normally chronic- lasting many years unless treated (Wittchen, 1988).

Impact of Phobias

Phobias are very distressing to live with. Many people who have them find it increasingly difficult to live normal functioning lives- both due to their fears, and the adjustments they must make to their lives to avoid the source of fear (Wittchen, Nelosn, and Lachner 1998).

Despite the suffering phobias create, only 31%of those who meet the criteria for specific phobia diagnosis seek out professional treatment (Regier, Narrow, & Rae, 1993). There are many possible reasons for this.

First, some individuals with phobias believe their condition is untreatable, or that there are no effective treatments available. Second, since the treatment for phobias often involves facing the feared situation, people may be reluctant to participate. Studies shows that around 25% of people with phobias are unwilling to face their feared situations as part of treatment, even if it leads to them being cured (Marks, 1992; Marks & O’Sullivan, 1988).

Third, many people with phobias find it easier to simply avoid the situation or object they fear, rather than attempting to seek treatment. Since phobias are inherently tied to one specific situation or event, making efforts to avoid the feared stimulus often appears an easier course of action. Depending on the kind of phobia in question, this may or may not be feasible, but many patients go to great lengths to cut the feared stimulus out of their lives.

Examples of adjustments people make can include:

A patient with a needle phobia putting off vital surgery since there is an injection as part of the treatment
A patient with a spider phobia moving to a new house to live in an area with fewer spiders
A construction worker being forced to avoid certain jobs due to a fear of heights
An individual forced to take public transport to work due to a driving phobia
A businessman with a fear of flying turning down a job offer because the new job would require frequent flying

Despite the fact that relatively few people with phobias come forward for treatment, phobias are actually one of the most treatable anxiety disorders.

How Do Phobias Affect Different Age Groups?

Children

Nearly all children experience unrealistic or exaggerated fears of some kind. Often these fears arise from simple childhood imagination and children normally grow out of them without issue. For a diagnosis of phobia to be met, the child would need to experience fear in excess of what would be expected at their age and level of development, and the level of distress and impairment caused would likewise need to be assessed based on the child’s development.

Treatment of phobia in children follows broadly the same formula as in adults. Two issues need to be accounted for- first, children do not always express their emotions in the same way as adults- in place of fear they may show behaviour such as tantrums, crying, screaming, or freezing in place. Second, children have little understanding of the idea of avoidance- they may try to avoid the situations or stimuli they fear but may not be consciously aware they are doing so. Psychologists attempting to work with phobic children therefore need to speak to parents or teachers who know the children well in order to understand the child’s normal patterns of behaviour.

Older Adults

Phobias are one of the most commonly experienced disorders in later life, though they are somewhat less common than earlier in adulthood. The distribution of different kinds of phobias is also different: phobias of enclosed spaces, flying, darkness and injections are equally common in older adults as in younger adults; while fears around thunderstorms and heights are more common in older adults.

Treatment using exposure remains effective in treating phobias in older adults, but two additional factors should be considered.

Firstly, specific phobias in older adults often co-occur with other mental and medical conditions, such as chronic obstructive pulmonary disease or coronary heart disease. Older adults are likely to be unaware of the presence of phobia as a separate condition, instead attributing their symptoms to these conditions.

Secondly, older adults tend to show anxiety differently to younger adults- in particular they may show less severe symptoms of anxiety and instead show symptoms of both anxiety and depression. It is therefore possible that an older adult may be misdiagnosed with depression if care is not taken to pinpoint the exact cause of the psychological distress.

Diagnosing Phobias

The Diagnostic and Statistical Manual (DSM) criteria for specific phobia are:

Marked fear or anxiety about a specific object or situation (such as flying, heights, animals, receiving an injection, seeing blood).

Note: In children, the fear or anxiety may be expressed by crying, tantrums, freezing, or clinging.

The phobic object or situation almost always provokes immediate fear or anxiety.
The phobic object or situation is actively avoided or endured with intense fear or anxiety.
The fear or anxiety is out of proportion to the actual danger posed by the specific object or situation and to the sociocultural context.
The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.
The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

These symptoms should also not be more easily explained by another condition.

Fears around phobic stimuli such as spiders, heights or needles are common- more than half of the population would report fears of such things. However, this does not necessarily mean more than half the world would be diagnosed with a phobia. These fears are, after all, somewhat justified- spiders can be harmful, and heights can be deadly.

A critical part of the phobia diagnosis is therefore that the fear must be disproportionate to the actual level of threat. Spiders may be dangerous and treating them with some level of wariness may be prudent, but altering your entire life to avoid contact with spiders and still showing extreme levels of fear about the possibility of encountering one is another matter.

The level of fear a phobia creates can vary greatly. The exact nature of the situation, proximity to the feared stimulus, and a great many contextual factors such as the presence of other people and duration of contact can affect how much fear is elicited. Panic attacks- sudden and severe fear responses- can also occur in the presence of the feared stimulus. Fear may also occur in anticipation of a feared event, or simply through imagining it. An important part of the phobia diagnosis is that fear is always felt in response to the phobic stimulus.

It is very common for individuals with phobias to actively try and avoid the source of their fear. Many individuals will go to great lengths of planning and inconvenience to avoid facing their fears. Examples range from relatively simple adjustments, such as avoiding overgrown areas where snakes are likely to be seen, to huge lifestyle changes and restrictions, such as having to walk or take public transport everywhere instead of driving. For people who have suffered with phobias for a long time, drastic lifestyle changes are not uncommon.

Features Supporting Phobia Diagnosis

People with phobias often show increased physiological arousal when near the source of their fears. The exact nature of this depends on the phobia category. Situational, natural environment and animal phobias often lead to activation of the fight and flight response system, whereas blood-injection-injury phobia is more likely to lead to a fainting or near-fainting reaction. This is caused by a brief rise in heart rate and blood pressure, followed by a significant drop in both.

People living with phobias are at a higher risk of suicide than other people – in fact they may be up to 60% more likely to attempt suicide than the general population. While phobias represent significant levels of distress in themselves, part of the reason for these higher suicide rates is due to the due to the high co-morbidity of phobias with other personality and anxiety disorders.

Prevalence of Phobias

The prevalence of all general phobias is around 7 to 9% of the US population in any given 12 months. Rates are similar in Europe and Australia, and slightly lower in Asia, Africa and Latin America.

There is some variation in phobia prevalence in different age groups. Rates are around 5% in younger children and 16% in adolescents. In older adults the prevalence rate is slightly less at 3-5%, possibly due to individuals who have lived with a phobia for many years no longer experiencing their symptoms as strongly- or simply learning to live with them.

Women are more likely to develop a phobia than men- in fact the ratio of women to men with phobias is around 2:1. Men are more likely to have fears of heights, while animal, environment and situational phobias are more common among women. Blood-injection-injury phobias are equally common across both genders.

Comorbidity

Phobias are very commonly experienced alongside other mental health conditions. Depression (especially in older adults), generalised anxiety, bipolar disorder, substance related disorders, somatic symptom related disorders and personality disorders are all commonly experienced alongside phobias. Since phobias normally have an early onset age, they are usually considered the primary disorder. Even so, when phobias co-occur with other anxiety disorders, the phobia is normally of a lesser severity.

Development and Course

Above we discussed how anxiety disorders generally can develop: through conditioning, modelling or misinformation- with some fears being more likely to develop due to evolutionary preparedness. All of these causes hold true for phobias as well. A phobia sometimes develops due to direct experience- a car crash leading to a fear of driving, a phobia of spiders after encountering a poisonous spider in your garden, and so on.

Research suggests that classical conditioning following a trauma experience accounts for 36% of phobia cases, while modelling or vicarious learning and misinformation account for around a further 8% each. This means that just under half of phobic patients do not know how or why their phobia began (Kendler, Myers, & Prescott, 2002).

Other reasons for phobia onset can include witnessing others in life-threatening or traumatic situations or unexpected panic attacks in certain situations leading to a phobia of those situations- for example a panic attack in an elevator leading to a phobia of enclosed spaces. Sometimes there is no apparent trigger that leads to the onset of a phobia.

Phobias have a relatively early onset- usually developing before the age of ten, although situation specific phobias typically have a slightly later onset than other kinds. It is still possible to develop a phobia at any age, especially given that phobias can develop following a traumatic event. Phobias which develop in childhood can fluctuate in intensity, but tend to stabilise if they persist into adulthood. Once a person with a phobia reaches adulthood, the phobia is unlikely to disappear or reduce in severity on its own.

While it is definitely thought that phobias typically have an early onset age, it is sometimes hard to separate the age of phobia onset from the age at which a person starts experiencing fear of that particular stimulus. Individuals may fear certain objects or situations from a childhood, but these fears may not meet the criteria for a phobia diagnosis until many years later. Research shows that on average there is a period of nine years between the initial onset of fear and it reaching sufficient intensity and impairment to be classified as a phobia.

Issues with Phobia Classification

Above we listed four main categories phobia: situational, animal, natural environment, and blood, injection and injury. These four categories are widely used but not without their issues. For example, some phobias are tricky to place into a single category: is a fear of bridges, for example, an environmental phobia or a situational phobia? What about a phobia of the dark?

Patients often find that these four categories are not especially helpful in allowing them to understand their condition. As a diagnosis, “specific phobia of ocean waves” is much more meaningful and helpful to a patient than “specific phobia, natural environment category”

Treatments for Specific Phobia

Phobias are the most treatable of all anxiety disorders. Research shows that those who attend treatment often show complete recovery. As many as 90% of phobia patients achieve significant, long-lasting reduction in phobia symptoms as a result of treatment. What’s more, such results can often be achieved very quickly- even in a single session (Öst, 1989; Öst, Brandberg, & Alm, 1997; Öst, Salkovskis, & Hellström, 1991).

When considering how phobias are treated, remember that anxiety is meant to serve a function. Treatment therefore does not aim to totally eliminate fear of phobic situations, but aims to teach patients that anxiety is a normal and safe thing to experience. Treatment therefore aims to promote fear tolerance, while addressing the many inaccurate thoughts a phobic individual may hold around their fears and reducing their reliance on safety behaviours and avoidance.

Exposure

The most well researched and effective treatment for phobias is called exposure.

In its simplest form, exposure is simply the process of putting yourself in contact with your feared situation. By facing your fear, you are able to learn that your fearful predictions and expectations may not be accurate. Often the things people with phobias fear no not pose any real threat- or at least are far less dangerous than the phobic individual expects. Learning this is the key to overcoming phobias. Facing the feared situations without relying on anxiety-reducing coping skills or “safety behaviours” is also essential, since as long as you believe safety behaviours are necessary, some level of fear will linger.

Exposure is highly effective, and is often capable of curing a phobia in a single session.

In preparation for exposing themselves to their feared stimuli, patients first create a fear “hierarchy” of situations that provoke fear, from least to most. Patients then work their way up the list, increasing the level of contact with the feared stimuli they are comfortable with, while never being forced to face a situation they find overwhelming. Ideally patients should expose themselves to each item on the list for at least an hour- this allows enough time for fear, negative thoughts and emotions to surface and then pass. Patients may experience fear at first, but should try to remain in the fearful situation until all fear has subsided. Exposure should be completed regularly- ideally every day- and may be completed with the help of a therapist or individually.

Exposure is an effective technique in part because it treats the fear and avoidance patterns which maintain phobias, rather than the beliefs or mental processes which led to its development. The exact process by which phobias are developed is not fully understood, so targeting the well-researched avoidance and fearful beliefs which maintain phobias is a more effective strategy (Clark, 1999).

Overcoming Phobias Through Inhibitory Learning

What happens in a person’s mind when they go through exposure training? The theory of inhibitory learning states that people who expose themselves to their feared situations learn safe associations with them, rather than simply un-learning previously-learned fears. After going through exposure, a patient who holds the belief “dogs are dangerous” does not lose this belief, but rather gains the new belief “dogs are safe”. A new, more helpful and accurate belief has been formed, but the original fearful belief remains on some level.

What does this mean in practical terms? If the original fearful belief is still present, there is always some risk that it will re-appear and affect how a person thinks and acts. Often a change of context or a long length of time passing can lead to the fearful belief reappearing. (Bouton, 2002). On a mental level, fears tend to be generalised across a wide range of situations, but safety needs to be learned afresh in each new situation.

The solution to this is to conduct as much exposure as possible- facing your fears in every conceivable situation so that the new beliefs and thoughts are properly embedded and generalised to any situation a person is likely to come across. Different contexts could include slight variations around the nature of the stimulus or situation, changes in proximity and the exact nature of the encounter, how the person is expected to act during the exposure, and the presence or absence of other people. A person with dog phobia, for example, may learn first that dogs are safe when they are being held by someone else, and then when running free, then when they themselves are holding the dog, and then do all of this again with different dog breeds, and so on.

Exposure should also aim to tackle unhelpful beliefs which can maintain or exacerbate anxiety, such as beliefs around one’s competence or inability to cope.

Types of Exposure Therapy

There are various forms of exposure- although all of them follow the same general principle of learning to feel safe in the presence of the feared stimuli.

In vivo exposure

Exposure in its most straightforward form, in vivo exposure involves the patient coming into direct proximity of their feared situation. Unless there are practical reasons this is not possible, in vivo exposure is often the default treatment plan.

Systematic desensitization

This is a special exposure process developed by Wolpe (1958, 1973) based on his theory of “reciprocal inhibition”. Systematic desensitization involves the patient imagining themselves facing their feared stimulus, while at the same time utilising Progressive Muscle Relaxation (PMR) techniques to stay calm. Systematic desensitisation proceeds in three stages: learning PMR exercises, constructing a ranked list or hierarchy of fears (as with other forms of exposure), and then imagining contact with each of their feared situations in turn while using PMR to stay calm- thereby removing the fear response.

Imaginal exposure

Imaginal exposure involves the patient imagining or visualising contact with the feared stimulus. Often this is undertaken when in vivo exposure is difficult or impractical- such as with exposure to flying, which would potentially require a lot of planning and money to repeatedly expose oneself to in person.

Virtual reality and computer assisted exposure

This more modern approach allows patients to come into virtual contact with their feared situations using computer technology. This can be done with either fully immersive virtual reality (VR) or simply by showing images or videos of the feared stimulus. If the technology is available, virtual exposure can often be practically easier than in vivo exposure, and may be used in conjunction with it.

Eye movement desensitization and reprocessing (EMDR)

This technique was originally developed by psychologist Francine Shapiro (1989) for the treatment of post-traumatic stress disorder (PTSD).

During EMDR, the patient focuses on a frightening image, memory, emotion, or thought, while the therapist moves their finger across the patient’s visual field. The patient tracks the movement of the finger with their eyes. Eye movement of this kind has been shown to aide in re-categorising and changing the thoughts related to the memory being processed. Thus this technique can help people to process and become less fearful of memories, thoughts and images, and can be used in phobias relating to these mental events. EMDR involves a degree of imaginal exposure- in fact some argue this is the real reason for its effectiveness in treating phobias (Renfrey & Spates, 1994).

Applied tension (AT)

This technique is mainly used in treating blood or injection phobias. Patients with these phobias often worry about the possibility of passing out in their presence, such as when having an injection or witnessing graphic injury. In Applied Tension training, patients are exposed to blood/injury stimuli while tensing their muscles to increase their blood pressure. This increase in blood pressure makes fainting impossible, thereby allowing the person to face their feared stimulus and learn that their fears of fainting are not necessarily true (Öst et al., 1991; Öst, Sterner, & Fellenius, 1989).

Cognitive Preparation

In phobia treatment, the main things need to happen for it to be successful are:

Through exposure, the patient must be presented with information that is incompatible with their maladaptive beliefs about the danger of the phobic stimulus.
Behaviours that interfere with the patient acquiring this new information- that is, safety behaviours- need to be identified and stopped.
New, helpful beliefs need to be formed and reinforced in the patient’s mind, and generalised to as many different situations as possible through repeated practice (Foa, Huppert, & Cahill, 2006).

To prepare for this work, treatment often begins by teaching patients about the psychological processes which have created and are maintaining their phobia. Patients are taught that fear is a useful emotion which serves a valid purpose, but which has become maladaptive and unhelpful. Specific education about the real risks around a patient’s phobic stimulus may also be part of this preparation stage: for example, a patient with spider phobia may learn how few spiders are actually dangerous to humans, and how rarely these spiders are encountered.

Patients also need to understand why exposure will be used as the main treatment. While exposure can understandably be a daunting task for a patient to undertake, a patient needs to find the concept credible and be motivated to take part for it to succeed (e.g., Öst, Stridh, & Wolf, 1998).

Does Treating Specific Phobia Require a Clinician?

Treating phobia can be time consuming and intensive for a therapist. In addition, demand for therapists almost always outweighs availability. Whether treatment actually requires a therapist, or whether it can be conducted on a self-help basis, is therefore an important question.

Research shows that for many people, it is perfectly possible to undertake phobia treatment successfully by yourself, without any involvement from a therapist. However, there will always be a continuum of ability to engage with self-help: some patients with phobia may be able to treat their symptoms totally autonomously, others may need some assistance getting started, others still may require help for longer.

Self-Assessment for Phobia

For anyone interested in self-help treatment for a phobia, understanding the different physical, mental and behavioural symptoms affecting you is the first step. Understanding how each one affects the other and developing a plan for how each symptom will be addressed is vital. If done in therapy, this would form the basis for the first 1 to 3 sessions of treatment, but can also be done using self-help materials.

To get an overview of these different symptoms, try going through a recent example of a fearful situation. Think of a recent example of a time you encountered the thing or situation you are afraid of, and ask yourself:

Was there a specific trigger to your feeling afraid?
How severe was the anxiety?
How long did it last?
What was the anxiety like- how did it feel in your body?
What did you do in response to your fear? Did you do anything to try and control or reduce the anxiety you felt? What effect did these actions have?
How did the situation resolve, and how did you feel afterwards?

You may also find it useful to think about the history of your anxiety as this may give you some clues as to the unhelpful beliefs and behaviours you have picked up along the way. Ask yourself:

When did you first become fearful of your phobic stimulus or situation?
What else was going on in your life at that time? Were you feeling stressed or anxious about anything else?
How did your parents (or main caregivers) act when they felt anxious? How did they respond to you when you showed fear or anxiety?
Are there any other experiences in your life which could have contributed to your fears?

As we mentioned earlier, understanding the full history of your phobia is not at all an essential part of treatment, so don’t worry if you can’t fully answer these questions.

Identifying Your Triggers

Now it’s time to think about the exact triggers which lead to you feeling anxious. Generally, cues or triggers fall into three categories: external cues, internal bodily sensations, and mental activity. Think about the following questions and try to identify all of your triggers in each category. This will form the basis of your exposure treatment plan.

External triggers

External triggers which make you feel anxious are usually the easiest to spot. Ask yourself:

In which situations do you feel afraid?
What do you fear will happen in these situations, specifically?
What situations do you avoid?
What actions do you use to keep yourself from feeling anxious during difficult situations?

Internal Bodily Triggers

Internal sensations, feelings and changes are another source of anxiety for many people with anxiety disorders. Examples include sudden, unpleasant unexplained feelings, physical changes which could be interpreted as being a sign of danger, or any physical symptom of anxiety you find especially distressing.

Ask yourself:

What bodily sensations cause you distress or anxiety when you experience them?
What changes to your body make you nervous?
Do any changes or feelings in your body make you feel like something bad is about to happen, or that your health might be in danger?
What physical signs or feelings do you fear that other people will notice?

Mental events

Unpleasant mental activities such as thoughts and memories may also trigger anxiety. To identify these, ask yourself:

What thoughts or memories are you afraid to experience?
Which thoughts or memories do you often try to shut out?
What triggers these unpleasant thoughts and memories?
What form do these thoughts take- are they images? Sounds? Memories?
What is it about these thoughts that is unpleasant for you?
Do you ever experience these thoughts as dreams or nightmares, or only when awake?

As well as looking at these questions to identify your triggers, it can be helpful to pinpoint the feared consequences of your phobic situation. What, specifically, do you think will happen if you get too near your phobic stimulus, or find yourself in your feared situation? Try to be as specific as possible here.

Safety Behaviours

We discussed safety behaviours above, and saw how they can lead to a person’s fear being maintained and create dependence on their continued use. Identifying your safety behaviours and making sure you cut them out of your behaviour is therefore an important part of treatment.

It can be difficult to identify safety behaviours, since they are often such an ingrained part of the way you act that people often do them without really thinking. Try thinking back to the last time you experienced your feared situation: what actions did you perform to try and make yourself feel safer? Were there any mental “rituals” or repeated processes you went through to try and alleviate some of the fear you felt? Try to figure out as much detail as you can about these actions- in what exact situations do they occur, and why exactly do you perform them- are they to make you feel safe, to reduce how visible your fears are to others, to increase your sense of control, or for some other reason entirely?

Factors Influencing Exposure Success

Treatment Engagement

The most common reason exposure doesn’t work is if the patient does not fully engage with it. Exposure may be stressful and will certainly involve some level of anxiety, and for this reason many patients struggle to get to grips with it, especially at first. While this is understandable, research conclusively shows that seeing exposure through is the most effective way to overcome a phobia (Sanderson & Bruce, 2007). Level of engagement with exposure homework during treatment can affect how well the treatment effects are maintained many years into the future.

Duration of Exposure

Another factor which can reduce the effectiveness of treatment is a lack of time spent in the presence of your feared stimulus during each exposure session. It’s very important to stay in your feared situation for as long as possible, to give your fears time to appear, and then subside (Marshall, 1985).

Multiple Phobias

As we said previously, it is relatively common to experience phobias alongside other disorders- and this can include other phobias (Hofmann, Lehman, & Barlow, 1997). A patient may, for example, be fearful of both heights and enclosed spaces- both of these phobias could impact them while in an elevator.

In situations with multiple phobias, the patient and therapist simply need to decide which aspect to work on first, and then address each issue in turn. All fear around one particular aspect of one of the phobias should be eliminated before moving on to the next, and this should continue until all aspects of each phobia have been fully treated.

Influence of Other Unpleasant Emotions and Sensations

Fear is the main emotion linked to phobias, but other emotions and sensations can also play a part.

Disgust. Many phobias produce feelings of disgust as well as anxiety. Phobias of spiders, vomiting, and any blood or injury related situations are just some examples. Fear and disgust should be regarded as totally separate emotions when treating phobias- levels of one do not necessarily affect the other. Disgust, like anxiety, is often reduced through exposure- but some research suggests it is reduced at a slightly slower pace (Olatunji et al., 2002).

Nausea. Feelings of nausea are common in many phobias (Haug, Mykletun, & Dahl, 2002). Fear of vomiting can be an issue during exposure as it may make a patient unwilling to take part in exposure. Fear of vomiting is often linked to a fear of losing control, or an inability to tolerate lack of control (see intolerance of uncertainty above). This belief can be addressed using cognitive treatments aimed at increasing the patient’s ability to tolerate uncertainty (Keefer et al., 2005). Exposure treatment may begin as normal once the patient has become more comfortable with the idea of losing control.

Lightheadedness/Fainting. Concerns about feeling lightheaded or fainting are common in blood, illness and injury phobias. Fainting in the presence of the feared stimulus is relatively common, even during exposure (Sarlo, Buodo, Munafo, Stegagno, & Palomba, 2008). This particular issue can be addressed using a specially designed technique, Applied Tension, which is described above (Öst, Fellenius, & Sterner, 1991). Applied Tension involves instructing a patient in tensing their muscles so as to raise blood pressure, thereby making fainting impossible.

Shame. Finally, shame is also a common emotion felt in relation to phobias. Phobias can be extremely debilitating, and may often lead to a person making major changes to their lifestyle, or becoming very dependent on others. It is not uncommon for patients to be very ashamed of their fears, and the disruption these fears cause to their lives. People with phobias often have rather low opinions of themselves as a result. Exposure should therefore be conducted in a way that is sensitive to this, and does not force the patient into any unnecessary public embarrassment.

Skill Deficits

Since many people with phobias have had them since childhood, their fears may have prevented them from ever learning good ways to act in the presence of their feared stimulus. A man who has avoided dogs all their life, for example, may never have learned the correct way to respond to a dog approaching him, or how to handle a dog appropriately. This lack of knowledge makes it more likely he will get a negative reaction from the dog, thus confirming his fears and creating a negative cycle. This can hinder the exposure process.

In situations like this it can be useful to train the patient in appropriate skills, so that when they encounter their feared situation, they know how to act in a way that is safe.

Cognitive Avoidance During Exposure

Patients taking part in exposure can sometimes engage in mental attempts to distract themselves from the situation. Refusing to fully engage with the exposure in this way is perfectly understandable, but like all safety behaviours, it can reduce the effectiveness of treatment (Rentz et al., 2003). When facing your fears, you need to fully face them, rather than being only partially mentally present. This may be more difficult, but is ultimately necessary to rid yourself of fear.

Engaging with The Change Process

Making any large, long-term change to our lives is a difficult and demanding thing to undertake, and overcoming a phobia is no exception. At the start of any change process, we often have mixed feelings about the prospect of change- some part of us may know that change is best, but some part is still hesitant. Perhaps it’s the unknown quality of change that we find daunting, or perhaps we see the mountain ahead of us and don’t feel ourselves capable of climbing it.

Everyone holds beliefs about the change process. These beliefs can either assist or obstruct you in the journey of change.

Uncovering these beliefs can be a helpful step in resolving any mixed feelings about change. Ask yourself the following questions:

What do you believe about the change process you are currently taking part in?
Are you finding the process easy or difficult? Do you think it should be easy? Why/why not?
What are the challenges involved in making this change to your life?
What are the positives and negatives of making this change?

Unhelpful beliefs about change, or your ability to change, can eat away at your motivation, reduce your engagement in the process and ultimately make it less likely you will succeed. So think about the above questions and see what you come up with.

Some possible answers to these questions, in relation to undertaking phobia treatment, may include:

I don’t have the time to work on overcoming my fears.
I’ve tried to overcome my phobia before and failed.
I have bigger worries and priorities right now.
I don’t know how to get started.
It’s easier to just manage my fear by working around the issue.
I don’t know if I’ll ever succeed, so it’s hard to keep going.
I’ve had this fear for so long there’s no chance of changing now.
I’ll never change- I’m not strong enough.
If I change now, it would mean admitting I’ve been living in a dysfunctional way for years.

These kinds of fears about change are perfectly understandable- the process of overcoming a phobia is a significant undertaking. It is therefore perfectly normal to have some mixed feelings about engaging with treatment- and it’s worth thinking this through fully. Think about both the positives and negatives of going through treatment- this can help prepare you for any difficulties you may experience along the way.

To put this another way- what are the possible benefits of keeping your phobia? That may seem like an odd question, but it can be an interesting one to think about.

Here are some answers that may come to mind:

My phobia is easier to live with than going through all this treatment.
I’m used to my fear and can manage it.
To manage my fear I just need to avoid certain situations. Changing would mean adjusting how I live.
If I keep my fears, I don’t really have to acknowledge them.
Facing and overcoming my phobia will require too much time and energy.
If I avoid trying to change, I avoid the risk of failing.

Do these answers ring true for you? If so, it is worth addressing these concerns now, so that they don’t become roadblocks to your progress further down the line.

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