An irrational fear that produces a conscious avoidance of the feared subject, activity, or situation is called a phobia.

EVERYONE has fears. However, some people are so affected by it that they arrange their lives to avoid whatever they are afraid of.

This irrational fear, which is called a phobia, may be towards a situation, place, object or animal. When the affected person is exposed to the source of the fear or thinks about it, anxiety and even panic can result.

The American Psychiatric Association defines phobia as “an irrational fear that produces a conscious avoidance of the feared subject, activity, or situation. The affected person usually recognises that the reaction is excessive.”

Phobias are a common anxiety disorder and can affect anyone, irrespective of gender, age or social background. Some phobias start in early childhood and resolve spontaneously as the child grows up. Other phobias start in adolescence and the 20s. Many phobias occur after a stressful experience or situation. Some phobias may persist for several years.

Types of phobias

Phobias are classified into simple and complex ones.

Simple phobias are fears about specific situations, places, objects or animals. They often develop in early childhood and sometimes result from an unpleasant experience. There are several types:

·Animal – Fear of dogs (cynophobia), cats (ailurophobia), insects (arachnophobia), etc

·Environment – Fear of heights (acrophobia), water (hydrophobia), etc

·Situations – Fear of flying (pteromerhanophobia), enclosed spaces (claustrophobia), etc

·Injection/injury – Fear of pain (algophobia), being beaten (rhabdophobia), etc

Complex fears are more problematic as they are frequently associated with deep seated fear or anxiety about particular situations, eg public or open places (agoraphobia), social phobia. The exact causes of complex phobias are unknown.

Agoraphobia is defined as a fear of being alone in public places. There is overwhelming anxiety in situations which can be embarrassing, or from which it might be difficult to get away. This leads to fears about leaving home, going out and about and travelling on public transport.

Social phobia is a strong, persisting fear of an interpersonal situation in which embarrassment can occur. This may be an object or situation, eg meetings, public speaking. It may be due to a previous anxious experience in a social situation or a lack of social confidence.

There are several theories for phobias. They include activation of the sympathetic nervous system, psychological theories ranging from displacement of an intra-psychic conflict to conditioning, and genetic theories. The risks of specific phobias and social phobia appear to be inherited in some families and twins.

Clinical features

All persons who have a phobia have a need to avoid the cause of their fear. The extent to which the source of the phobia is avoided varies between individuals. For example, a person who has a phobia for a dentist may not have any contact with him or her at all whereas another person may only consult a dentist when there are certain symptoms.

Phobias can limit a person’s activities of daily living and may cause anxiety and even depression.

The symptoms may be physical or psychological. Panic attacks are common and frequently occur suddenly, without warning.

The physical symptoms include rapid heart beat (palpitations), dizziness, difficulty breathing, excessive sweating, muscle aches, frequent passing of urine, tiredness, trembling, confusion and even disorientation.

Psychological symptoms occur particularly in severe cases. They include feelings of horror and fear of fainting, loss of control and even dying.

Several phobias may be interlinked. For example, a person with a fear of going out (agoraphobia) may also have a fear of being left alone (monophobia) and trapped in an enclosed place (claustrophobia).

The majority of people with a phobia are aware of their condition. Many do not have a diagnosis made by a doctor. Instead, they institute self measures to avoid whatever they are afraid of.

There are questionnaires available from patient organisations which can assist an individual to make a self assessment and even a diagnosis of agoraphobia and social phobia.

Individuals who think they may have a phobia would find it useful to seek help from the family doctor or a specialist like a psychiatrist or psychologist. This is because almost all phobias can be cured with treatment.

Management

Most phobias are curable. However, there is no single treatment for all phobias. In some instances, the doctor may advise a combination of different treatments.

Many people who have a phobia, particularly simple phobias, do not require treatment as avoidance of the object of their fear takes care of the problem. This is called desensitisation therapy and involves gradual exposure to the object of the fear over a period of time so that it leads to a decrease in anxiety about the object.

However, avoidance may not be always possible with certain phobias, eg fear of flying (pteromerhanophobia).

Talking treatments, ie counseling, cognitive behaviour therapy (CBT) and psychotherapy are very effective. Counseling involves a trained counselor listening to a patient’s fear and providing advice about how to overcome it.

CBT involves exploration of the patient’s thoughts, feelings and behaviour in order to develop effective ways of addressing the problem. Psychotherapy involves a detailed approach to finding the cause of the problem and advising on methods to overcome it.

Medications are usually not prescribed as talking treatments are effective. However, they are prescribed for treating the effects of phobias, like anxiety. The medicines that are usually prescribed are antidepressants, tranquilisers and beta blockers.

Antidepressants are frequently prescribed to reduce anxiety. There are several types of antidepressants, ie selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants (TCAs), serotonin norepinephrine reuptake inhibitors (SNRIs) and monoamine oxidase inhibitors (MAOIs).

Antidepressant medicines are not addictive but withdrawal symptoms are common if they are stopped suddenly or a dose is missed. The side effects vary with individuals and the type of antidepressant.

SSRIs increase the brain’s levels of serotonin, a compound which is thought to improve a person’s mood. They are as effective as the older TCAs but have fewer side effects. The side effects of SSRIs, which include dry mouth, nausea and headaches, ease off with the passage of time. There are reports of increased risk of self-harm and suicidal tendencies with SSRIs.

TCAs increase the brain’s levels of serotonin and noradrenaline, thereby improving a person’s mood. The side effects include dry mouth, blurred vision, constipation, problems passing urine and drowsiness, and these usually ease off after about 10 days. Cannabis should not be taken with TCAs as the heart rate can increase.

SNRIs, which are more recent additions, increase the brain’s levels of serotonin and noradrenaline, thereby improving a person’s mood. Their mode of action differs slightly from the SSRIs and TCAs.

Venlafaxine is a selective serotonin and noradrenaline reuptake inhibitor (SNRI) used to treat general anxiety disorder. It increases the amount of serotonin and noradrenaline in the brain. The side effects include nausea, dry mouth, constipation, insomnia and sweating.

It cannot be prescribed if there is untreated high blood pressure, a recent heart attack or when there is risk of irregular heartbeats. Regular monitoring of the blood pressure is necessary when taking this medicine.

MAOIs are sometimes used to treat social phobia. The side effects of MAOIs include blurred vision, nausea, trembling, increased appetite and difficulty sleeping. They can also cause a marked increase in blood pressure, leading to severe headache, chest pain, rapid heart rate and stiff neck, which is a medical emergency.

People who are taking MAOIs must not take food containing tyramine, eg pickled fish or meat, cheese. One should also not consume alcohol or fermented liquids. A list of such foods will be provided by the doctor. As there are interactions between the MAOIs and many medicines, one should only consume the latter after checking with the doctor.

Benzodiazepines are categorised as minor tranquilisers. They are very effective in treating anxiety, easing the symptoms within an hour or so after consumption.

However, they cannot be used for long periods of time because of their addictive potential if used for longer than four weeks, and loss of effectiveness after this period. The side effects include loss of balance, tiredness, drowsiness and confusion. It is important to avoid driving or operating machinery when taking benzodiazepines.

Beta blockers are often used in the treatment of high blood pressure and heart problems. They are also prescribed sometimes to reduce anxiety symptoms like palpitations. They reduce the blood pressure and heart rate. The side effects include cold fingers, sleep problems and tiredness.

> Dr Milton Lum is a member of the board of Medical Defence Malaysia. This article is not intended to replace, dictate or define evaluation by a qualified doctor. The views expressed do not represent that of any organisation the writer is associated with. For further information, e-mail starhealth@thestar.com.my. The information provided is for educational and communication purposes only and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader’s own medical care. The Star does not give any warranty on accuracy, completeness, functionality, usefulness or other assurances as to the content appearing in this column. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.

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