case study of a phobia

Little Hans – Freudian Case Study

Saul McLeod, PhD

Editor-in-Chief for Simply Psychology

BSc (Hons) Psychology, MRes, PhD, University of Manchester

Saul McLeod, PhD., is a qualified psychology teacher with over 18 years of experience in further and higher education. He has been published in peer-reviewed journals, including the Journal of Clinical Psychology.

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Olivia Guy-Evans, MSc

Associate Editor for Simply Psychology

BSc (Hons) Psychology, MSc Psychology of Education

Olivia Guy-Evans is a writer and associate editor for Simply Psychology. She has previously worked in healthcare and educational sectors.

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Case Study Summary

• Little Hans was a 5-year-old boy with a phobia of horses. Like all clinical case studies, the primary aim was to treat the phobia.
• However, Freud’s therapeutic input in this case was minimal, and a secondary aim was to explore what factors might have led to the phobia in the first place, and what factors led to its remission.
• From around three years of age, little Hans showed an interest in ‘widdlers’, both his own penis and those of other males, including animals. His mother threatens to cut off his widdler unless he stops playing with it.
• Hans’s fear of horses worsened, and he was reluctant to go out in case he met a horse. Freud linked this fear to the horse’s large penis. The phobia improved, relating only to horses with black harnesses over their noses. Hans’s father suggested this symbolized his moustache.
• Freud’s interpretation linked Hans’s fear to the Oedipus complex , the horses (with black harnesses and big penises) unconsciously representing his fear of his father.
• Freud suggested Hans resolved this conflict as he fantasized about himself with a big penis and married his mother. This allowed Hans to overcome his castration anxiety and identify with his father.

Freud was interested in the role of infant sexuality in child development. He recognised that this approach may have appeared strange to people unfamiliar with his ideas but observed that it was inevitable for a psychoanalyst to see this as important. The case therefore focused on little Hans’s psychosexual development and it played a key role in the formulation of Freud’s ideas within the Oedipus Conflict , such as the castration complex.

‘Little Hans’ was nearly five when has was seen by Freud (on 30th March 1908) but letters from his father to Freud provide the bulk of the evidence for the case study. These refer retrospectively to when Hans was less than three years old and were supplied to Freud through the period January to May 1908 (by which time little Hans was five years old).

The first reports of Hans were when he was 3 years old when he developed an active interest in his ‘widdler’ (penis), and also those of other people. For example, on one occasion, he asked, ‘Mummy, have you got a widdler too?

Throughout this time, the main theme of his fantasies and dreams was widdlers and widdling.  When he was about three and a half years old his mother told him not to touch his widdler or else she would call the doctor to come and cut it off.

When Hans was almost 5, Hans’ father wrote to Freud explaining his concerns about Hans. He described the main problem as follows:

He is afraid a horse will bite him in the street, and this fear seems somehow connected with his having been frightened by a large penis’.

The father went on to provide Freud with extensive details of conversations with Hans. Together, Freud and the father tried to understand what the boy was experiencing and undertook to resolve his phobia of horses.

Freud wrote a summary of his treatment of Little Hans, in 1909, in a paper entitled “ Analysis of a Phobia in a Five-year-old Boy. “

Case History: Little Hans’ Phobia

Since the family lived opposite a busy coaching inn, that meant that Hans was unhappy about leaving the house because he saw many horses as soon as he went out of the door.

When he was first asked about his fear Hans said that he was frightened that the horses would fall down and make a noise with their feet.  He was most frightened of horses which were drawing heavily laden carts, and, in fact, had seen a horse collapse and die in the street one time when he was out with his nurse.

It was pulling a horse-drawn bus carrying many passengers and when the horse collapsed Hans had been frightened by the sound of its hooves clattering against the cobbles of the road.  He also suffered attacks of more generalized anxiety . Hans’ anxieties and phobia continued and he was afraid to go out of the house because of his phobia of horses.

When Hans was taken to see Freud (on 30th March 1908), he was asked about the horses he had a phobia of. Hans noted that he didn’t like horses with black bits around the mouth.

Freud believed that the horse was a symbol of his father, and the black bits were a mustache.  After the interview, the father recorded an exchange with Hans where the boy said ‘Daddy don’t trot away from me!

Over the next few weeks Hans” phobia gradually began to improve.  Hans said that he was especially afraid of white horses with black around the mouth who were wearing blinkers.  Hans” father interpreted this as a reference to his mustache and spectacles.

• In the first, Hans had several imaginary children. When asked who their mother was, Hans replied “Why, mummy, and you”re their Granddaddy”.
• In the second fantasy, which occurred the next day, Hans imagined that a plumber had come and first removed his bottom and widdler and then gave him another one of each, but larger.

Freud’s Interpretation of Hans’ Phobia

After many letters were exchanged, Freud concluded that the boy was afraid that his father would castrate him for desiring his mother. Freud interpreted that the horses in the phobia were symbolic of the father, and that Hans feared that the horse (father) would bite (castrate) him as punishment for the incestuous desires towards his mother.

Freud saw Hans” phobia as an expression of the Oedipus complex . Horses, particularly horses with black harnesses, symbolized his father. Horses were particularly suitable father symbols because of their large penises.

The fear began as an Oedipal conflict was developing regarding Hans being allowed in his parents” bed (his father objected to Hans getting into bed with them).

Hans told his father of a dream/fantasy which his father summarized as follows:

‘In the night there was a big giraffe in the room and a crumpled one: and the big one called out because I took the crumpled one away from it.  Then it stopped calling out: and I sat down on top of the crumpled one’.

Freud and the father interpreted the dream/fantasy as being a reworking of the morning exchanges in the parental bed.  Hans enjoyed getting into his parent’s bed in the morning but his father often objected (the big giraffe calling out because he had taken the crumpled giraffe – mother – away).

Both Freud and the father believed that the long neck of the giraffe was a symbol for the large adult penis.  However Hans rejected this idea.

The Oedipus Complex

Freud was attempting to demonstrate that the boy’s (Little Hans) fear of horses was related to his Oedipus complex .  Freud thought that, during the phallic stage (approximately between 3 and 6 years old), a boy develops an intense sexual love for his mothers.

Because of this, he sees his father as a rival, and wants to get rid of him.  The father, however, is far bigger and more powerful than the young boy, and so the child develops a fear that, seeing him as a rival, his father will castrate him.

Because it is impossible to live with the continual castration-threat anxiety provided by this conflict, the young boy develops a mechanism for coping with it, using a defense mechanis m known as identification with the aggressor .

He stresses all the ways that he is similar to his father, adopting his father’s attitudes, mannerisms and actions, feeling that if his father sees him as similar, he will not feel hostile towards him.

Freud saw the Oedipus complex resolved as Hans fantasized himself with a big penis like his father’s and married to his mother with his father present in the role of grandfather.

Hans did recover from his phobia after his father (at Freud’s suggestion) assured him that he had no intention of cutting off his penis.

Critical Evaluation

Case studies have both strengths and weaknesses. They allow for detailed examinations of individuals and often are conducted in clinical settings so that the results are applied to helping that particular individual as is the case here.

However, Freud also tries to use this case to support his theories about child development generally and case studies should not be used to make generalizations about larger groups of people.

The problems with case studies are they lack population validity. Because they are often based on one person it is not possible to generalize the results to the wider population.

The case study of Little Hans does appear to provide support for Freud’s (1905) theory of the Oedipus complex.  However, there are difficulties with this type of evidence.

There are several other weaknesses with the way that the data was collected in this study. Freud only met Hans once and all of his information came from Hans father. We have already seen that Hans’ father was an admirer of Freud’s theories and tried to put them into practice with his son.

This means that he would have been biased in the way he interpreted and reported Hans’ behavior to Freud. There are also examples of leading questions in the way that Hans’ father questioned Hans about his feelings. It is therefore possible that he supplied Hans with clues that led to his fantasies of marriage to his mother and his new large widdler.

Of course, even if Hans did have a fully-fledged Oedipus complex, this shows that the Oedipus complex exists but not how common it is.  Remember that Freud believed it to be universal.

At age 19, the not-so Little Hans appeared at Freud’s consulting room having read his case history.  Hans confirmed that he had suffered no troubles during adolescence and that he was fit and well.

He could not remember the discussions with his father, and described how when he read his case history it ‘came to him as something unknown’

Finally, there are problems with the conclusions that Freud reaches. He claims that Hans recovered fully from his phobia when his father sat him down and reassured him that he was not going to castrate him and one can only wonder about the effects of this conversation on a small child!

More importantly, is Freud right in his conclusions that Hans’ phobia was the result of the Oedipus complex or might there be a more straightforward explanation?

Hans had seen a horse fall down in the street and thought it was dead. This happened very soon after Hans had attended a funeral and was beginning to question his parents about death. A behaviorist explanation would be simply that Hans was frightened by the horse falling over and developed a phobia as a result of this experience.

Gross cites an article by Slap (an American psychoanalyst) who argues that Hans’ phobia may have another explanation. Shortly after the beginning of the phobia (after Hans had seen the horse fall down) Hans had to have his tonsils out.

After this, the phobia worsened and it was then that he specifically identified white horses as the ones he was afraid of. Slap suggests that the masked and gowned surgeon (all in white) may have significantly contributed to Hans’ fears.

The Freud Archives

In 2004, the Freud Archives released a number of key documents which helped to complete the context of the case of little Hans (whose real name was Herbert Graf).

The released works included the transcript of an interview conducted by Kurt Eissler in 1952 with Max Graf (little Hans’s father) as well as notes from brief interviews with Herbert Graf and his wife  in 1959.

Such documents have provided some key details that may alter the way information from the original case is interpreted. For example, Hans’s mother had been a patient of Freud herself.

Another noteworthy detail was that Freud gave little Hans a rocking horse for his third birthday and was sufficiently well acquainted with the family to carry it up the stairs himself.

It is interesting to question why, in the light of Hans’s horse phobia, details of the presence of the gift were not mentioned in the case study (since it would have been possible to do so without breaking confidentiality for either the family or Freud himself).

Information from the archived documents reveal much conflict within the Graf family. Blum (2007, p. 749) concludes that:

“Trauma, child abuse [of Hans’s little sister], parental strife, and the preoedipal mother-child relationship emerge as important issues that intensified Hans’s pathogenic oedipal conflicts and trauma. With limited, yet remarkable help from his father and Freud, Little Hans nevertheless had the ego strength and resilience to resolve his phobia, resume progressive development, and forge a successful creative career.”

Support for Freud (Brown, 1965)

Brown (1965) examines the case in detail and provides the following support for Freud’s interpretation.

1 . In one instance, Hans said to his father –“ Daddy don”t trot away from me ” as he got up from the table. 2 . Hans particularly feared horses with black around the mouth.  Han’s father had a moustache. 3. Hans feared horses with blinkers on. Freud noted that the father wore spectacles which he took to resemble blinkers to the child. 4 . The father’s skin resembled white horses rather than dark ones.  In fact, Hans said, “Daddy, you are so lovely. You are so white”. 5 . The father and child had often played at “horses” together.  During the game the father would take the role of horse, the son that of the rider.

Ross (2007) reports that the interviews with Max and Herbert Graf provide evidence of the psychological problems experienced by Little Hans’s mother and her mistreatment of her husband and her daughter (who committed suicide as an adult).

Ross suggests that “Reread in this context, the text of “A Phobia in a Five-year-old Boy” provides ample evidence of Frau Graf’s sexual seduction and emotional manipulation of her son, which exacerbated his age-expectable castration and separation anxiety, and her beating of her infant daughter.

The boy’s phobic symptoms can therefore be deconstructed not only as the expression of oedipal fantasy, but as a communication of the traumatic abuse occurring in the home.

Blum, H. P. (2007). Little Hans: A centennial review and reconsideration . Journal of the American Psychoanalytic Association, 55 (3), 749-765.

Brown, R. (1965). Social Psychology . Collier Macmillan.

Freud, S. (1905). Three essays on the theory of sexuality . Se, 7.

Freud, S. (1909). Analysis of a phobia of a five year old boy. In The Pelican Freud Library (1977), Vol 8, Case Histories 1, pages 169-306

Graf, H. (1959). Interview by Kurt Eissler. Box R1, Sigmund Freud Papers. Sigmund Freud Collection, Manuscript Division, Library of Congress, Washington, DC.

Graf, M. (1952). Interview by Kurt Eissler. Box 112, Sigmund Freud Papers. Sigmund Freud Collection, Manuscript Division, Library of Congress, Washington, DC.

Ross, J.M. (2007). Trauma and abuse in the case of Little Hans: A contemporary perspective . Journal of the American Psychoanalytic Association, 55 (3), 779-797.

Further Information

• Sigmund Freud Papers: Interviews and Recollections, -1998; Set A, -1998; Interviews and; Graf, Max, 1952.
• Sigmund Freud Papers: Interviews and Recollections, -1998; Set A, -1998; Interviews and; Graf, Herbert, 1959.
• Wakefield, J. C. (2007). Attachment and sibling rivalry in Little Hans: The fantasy of the two giraffes revisited. Journal of the American Psychoanalytic Association, 55(3), 821-848.
• Bierman J.S. (2007) The psychoanalytic process in the treatment of Little Hans. Psychoanalytic Study of the Child, 62: 92- 110
• Re-Reading “Little Hans”: Freud’s Case Study and the Question of Competing Paradigms in Psychoanalysis
• An” Invisible Man”?: Little Hans Updated

Module 4: Anxiety Disorders

Case studies: examining anxiety, learning objectives.

• Identify anxiety disorders in case studies

Case Study: Jameela

Jameela was a successful lawyer in her 40s who visited a psychiatrist, explaining that for almost a year she had been feeling anxious. She specifically mentioned having a hard time sleeping and concentrating and increased feelings of irritability, fatigue, and even physical symptoms like nausea and diarrhea. She was always worried about forgetting about one of her clients or getting diagnosed with cancer, and in recent months, her anxiety forced her to cut back hours at work. She has no other remarkable medical history or trauma.

For a patient like Jameela, a combination of CBT and medications is often suggested. At first, Jameela was prescribed the benzodiazepine diazepam, but she did not like the side effect of feeling dull. Next, she was prescribed the serotonin-norepinephrine reuptake inhibitor venlafaxine, but first in mild dosages as to monitor side effects. After two weeks, dosages increased from 75 mg/day to 225 mg/day for six months. Jameela’s symptoms resolved after three months, but she continued to take medication for three more months, then slowly reduced the medication amount. She showed no significant anxiety symptoms after one year. [1]

Case Study: Jane

Jane was a three-year-old girl, the youngest of three children of married parents. When Jane was born, she had a congenital heart defect that required multiple surgeries, and she continues to undergo regular follow-up procedures and tests. During her early life, Jane’s parents, especially her mother, was very worried that she would die and spent every minute with Jane. Jane’s mother was her primary caregiver as her father worked full time to support the family and the family needed flexibility to address medical issues for Jane. Jane survived the surgeries and lived a functional life where she was delayed, but met all her motor, communication, and cognitive developmental milestones.

Jane was very attached to her mother. Jane was able to attend daycare and sports classes, like gymnastics without her mother present, but Jane showed great distress if apart from her mother at home. If her mother left her sight (e.g., to use the bathroom), Jane would sob, cry, and try desperately to open the door. If her mother went out and left her with a family member, Jane would fuss, cry, and try to come along, and would continually ask to video-call her, so her mother would have to cut her outings short. Jane also was afraid of doctors’ visits, riding in the car seat, and of walking independently up and down a staircase at home. She would approach new children only with assistance from her mother, and she was too afraid to take part in her gymnastics performances.

Jane also had some mood symptoms possibly related to her medical issues. She would intermittently have days when she was much more clingy, had uncharacteristically low energy, would want to be held, and would say “ow, ow” if put down to stand. She also had difficulty staying asleep and would periodically wake up with respiratory difficulties. [2]

• Bandelow, B., Michaelis, S., & Wedekind, D. (2017). Treatment of anxiety disorders. Dialogues in clinical neuroscience, 19(2), 93–107. ↵
• Hirshfeld-Becker DR, Henin A, Rapoport SJ, et alVery early family-based intervention for anxiety: two case studies with toddlersGeneral Psychiatry 2019;32:e100156. doi: 10.1136/gpsych-2019-100156 ↵
• Modification, adaptation, and original content. Authored by : Margaret Krone for Lumen Learning. Provided by : Lumen Learning. License : CC BY: Attribution
• Treatment of anxiety disorders. Authored by : Borwin Bandelow, Sophie Michaelis, Dirk Wedekind. Provided by : Dialogues in Clinical Neuroscience. Located at : http://Treatment%20of%20anxiety%20disorders . License : CC BY: Attribution

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• Social Phobia/Anxiety Case Study: Jim

Jim was a nice looking man in his mid-30’s.  He could trace his shyness to boyhood and his social anxiety to his teenage years.  He had married a girl he knew well from high school and had almost no other dating history.  He and his wife, Lesley, had three children, two girls and a boy.

At our first meeting, Jim was very shy and averted his eyes from me, but he did shake hands, respond, and smile a genuine smile.  A few minutes into our session and Jim was noticeably more relaxed.  "I’ve suffered with this anxiety for as long as I can remember", he said.  "Even in school, I was backward and didn’t know what to say.  After I got married, my wife started taking over all of the daily, family responsibilities and I was more than glad to let her."

If there was an appointment to be made, Lesley made it.  If there was a parent-teacher conference to go to, Lesley went to it.  If Jim had something coming up, Lesley would make all the social arrangements.  Even when the family ordered takeout food, it was Lesley who made the call.  Jim was simply too afraid and shy.

Indeed, because of his wife, Jim was able to avoid almost all social responsibility -- except at his job.  It was his job and its responsibilities that brought Jim into treatment.

Years earlier, Jim had worked at a small, locally-owned record and tape store, where he knew the owner and felt a part of the family.  The business was slow and manageable and he never found himself on display in front of lines of people.  Several years previously, however, the owner had sold his business to a national record chain, and Jim found himself a lower mid-range manager in a national corporation, a position he did not enjoy.

"When I have to call people up to tell them that their order is in," he said, "I know my voice is going to be weak and break, and I will be unable to get my words out.  I’ll stumble around and choke up....then I’ll blurt out the rest of my message so fast I’m afraid they won’t understand me.  Sometimes I have to repeat myself and that is excruciatingly embarrassing........"

Jim felt great humiliation and embarrassment about this afterwards: he couldn’t even make a telephone call to a stranger without getting extremely anxious and giving himself away.  That was pretty bad!  Then he would beat himself up.  What was wrong with him?  Why was he so timid and scared?  No one else seemed to be like he was.  He simply must be crazy!  After a day full of this pressure, anxiety and negative thinking, Jim would leave work feeling fatigued, tired, and defeated.

Meanwhile, his wife, being naturally sociable and vocal, continually enabled Jim not to have to deal with any social situations.  In restaurants, his wife always ordered.  At home, she answered the telephone and made all the calls out.  He would tell her things that needed to be done and she would do them.

He had no friends of his own, except for the couples his wife knew from her work.  At times when he felt he simply had to go to these social events, Jim was very ill-at-ease, never knew what to say, and felt the silences that occurred in conversation were his fault for being so backward.  He knew he made everyone else uncomfortable and ill-at-ease.

Of course, the worst part of all was the anticipatory anxiety Jim felt ahead of time – when he knew he had to perform, do something in public, or even make phone calls from work.  The more time he had to worry and stew about these situations, the more anxious, fearful and uncomfortable he felt.

REMARKS: Jim presented a very typical case of generalized social phobia/social anxiety.  His strong anticipation and belief that he wouldn’t do well at social interactions and in social events became a self-fulfilling prophecy, and his belief came true: he didn’t do well.  The more nervous and anxious he got over a situation, and the more attention he paid to it, the more he could not perform well.  This was a very negative paradox or "vicious cycle" that all people with social anxiety get stuck in.  If your beliefs are strong that you will NOT do well, then it is likely you will not do well.  Therefore, thoughts, beliefs, and emotions need to be changed.

The depression (technically "dysthymia") that comes about after the anxious event continued to fuel the fire.  "I’ll never be able to deal with this," Jim would tell himself, thus constantly reinforcing the fact that he saw himself as a failure and a loser.

Unusual in this situation is that Jim’s wife remained loyal to him, understood his problem to some extent, and even seemed to enjoy her role as the family’s "social director".  The more and more she did for Jim, the more and more he could avoid.  It got so bad that Jim, who loved to listen to new albums and read new books -- could not even go to stores or to the library.  He would tell his wife what to buy and she would buy it.  She even kept track of when the library books were due and made sure she took them back on time.

This family situation is unusual because most people with social anxiety/social phobia have an extremely difficult time making and continuing personal relationships -- because of self-consciousness and the need for more privacy than most other people.  In fact, social phobia ranks among one of the highest psychological disorders when it comes to failed relationships, divorce, and living alone.

TREATMENT for Jim consisted of the normal course of cognitive strategies so that he would relearn and rethink what he was doing to himself.  He was cooperative from the beginning, and progressed nicely doing therapy.  He took each of the practice handouts and spent time each day practicing.  He made a "special time" for himself that his family respected and he used this place and time to practice the cognitive strategies his mind had to learn.

His biggest real-life fear, speaking to another person in public, was not really a speaking problem; it was an anxiety problem.  There was nothing wrong with Jim’s voice, his reading ability, or his speaking ability.  Jim was a bright man who had associated great anxiety around these social events in public situations.

The course of treatment here is NOT to practice!  In fact, practicing would just draw attention to what Jim perceived was the problem: his voice, his awkwardness, his perceived inability to speak to others.  Thus, it would reinforce the very behaviors we do not want to reinforce.

Instead, Jim worked on paradoxes.  We deliberately goofed-up.  We tried to make as many mistakes as possible.  We injected humor into the situation and found that when he exaggerated his fears, he thought this was funny.  Although more is involved than just this, the concept here is to de-stress the situation and enable the person to see it for what it is: NO BIG DEAL!  If you make a mistake, SO WHAT?  Everyone else does too!

Over the weeks, before group therapy began, Jim did a number of interesting things in public that began proving to him that he was NOT the center of attention, and it just didn’t matter if he made a mistake or two.  After all, he was human just like everyone else.  It’s this idea of perfectionism, of always having to "do your best" that must be broken down.  Jim was human; humans make mistakes; so what?  It was certainly nothing to get upset about.  In fact, as time went by, it become even more funny and humorous, rather than humiliating or embarrassing.

After completion of the behavioral group therapy, Jim had an opportunity for advancement in his company, which he now felt comfortable to take.  The promotion entailed holding weekly meetings in which he was in charge.  He would have to do some public speaking and respond to his employees’ questions.  By this time, Jim was feeling much more comfortable and much less anxious about the whole situation.  "I think I’ll deliberately goof up," he joked to me before the start of his new job.  "It would be interesting to see how everyone else responds."

To say that Jim did not have any anticipatory anxiety before taking this position or before making his weekly presentations would be inaccurate.  The difference was now they were manageable.  They were simply minor roadblocks that could be overcome.  Jim’s thinking about social events and activities had changed a great deal since the first day I saw him in therapy.

I talked to Jim a few months ago and everything was going well.  His responsibilities at work had increased slightly, but Jim now had the ability and beliefs to deal with them.  He was much more confident and had a feeling of being in control.  He was doing more around the house and his wife was a little surprised at his metamorphosis.  Luckily, this did not change the marriage dynamics adversely, and the last time I talked with him, Jim had become a father again: another little boy.

"He’s the last," Jim said, laughing over the phone, "I can’t get too distracted.  I’ve got too many speeches to give now."

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The Anxiety Network began in 1995 due to growing demand from people around the world wanting help in understanding and overcoming their anxiety disorder.  The Anxiety Clinic of Arizona and its website, The Anxiety Network, received so much traffic and requests for help that we found ourselves spending much of our time in international communication and outreach.  Our in-person anxiety clinic has grown tremendously, and our principal internet tool, The Anxiety Network, has been re-written and re-designed with focus on the three major anxiety disorders: panic, social anxiety, and generalized anxiety disorder.  

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Case Study: Overcoming Anxiety – Success Stories

In this article

Anxiety is a formidable adversary in the everyday life of many people in the UK. According to statistics, around 6% of people are diagnosed with generalised anxiety disorder (GAD) every week and, in total, more than 8 million people experience an anxiety disorder. Characterised by excessive apprehension, worry and fear, anxiety comes in many forms. Generalised anxiety disorder is a persistent and excessive worry about everyday events. Social anxiety disorder , however, focuses on overwhelming fears of social situations. There are also several other disorders with anxiety-based symptoms. These include panic disorder, specific phobias , obsessive-compulsive disorder ( OCD ), post-traumatic stress disorder ( PTSD ), selective mutism and separation anxiety disorder. In this article, we’ll explore three case studies on people with different anxiety problems and how they overcame them. 

Case Study 1: Overcoming Social Anxiety

Meet Sarah*, a 28-year-old professional who, for years, grappled with the debilitating effects of social anxiety disorder. Sarah’s anxiety manifested itself in a fear of social interactions. Since this problem crept up over time, Sarah didn’t realise how much of a problem she had until her early 20s when she left university and began working in her professional field. Ultimately, Sarah recognised she had a problem that others didn’t seem to have, and it left her isolated and hindered in both her personal life and professional sphere. 

Sarah’s social anxiety manifested itself in her avoidance of social events and gatherings. In work meetings she couldn’t avoid, she would feel sick, lightheaded and extremely nervous. She chose not to socialise with her colleagues and found it difficult to maintain friendships with more outgoing people. The most profound symptom for Sarah was her intense fear of being scrutinised and criticised. These intense emotions took their toll on her self-esteem. Recognising the need for change, Sarah began to explore her feelings and sought help.

Sarah knew there was no quick fix. Anxiety was something she’d lived with her entire life and she’d managed to mask her issues quite well. Her transformation began with her seeking the guidance of a mental health professional. After speaking initially with her GP, Sarah began a course of cognitive-behavioural therapy ( CBT ) where she gained valuable insights into the irrational thought patterns that were fuelling her anxiety. CBT equipped her with practical tools to challenge and reframe her thoughts. Gradually, these tools helped her to diminish the power anxiety held over her in specific situations. 

At the same time, Sarah engaged in exposure therapy. This therapeutic approach introduced her gradually to situations that ordinarily would cause her immense fear. However, this systematic desensitisation process was done in a controlled and supportive environment, which allowed her to confront her anxieties gradually. Over time, Sarah was able to build up her resilience and confidence in these situations.

Beyond therapy and with the advice of an online support group, Sarah adopted mindfulness practices. She incorporated meditation and deep breathing into her daily routine. These mindfulness practice techniques became invaluable to her and helped her stay present and manage anxious thoughts during social interactions.

Sarah also took it upon herself to make lifestyle changes to promote good mental wellbeing. She began exercising routinely rather than sporadically as she had done before and noticed improvements in mood and a reduction in stress. 

Through consistent effort, Sarah emerged triumphant over her social anxiety. Today, she is able to deal with social situations much more easily than before. She can handle new situations well, both professionally and personally, while acknowledging that she’ll always have a tendency to feel anxious and will need to continue practising techniques that she now knows work.

Sarah’s story underscores the effectiveness of tailored therapeutic interventions and lifestyle adjustments. Sarah remained committed and open-minded about the route she was taking. Though she chose not to try medication, she recognised that this was available to her if her chosen pathway didn’t have the desired effects she was looking for. Her journey serves as an inspiration for others dealing with similar struggles who are perhaps fearful of turning to medication.  

Case Study 2: Triumphing Over Panic Attacks

Alex,* a 35-year-old plumber from Barnsley in South Yorkshire, struggled with the debilitating impact of frequent panic attacks for a number of years. Alex’s initial experiences with panic attacks occurred suddenly and intensely. He had recently undergone a series of major life changes, including a job promotion that came with increased responsibilities and higher expectations. Though he was excited and enthusiastic about the professional growth, the added pressure triggered heightened stress levels. Simultaneously, there were changes in his personal life. He’d just become a father for the first time and his child had had to spend several weeks in the NICU. 

The combination of stressors, both professional and personal, created a perfect storm for anxiety. The pressure to excel in a new job while adapting to fatherhood and an ill baby became overwhelming for Alex. The first panic attack occurred just after a particularly stressful work meeting during which his wife, who was at the NICU with their baby, had called his mobile several times. After the initial panic attack, a cycle of anxiety and panic attacks began.

Alex’s initial experiences of panic attacks were characterised by sudden and intense episodes of fear, shortness of breath and dizziness. These attacks had a huge impact on various aspects of Alex’s life, causing disruptions in his work life and personal relationships. 

Recognising the severity of the situation and needing to be strong for his wife and baby, Alex took the crucial step of seeking professional help. Alex was diagnosed with panic disorder, after which he began a course of treatment. Alex began cognitive-behavioural therapy as well as medication. 

Alex’s therapist worked with him to develop coping strategies that empowered him to overcome the triggers to his panic attacks. His anti-anxiety medication and antidepressants helped Alex in the initial stages of treating his disorder to alleviate the frequency and intensity of his panic attacks. 

On a personal level, Alex began ensuring he looked after himself through sufficient sleep, regular exercise and a healthier diet. Over time, Alex was able to come off his medication and, with continuing techniques learned in CBT, began living a life free from panic attacks once again. 

Case Study 3: Mastering Generalised Anxiety

Chris’s*experiences with GAD were characterised by a constant state of worry and apprehension about various aspects of his life, from school performances to personal relationships. The generalised nature of the anxiety made it difficult for him to understand specific triggers, which led to a pervasive sense of unease and heightened stress levels. 

After opening up to his parents, Chris saw his GP who offered him support through CBT. He also had support from his sixth-form college. 

Chris’s CBT therapist helped him to see and challenge the maladaptive thought patterns he had. Through a series of structured sessions, Chris learned to identify and reframe irrational thoughts to gain a more balanced perspective on perceived threats. CBT provided Chris with practical tools and coping strategies that empowered him to manage situations that caused him anxiety.

At college, Chris joined a mindfulness group to learn techniques like meditation and relaxation. This helped him to reduce how often he wound up ruminating on future uncertainties. After committing to therapy and working hard to manage his anxiety, Chris became much more resilient. 

Chris’s journey highlights the effectiveness of evidence-based interventions like CBT and mindfulness techniques in managing GAD. By addressing both the cognitive and emotional aspects of the disorder, people with GAD can form adaptive coping mechanisms to regain control over their lives. 

Common Themes and Strategies

As we explore the diverse narratives of triumph over anxiety, several common themes emerge. Key among these is the importance of seeking support. Be it friends, family or mental health professionals, it is one of the most important principles that contribute to successful recovery.

Recognition and acknowledgement

In each case study, the individuals were all the first people to recognise and acknowledge that things weren’t right. This critical self-awareness marked the initial step to seeking help and initiating recovery. Acknowledging that things weren’t right allowed them to confront their issues and consider the possibility of—and hope for—positive change.

Professional guidance

All three individuals in our case studies recognised the importance of seeking professional help. Mental health professionals played an important role in their recoveries, providing tailored interventions like CBT and medication. Therapeutic relationships provide a safe space for exploration, understanding and the development of coping strategies. 

Holistic approaches

A holistic approach to mental wellbeing in addition to professional interventions was key here too. Lifestyle changes like mindfulness practice, regular exercise and healthy diets were integral to their improvement. 

Support systems

The support of friends and family is important too. Whether it was Sarah navigating social situations, Alex overcoming panic attacks or Chris managing his generalised anxiety at college, the presence of a supportive network was important. Open communication, understanding and empathy from loved ones create an environment that is conducive to recovery.

Coping mechanisms

Developing coping mechanisms was also integral to all three people’s recoveries. Each individual engaged in techniques tailored to their specific anxiety disorders. Exposure therapy can help with some phobias and social anxiety, whereas CBT can work with all forms of anxiety.

Persistence and commitment

Persistence and commitment are required to overcome anxiety, which is what makes this condition so tricky to manage. It’s a journey that takes a long time and there may be many bumps in the road on the way.

The Role of Resilience

One recurring theme stands out in all three case studies: resilience. Resilience is often defined as the ability to bounce back from adversity. Building resilience plays a huge role in any person’s journey to overcoming an anxiety disorder. It’s important to know that setbacks will happen and that this is natural and inevitable.

Navigating setbacks

Whether it’s facing initial discomfort or experiencing a panic attack after treatment has started, setbacks are an important part of the recovery process. Resilience means continuing to try despite the setback. 

Learning and growth

Resilience enables you to see and approach a setback as an opportunity for learning and growth. Setbacks are not indicative of failure; they represent moments of refinement. They allow individuals to refine their coping mechanisms and build emotional strength.

Celebrating progress

Resilience isn’t just about getting through a tough time; it’s about celebrating progress. Recognising and acknowledging achievements, whether this is overcoming a fear or working well with coping strategies, reinforces the process.

Inspiring Others

The power of real-life success stories shows others who are about to start their journey or who have just started, that it is possible to get better. Sharing success stories is a beacon of hope for others. What’s more, openness is key to breaking the stigma that surrounds mental health. It shows that anxiety disorders can affect anyone, and that seeking help is not a sign of weakness but a courageous step towards a better future.

Real-life stories make the journey more tangible for individuals currently struggling with anxiety. Knowing that others have walked similar paths and come through the other side is positive. It instils a sense of optimism and motivation. Success stories also help to validate experiences. They make individuals feel less alone and isolated, showing that their conditions are legitimate and worthy of space. 

Ultimately, case studies like Sarah’s, Alex’s and Chris’s serve as catalysts. They highlight the transformations that are possible, thus motivating individuals to take the first steps themselves. 

Key Takeaways:

• Professional support matters: seeking professional help is a crucial step in the recovery process. Therapies like CBT and medication play a pivotal role.
• See the problem holistically: approach your mental wellbeing from a holistic perspective. Make lifestyle changes and seek social support.
• See resilience as a pillar: resilience is a key factor in recovery. Acknowledge setbacks, learn from them, and celebrate progress.
• Success is possible: through commitment, resilience and a combination of strategies, triumph over anxiety is an achievable reality.

*names have been changed

Anxiety Awareness

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About the author

Louise Woffindin

Louise is a writer and translator from Sheffield. Before turning to writing, she worked as a secondary school language teacher. Outside of work, she is a keen runner and also enjoys reading and walking her dog Chaos.

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Case Studies For Overcoming Phobias

PHOBIA CASE STUDY

Overcoming a Phobia of Open Water

About Phobias

It is usually understood that fear is rational, but is known as a phobia when the fear becomes irrational. These irrational fears are driven by emotions; meaning willpower, facts and reassurance have little impact.  Phobias can make the sufferer’s life miserable, cause embarrassment and undermine self-esteem.  Phobias can easily develop in childhood or in adulthood, and can often start from something very simple.  However, no-one needs to live with a phobia, as there is a way to deal with it in a positive and lasting way.

Neuro-Linguistic Programming (NLP) provides that positive process, and does not involve a lengthy analysis of where it started, or having to be exposed to the topic of the phobia.  It’s easy to do and works in line with the way we store our memories.

CLIENT:  Bex

PHOBIA:  Open Water

DATE:  March 2011

Bex has had an irrational fear of open water for over 30 years.  The fear of the sea, rivers and lakes started from an early age when she watched Jaws the movie.

This phobia had caused Bex to miss out on a number of experiences that she now regrets, including holidays, swimming and boat trips with the children.  An expensive and exotic holiday was coming up and Bex finally decided that she was not going to let this phobia spoil her trip.  She wanted to go snorkelling, on boat trips and even a banana ride – if only she could overcome the phobia.

Overcoming Phobias with NLP

Bex contacted Karen in order to overcome this phobia once and for all, and the session was booked.  Before the session, Karen asked Bex to think of a situation which would prove to her that her phobia was cured, once the process had been completed.  Bex decided that a boat trip would really prove it to her, especially as the last time she went on a slow sight-seeing boat she sat in the middle of the boat in tears for the entire trip.

Within 45 minutes, Bex had transformed from being petrified of the thought of open water, to someone who could not wait to go on her first boat in 30 years.  Bex described the process as “unbelievable” and was “surprised, and really pleased that the emotions have disappeared entirely”.

Prove the Phobia Has Gone

It was now over to the boat trip that Bex had chosen as her final proof that the phobia had been overcome.  When she arrived at the venue, the sight-seeing boat was out of action but thanks to the great team there, they offered a speed boat trip instead!  This would really be a test, given her previous experience in a boat.  However, Bex had no nerves, no reservations and was so excited about the opportunity.  And as you can see if you look at the short video, Bex thoroughly enjoyed the experience, which lasted for over an hour!

What Bex had to say

“The whole process was just unbelievable, so easy and completely stress-free.  It only took 45 minutes and by the end of that I was surprised, and really pleased, that the emotions had disappeared entirely.  I just couldn’t wait to get on that boat – my phobia was gone and I was so excited about my upcoming holiday.  Thanks to Karen I am going to enjoy my trip completely, and may even try a banana boat if I can persuade the others to join me!  I would highly recommend anyone who has a phobia stopping them enjoying life, to speak to Karen and get rid of it.  I wasted too many years with this fear, only to have it gone in less than an hour, once I’d decided enough was enough.  I wish I had sorted it out a long time ago, but now that I have, I’m going to make the most of it at every opportunity.”

If you want to see a rehearsal for a video testimonial from Bex, we’ve included it HERE .  It may make you smile!!

To find out how you can overcome your phobias, contact Karen now using the Contact Us Form.

Overcoming a Phobia of Flying

CLIENT:  Anonymous (we’ll call them Sam)

PHOBIA:  Fear of Flying

DATE:  May 2013

Sam had an irrational and debilitating fear of flying since a teenager.  A traumatic experience on the underground resulted in feelings of being trapped extended to flying, lifts and being in crowds.  Sam had found very ingenious (and expensive) ways of getting around without having to use the Underground, and would use medication, lack of sleep and avoidance tactics to cope with the fear of flying.

With a long-haul US trip required in Sam’s business role, Sam decided that it was time to confront this phobia and find a way to overcome it once and for all.

Having only had one telephone conversation with Karen, Sam’s friends had already noticed the difference in Sam’s attitude to anxiety and worrying about the future.  The phobia session was booked and during that session the underlying cause of the phobia was discovered fully.  It was agreed that a trip on the Underground would be immediate proof for Sam to know when the phobia had been overcome and that Sam would then be ready for the flight a couple of weeks later.

Within an hour and a half, Sam had transformed from the nervous and anxious phobia sufferer to someone who was “excited” when travelling down the escalator to the underground (something few of us usually say!).

Sam was surprised how normal and calm Sam felt that day, and then continued travelling on the underground.  “Friday evening I had a lot of luggage with me and couldn’t be bothered to walk to Liverpool Street, so caught the tube.  Over time it will save me a fortune in cabs!  I still can’t believe I’m going underground.”  “Couldn’t be bothered to walk… so took the tube” were certainly not words Sam thought about ever saying again.

Then it was onwards and upwards for the flying to the US and then shortly after returning, back on the plane for a trip to Scotland.  How things had changed!

What Sam had to Say

“Things have definitely changed for me.  I’m so grateful for what you’ve done for me.  My work colleagues are really surprised when I say I flew to our meetings in Scotland, rather than catching the train.  And it is so much better not to have to go on long-haul business trips early, just to get over the after-effects of flying the way I used to.  I can’t begin to thank you enough.”

HELP AVAILABLE

If you are suffering from phobias, fears and anxiety and think that NLP may be able to help you, then please contact us using the  Contact Form  for an initial discussion.

Find out a little more about Neuro Linguistic Programming (NLP)  here

Social Anxiety Disorder: A Comprehensive Case Study Analysis

Hearts racing and minds reeling, millions navigate a world where everyday interactions feel like walking through a minefield of judgment and scrutiny. This pervasive experience is the hallmark of social anxiety disorder, a condition that affects countless individuals worldwide, impacting their daily lives and overall well-being. To truly understand the complexities of this disorder and develop effective treatment strategies, researchers and clinicians often turn to case studies, which provide invaluable insights into the lived experiences of those grappling with social anxiety.

Understanding Social Anxiety Disorder

Social anxiety disorder, also known as social phobia, is characterized by an intense and persistent fear of social situations. Individuals with this condition experience overwhelming anxiety and self-consciousness in everyday social interactions, often fearing negative judgment or embarrassment. The impact of social anxiety extends far beyond mere shyness, significantly interfering with personal relationships, professional opportunities, and overall quality of life.

The prevalence of social anxiety disorder is staggering, affecting an estimated 7% of the global population. This translates to millions of individuals worldwide who struggle with the debilitating effects of this condition. From avoiding social gatherings to experiencing panic attacks in public spaces, the manifestations of social anxiety can be both diverse and profound.

To truly grasp the nuances of social anxiety disorder and develop effective treatment approaches, clinicians and researchers rely heavily on case studies. These in-depth analyses of individual experiences provide a wealth of information that cannot be captured by statistical data alone. By examining specific cases, professionals can identify patterns, explore unique manifestations, and refine treatment strategies to better serve those affected by social anxiety.

Case Study Background: Meet Sarah

In this comprehensive case study analysis, we’ll delve into the experience of Sarah, a 28-year-old marketing professional who has been grappling with social anxiety disorder for over a decade. Sarah’s journey offers valuable insights into the onset, progression, and treatment of this challenging condition.

Sarah grew up in a small town in the Midwest, describing herself as a shy and introverted child. While she had a close-knit group of friends throughout her school years, she often felt uncomfortable in large social gatherings or when required to speak in front of her class. However, it wasn’t until her college years that her anxiety began to escalate significantly.

The onset of Sarah’s more severe social anxiety symptoms coincided with her move to a large university in a bustling city. Suddenly thrust into an environment where she knew no one, Sarah found herself overwhelmed by the constant social interactions required in her new setting. She began experiencing intense physical symptoms, including rapid heartbeat, sweating, and trembling, whenever she had to participate in class discussions or attend social events.

As her symptoms worsened, Sarah sought help from the university’s counseling center. After a thorough assessment process, including interviews, questionnaires, and comprehensive social anxiety disorder tests , Sarah was diagnosed with social anxiety disorder. This diagnosis marked the beginning of her journey towards understanding and managing her condition.

Symptoms and Manifestations

Sarah’s experience with social anxiety disorder manifested in a variety of physical, cognitive, and behavioral symptoms. Physically, she reported experiencing:

1. Rapid heartbeat and palpitations 2. Excessive sweating, particularly on her palms and forehead 3. Trembling or shaking, especially in her hands 4. Nausea and stomach discomfort 5. Difficulty breathing or a sensation of choking

These physical symptoms often intensified in situations where Sarah felt she was being observed or evaluated, such as during presentations at work or when meeting new people.

Cognitively, Sarah’s social anxiety was characterized by persistent negative thought patterns and beliefs. She frequently experienced:

1. Intense fear of judgment or criticism from others 2. Excessive self-consciousness and hyper-awareness of her actions 3. Negative self-talk and self-criticism 4. Catastrophic thinking about potential social failures 5. Difficulty concentrating in social situations due to racing thoughts

These cognitive patterns significantly impacted Sarah’s ability to engage in social interactions and professional activities, often leading to a cycle of avoidance and increased anxiety.

Behaviorally, Sarah developed various avoidance strategies to cope with her anxiety. These included:

1. Declining invitations to social events or gatherings 2. Avoiding eye contact or speaking up in meetings at work 3. Using alcohol as a social lubricant to ease her anxiety 4. Overpreparation for presentations or social interactions to minimize potential mistakes 5. Relying heavily on digital communication to avoid face-to-face interactions

While these avoidance strategies provided temporary relief, they ultimately reinforced Sarah’s anxiety and limited her personal and professional growth.

Treatment Approach

Upon receiving her diagnosis, Sarah began a comprehensive treatment plan that incorporated both psychotherapy and medication management. The primary therapeutic approach used was Cognitive-Behavioral Therapy (CBT), a well-established and effective treatment for social anxiety disorder.

CBT sessions focused on helping Sarah identify and challenge her negative thought patterns and beliefs about social situations. Her therapist employed various techniques, including:

1. Cognitive restructuring to help Sarah recognize and reframe irrational thoughts 2. Mindfulness exercises to increase awareness of her anxiety symptoms and reduce their intensity 3. Role-playing exercises to practice social skills and build confidence 4. Gradual exposure to anxiety-provoking situations in a controlled environment

In addition to CBT, Sarah’s treatment plan included group therapy sessions specifically designed for individuals with social anxiety . These sessions provided a supportive environment where Sarah could practice social interactions and learn from others facing similar challenges.

To address the physical symptoms of her anxiety, Sarah’s psychiatrist prescribed a selective serotonin reuptake inhibitor (SSRI), which helped reduce the intensity of her anxiety symptoms and improved her overall mood.

A crucial component of Sarah’s treatment was exposure therapy, which involved gradually facing feared social situations in a structured and supported manner. This approach helped Sarah build confidence and develop more adaptive coping strategies. Some exposure exercises included:

1. Initiating conversations with strangers in low-pressure settings 2. Participating in social events without using alcohol as a crutch 3. Volunteering to lead presentations at work 4. Attending networking events in her industry

Throughout her treatment, Sarah also engaged in social skills training to improve her ability to navigate various social situations with greater ease and confidence.

Progress and Outcomes

As Sarah progressed through her treatment, she began to experience significant improvements in her social functioning and overall quality of life. In the short term, she reported:

1. Reduced physical symptoms of anxiety in social situations 2. Increased willingness to engage in social activities 3. Improved performance and confidence at work 4. Better ability to challenge and reframe negative thoughts

Over the long term, Sarah developed more effective strategies for managing her symptoms and maintaining her progress. She continued to practice the skills learned in therapy and gradually expanded her social circle. While she still experienced occasional anxiety in certain situations, she felt better equipped to handle these challenges without resorting to avoidance behaviors.

From Sarah’s perspective, the combination of CBT, medication, and exposure therapy was instrumental in her recovery. She particularly valued the practical skills she gained through therapy, which allowed her to approach social situations with greater confidence and self-compassion.

Analysis and Insights

Sarah’s case study offers valuable insights into the treatment of social anxiety disorder and highlights several key factors contributing to her success:

1. Comprehensive approach: The combination of psychotherapy, medication, and exposure techniques addressed multiple aspects of Sarah’s anxiety.

2. Personalized treatment plan: Sarah’s therapy was tailored to her specific needs and experiences, focusing on the situations that caused her the most distress.

3. Gradual exposure: The step-by-step approach to facing feared situations allowed Sarah to build confidence incrementally.

4. Skill development: Learning practical social skills and cognitive techniques provided Sarah with tools to manage her anxiety in real-world situations.

5. Supportive environment: Group therapy sessions offered a safe space for Sarah to practice social interactions and gain support from peers.

Despite the overall success of Sarah’s treatment, there were challenges encountered along the way. These included:

1. Initial resistance to exposure exercises due to fear of discomfort 2. Difficulty in consistently applying cognitive techniques during high-stress situations 3. Occasional setbacks or temporary increases in anxiety symptoms

Addressing these challenges required patience, persistence, and ongoing support from Sarah’s treatment team.

The insights gained from Sarah’s case have important implications for future social anxiety disorder case studies and treatment approaches. They highlight the need for:

1. Individualized treatment plans that address the unique manifestations of social anxiety in each patient 2. A focus on long-term skill development and coping strategies, rather than just symptom reduction 3. Integration of various therapeutic modalities to address different aspects of the disorder 4. Ongoing support and follow-up to maintain progress and prevent relapse

Sarah’s journey with social anxiety disorder illustrates the complex nature of this condition and the potential for significant improvement with appropriate treatment. Her case underscores the importance of a comprehensive, individualized approach that combines evidence-based therapies, medication when necessary, and ongoing support.

As research in the field of social anxiety continues to evolve, case studies like Sarah’s provide invaluable insights that inform future treatment strategies. They remind us that while social anxiety disorder can be a challenging condition, it is also highly treatable. With the right support and interventions, individuals like Sarah can learn to manage their symptoms effectively and lead fulfilling lives.

Looking ahead, the field of social anxiety research and treatment continues to advance. Emerging areas of focus include:

1. The role of virtual reality in exposure therapy for social anxiety 2. The potential of mindfulness-based interventions in managing anxiety symptoms 3. Exploration of the relationship between social anxiety and related conditions like OCD 4. Investigation into the potential benefits of social anxiety in certain contexts

As our understanding of social anxiety disorder deepens, so too does our ability to provide effective, compassionate care to those affected by this condition. Sarah’s story serves as a testament to the power of perseverance, evidence-based treatment, and the human capacity for growth and change in the face of significant challenges.

For individuals struggling with social anxiety, it’s important to remember that help is available. Whether you’re experiencing high-functioning social anxiety or more severe symptoms, seeking professional support can be a crucial first step towards managing your condition and improving your quality of life. With the right tools and support, it’s possible to navigate the complexities of social anxiety and build a life filled with meaningful connections and personal growth.

References:

1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

2. Heimberg, R. G., Brozovich, F. A., & Rapee, R. M. (2010). A cognitive behavioral model of social anxiety disorder: Update and extension. In S. G. Hofmann & P. M. DiBartolo (Eds.), Social anxiety: Clinical, developmental, and social perspectives (2nd ed., pp. 395-422). Academic Press.

3. National Institute of Mental Health. (2022). Social Anxiety Disorder: More Than Just Shyness. https://www.nimh.nih.gov/health/publications/social-anxiety-disorder-more-than-just-shyness

4. Stein, M. B., & Stein, D. J. (2008). Social anxiety disorder. The Lancet, 371(9618), 1115-1125.

5. Clark, D. M., & Wells, A. (1995). A cognitive model of social phobia. In R. G. Heimberg, M. R. Liebowitz, D. A. Hope, & F. R. Schneier (Eds.), Social phobia: Diagnosis, assessment, and treatment (pp. 69-93). The Guilford Press.

6. Hofmann, S. G., & Otto, M. W. (2017). Cognitive behavioral therapy for social anxiety disorder: Evidence-based and disorder-specific treatment techniques. Routledge.

7. Craske, M. G., Niles, A. N., Burklund, L. J., Wolitzky-Taylor, K. B., Vilardaga, J. C., Arch, J. J., … & Lieberman, M. D. (2014). Randomized controlled trial of cognitive behavioral therapy and acceptance and commitment therapy for social phobia: Outcomes and moderators. Journal of Consulting and Clinical Psychology, 82(6), 1034-1048.

8. Goldin, P. R., Morrison, A., Jazaieri, H., Brozovich, F., Heimberg, R., & Gross, J. J. (2016). Group CBT versus MBSR for social anxiety disorder: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 84(5), 427-437.

9. Kessler, R. C., Petukhova, M., Sampson, N. A., Zaslavsky, A. M., & Wittchen, H. U. (2012). Twelve‐month and lifetime prevalence and lifetime morbid risk of anxiety and mood disorders in the United States. International Journal of Methods in Psychiatric Research, 21(3), 169-184.

10. Ruscio, A. M., Brown, T. A., Chiu, W. T., Sareen, J., Stein, M. B., & Kessler, R. C. (2008). Social fears and social phobia in the USA: results from the National Comorbidity Survey Replication. Psychological Medicine, 38(1), 15-28.

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Case-based learning: anxiety disorders

There are many types of anxiety disorders with varying levels of severity. Pharmacists should know the treatment options that are available and how to support patients. 

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Anxiety is a common mental health condition that affects approximately 6.6% of the population in England each week, along with one in six adults experiencing or being identified as having a common mental health condition per week [1] , [2] . Data suggest that women are almost twice as likely to be diagnosed with anxiety compared with men; however, the reason for this is unclear [3] , [4] . Although a large number of people are affected by mental health conditions (e.g. anxiety or depression), only 39% of adults aged 16–74 years are accessing treatment for them [5] .

Mental health conditions typically worsen over time and can negatively impact on social activities, relationships, career performance, academic work and general quality of life [6] . As such, patients that present with conditions, such as generalised anxiety disorder (GAD), are frequently seen in the community, with pharmacists having the opportunity to significantly impact on the patient’s quality of life by providing information on the treatment options that are available [7] . While occasional anxiety is a normal aspect of day-to-day life, persistent symptoms can indicate the possible presence of an anxiety disorder, which can often be debilitating. Anxiety has also been known to precipitate physiological responses, such as tachycardia and hyperhidrosis [8] . ’Functional impairment’ is a term that is often used to describe the degree to which an illness can limit a person’s ability to carry out some of their normal daily tasks; anxiety can affect this to differing degrees [9] .

There are multiple factors that could predispose or potentially encourage the manifestation of anxiety, which are often attributable to a combination of genetic and environmental factors [10] . In addition, studies suggest that alcohol and illicit drug use, particularly the use of stimulants and hallucinogens, are associated with higher rates of incidence [11] , [12] . Instances of childhood abuse and sexual abuse are also identified as potential causative factors for anxiety and depression [13] . However, there is a broad range of patients affected by anxiety, for whom there is often an unknown cause.

Types of anxiety

Anxiety disorder is an inclusive term for several disorders, including:

• Panic disorder;
• Selective mutism;
• Separation anxiety;
• Social anxiety disorder [14] .

The most common types of anxiety disorder include:

• Social anxiety disorder — this is considered to be the most common form of anxiety; in up to 50% of cases, it is present in individuals by age 11 years [15] . Symptoms include a persistent fear of social performance, panic attacks and a large fear of humiliating oneself in public [15] ;
• Phobic disorder — this broadly refers to a fear of places, situations, objects and animals. For example, agoraphobia is often considered to be simply a fear of open spaces, but it is far more serious and can include a fear of being in a place that individuals will find difficult to escape from or receive aid if things go wrong [16] .

Avoidance behaviour is common to both social anxiety disorder and phobic disorder, with patients actively trying not to encounter the feared stimulus (e.g. avoiding going outside, such as in cases of agoraphobia) [17] , [18] , [19] . This behaviour can hugely impact on a patient’s ability to maintain functional capacity.

Symptoms and diagnosis

Symptoms may involve feelings of restlessness, palpitations, problems with concentrating, uncontrollable worry, sleep disturbances and general irritability [6] .

Diagnosis of anxiety would initially be made by a GP following a comprehensive review of the following:

• Symptomatic presentation of the patient;
• Frequency of symptoms;
• Degree of severity of distress;
• Functional impairment.

History of substance misuse, comorbidities and past medical history should be considered as part of a holistic approach to diagnosis [20] .

In addition, differential diagnoses must be considered before a formal diagnosis is made. Anaemia and hyperthyroidism are two conditions that must be ruled out and/or treated as they can both manifest symptoms of anxiety disorders [21] , [22] . Blood analysis and further tests may be necessary to ensure a correct diagnosis is made [22] , [23] . As stated by the National Institute for Health and Care Excellence (NICE), diagnostic tools, such as the Diagnostic and Statistical Manual of Mental Disorders , can be utilised for anxiety disorders [21] . The criteria include a minimum of six months of incessant and uncontrollable worries, disproportionate to actual risk, and three of the following symptoms:

• Being easily fatigued;
• Irritability;
• Muscle tension;
• Poor concentration;
• Restlessness/nervousness;
• Sleep disturbance [21] .

The ‘International Classification of Diseases, 10th revision’, a disease classification tool, offers a similar criteria [21] . There are also other resources available to healthcare professionals to work through with patients, such as the GAD-7 questionnaire for anxiety and the personal health questionnaire-9 (PHQ-9) for depression [21] . Questions typically ask how frequently certain symptoms have occurred in the preceding two weeks. Both GAD-7 and PHQ-9 allow assessors to distinguish between anxiety and depression, and provide an indication as to the severity of presentation, which can guide therapy. These are typically asked by a GP during an initial consultation with the patient and may include questions such as: ‘Over the past two weeks, how often have you been bothered by feeling nervous, anxious or on edge?’ [24]

The GAD-7 questionnaire can also be used as a tool to determine the severity of its presentation, with scores of 5 and above, 10 and above, and 15 and above (out of a possible 21) referring to mild, moderate and severe anxiety, respectively [25] . Higher scores are strongly associated with functional impairment, although individual characteristics of presentation will affect how the patient is treated.

Pharmacological treatment

For patients with mild anxiety, pharmacotherapy is not recommended. However, as per NICE guidelines, pharmacological treatment is recommended where significant functional impairment exists [26] . First-line drug treatment involves selective serotonin reuptake inhibitors (SSRIs; e.g. sertraline or fluoxetine) [26] .

SSRIs are widely used for GAD and are often well tolerated. In addition, they are considered to be safer in overdose than most other similarly indicated medicines, because they carry a lower risk of cardiac conduction abnormalities and seizures [27] , [28] , [29] . Selective serotonin–noradrenaline reuptake inhibitors (SNRIs; e.g. duloxetine and mirtazapine) are a suitable alternative; pregabalin is a tertiary option if the others are unsuitable or poorly tolerated [26] .

It is important to manage the patients’ expectations with pharmacological therapies. Providing a clear message that it could take between four and six weeks before the patient notices a benefit from their medicine is essential, as this will help ensure that they take their medication as directed. Patients should also be made aware of side effects and the withdrawal process (e.g. associated side effects) prior to commencing therapy [26] .

Common side effects of SSRIs include abnormal appetite, arrhythmias, impaired concentration, confusion, gastrointestinal discomfort and sleep disorders [27] . The incidence of side effects is reported to be highest within the first two weeks of starting treatment [30] . Although most common side effects tend to improve over time, sexual dysfunction can persist [31] . There is an increased risk with SSRIs in certain patient groups (e.g. young adults, children and patients with a previous history of suicidal behaviour) of suicidal ideation and self-harm; therefore, initiation of SSRIs must be reviewed weekly in those under aged under 30 years for the first four weeks of treatment. If the risk of recurrent suicidal behaviour is a concern, the healthcare professional may want to seek advice from the local crisis or home-based treatment team; SSRIs generally have a better safety profile than other drugs used for anxiety, but may require frequent monitoring in this case [32] , [26] .

SSRIs are one of several classes of medicines that pose a risk for long QT syndrome, which occurs as a result of a prolonged QT interval on the electrocardiogram measurements of the heart. This can lead to torsades de pointes (a specific type of abnormal heart rhythm) and possible sudden cardiac death [33] [34] , [35] .

It is important that SSRIs are withdrawn slowly to minimise the occurrence of SSRI discontinuation syndrome — an abrupt cessation of treatment that can cause a combination of psychological and physiological symptoms; the most common including nausea, dizziness, headache and lethargy [36] . Tapering drug doses slowly over several weeks will mitigate the effects of the withdrawal and minimise unnecessary re-initiation of the SSRI [37] .

Considerations for selective serotonin reuptake inhibitors and selective serotonin–noradrenaline reuptake inhibitors

Serotonin syndrome is a serious side effect that can occur with the use of SSRIs and SNRIs. It occurs as a result of overactivation of the 5-HT1A and 5-HT2A receptors, precipitated by serotonergic drug use [38] . Symptoms typically range from confusion and agitation to more serious symptoms, such as seizures, arrhythmias and loss of consciousness [31] . The risk of the syndrome is higher if patients are taking other medicines that can increase serotonin levels in the brain, such as tramadol and metoclopramide. Taking 5-HT1F agonists, which include sumatriptan, or a combination of medicines with the same effect, can also increase risk [39] .

If a decision is made to initiate an SSRI, despite the associated risk, patients should be provided with suitable information concerning the syndrome, which can be found on or printed from the NHS website [31] . If a patient experiences symptoms of serotonin sydrome, they should be advised to contact their GP surgery immediately. If this is unavailable, they should call NHS 111 for advice.

Alongside serotonin syndrome, SSRIs have been known to contribute to inappropriate antidiuretic hormone secretion, which is related to hyponatremia and has symptoms including headache, insomnia, nervousness and agitation [40] . 

Patients with anxiety disorders should be monitored as frequently as the severity of the disorder demands, which is essential to protect patients and improve their quality of life. Guidance from the British National Formulary states that patients being initiated on an SSRI should be reviewed every one to two weeks after initiation, with response being assessed at four weeks to determine whether continuation of the drug is suitable [27] . NICE guidelines expand on this by encouraging three-monthly reviews of drug therapy to assess clinical effectiveness [20] .

Non-pharmacological treatment

Patients should be advised to minimise alcohol intake and make time for activities they find relaxing. They should also be encouraged to exercise every day, aiming to do 150 minutes of moderate-intensity exercise (e.g. walking or cycling) per week as exercising has been shown to improve mental health [41] , [42] . A study has demonstrated that those who exercise had 43.2% fewer days of poor mental health, with team sports having the largest association with reduction in mental health burden [43] .

Psychological treatment

Cognitive behavioural therapy (CBT) is a common psychological treatment used for those with anxiety. This therapy aims to transform negative thinking into more structured thought patterns, which then assist the patient in making changes to their thought processes to encourage positive thinking. CBT is suitable for patients that present with ongoing anxiety and does not look at patient history [34] . This type of treatment may be useful for patients with mild anxiety, as an addition to medicine or for those who do not wish to take medicine. It can be conducted individually or as part of a group.

Guided self-help — a process by which a patient is able to work through a course with the support of a trained therapist — and counselling are other treatments available through the NHS that may benefit patients with mild anxiety or as an adjunct to prescription medicines [44] .

Specialist referral and suicide risk

Specialist referral should be considered if patients:

• Have not responded to initial therapy;
• Have comorbidities, such as alcohol or substance misuse;
• Are at significant suicide risk.

Healthcare professionals should always assess suicide risk by discussing the patients’ feelings about self-harm openly and considering other contributing factors, such as the use of prescribed or illicit drugs. Healthcare professionals must take opportunities to make interventions — for example, referring patients for urgent mental health assessment or in the case of serious concerns, calling emergency services [23] .

In the UK, area-specific community programmes and the charity  Anxiety UK  can provide patients with further advice on managing their anxiety. However, many primary care networks are now recruiting social prescribers, who will have the ability to direct patients to attend local groups that are more suited to individual needs. Community pharmacists are also likely to be aware of local support networks.

Case studies

Case study 1: a woman taking interacting medicines

Joanne*, a woman aged 65 years, approaches the pharmacy counter. She is concerned about heart palpitations she has been experiencing recently.

After inviting Joanne into the consultation room, you ask her if she is taking any medicines. She says that she is taking amitriptyline for the pain in her legs. She has also recently started taking a new medicine and states that she is on other medicines, but cannot recall the names. You ask for permission to view her summary care record and note that there is furosemide on her list of medicines. She was started on citalopram two weeks prior and was prescribed a seven-day course of clarithromycin three days ago.

You are concerned that Joanne is experiencing long QT syndrome, since the selective serotonin reuptake inhibitor (SSRI) citalopram is a risk factor for QT prolongation — as are the tricyclic antidepressant amitriptyline and the antibiotic clarithromycin [33] , [45] , [46] . In addition, furosemide can also precipitate hypokalaemia, which has been known to affect the QT interval [47] .

Advice and recommendations

You advise Joanne to stop taking the citalopram that has been prescribed to her until she can see a GP, which is a matter of urgency, as you believe it could be related to the medicines she is taking. You advise that she should try and get a same-day appointment if possible. The GP will likely request an electrocardiogram and stop the SSRI if results demonstrate long QT syndrome.

Case study 2: a man with concerns about his medicine

Gareth*, an investment banker aged 52 years, attends the pharmacy and asks to purchase sildenafil over the counter, owing to his erectile dysfunction. He is referred to you and you sit with him in the consultation room.

During the consultation, you begin to ask questions about his history and whether the erectile dysfunction is a new condition that he is experiencing. He states that he has been worried about it for the last couple of months. You then discuss his lifestyle and ask him questions about his medicines, in which he states he started taking a new medicine, fluoxetine, several months ago. He has been under significant stress at his workplace and was started on fluoxetine owing to his anxiety.

You consider the following:

• The erectile dysfunction that Gareth is experiencing could be related to the stress he is experiencing as part of his work;
• The possibility there could be an underlying reason for the problem related to his general health;
• That the prescribed fluoxetine may be causing his erectile dysfunction because this is a side effect of selective serotonin reuptake inhibitors [48] .

You explain your rationale with Gareth and indicate that you do not think it is appropriate to sell him sildenafil now. You suggest he goes back to his GP to discuss the symptoms that he has been having. The GP may decide to try an alternative medicine, but, given that he has been taking the fluoxetine for a few months, he should not discontinue it until advised to do so by his GP. You explain that if his GP advises him to stop the medicine, there will be a specific withdrawal process to minimise the side effects and that you would be able to advise him on this.

Case study 3: a man who is displaying symptoms of moderate anxiety

Anton*, a university graduate aged 21 years, attends the pharmacy and asks to speak to the pharmacist in private. He states he is worried about heart palpitations that he has been experiencing. He is visibly sweating and looks on edge.

You invite Anton into the consultation room and ask him about his symptoms. He states that he has started a new job and that the palpitations start when he is feeling anxious. His symptoms are occurring most days of the week and he says it makes him “feel on edge”. He adds that he does not want to socialise with his co-workers. It is starting to affect his sleep and he does not know what to do. He also states that he has occasional pain in his chest.

Treatment options

Anton is demonstrating symptoms of moderate anxiety, given his desire to avoid socialising, and has a degree of functional impairment. However, as he has potential cardiac symptoms, these issues could be related to another condition.

When questioned, he confirms he has no other problems with his health, but you feel the patient needs further investigation — for example, an electrocardiogram test to measure the electrical activity of his heart to rule out underlying cardiac problems. His presentation concerns you and you feel he needs to see a doctor today to assess the differential diagnosis, as you are worried about his chest pain and palpitations.

You encourage Anton by saying that it is great that he felt he could talk to a pharmacist about this, but explain that he would benefit from a consultation with a GP. You explain that his symptoms could be related to anxiety and that you think he may need something to help him manage. He agrees to let you contact his local practice. As you have a good relationship with the practice, you manage to secure an appointment for him to see a GP that day. If a GP appointment had been unavailable, you could have telephoned NHS 111 for Anton to seek access to support.

*All cases are fictional

Useful resources

• NHS: Do I have an anxiety disorder?

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[21] National Institute for Health and Care Excellence. NICE Pathways. Generalised anxiety disorder. 2019. Available at: https://pathways.nice.org.uk/pathways/generalised-anxiety-disorder (accessed May 2020)

[22] British Thyroid Foundation. Hyperthyroidism. 2018. Available at: https://www.btf-thyroid.org/hyperthyroidism-leaflet (accessed May 2020)

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Specific phobias

Contributors

Anxiety disorders are among the most prevalent mental disorders, but the subcategory of specific phobias has not been well studied. Phobias involve both fear and avoidance. For people who have specific phobias, avoidance can reduce the constancy and severity of distress and impairment. However, these phobias are important because of their early onset and strong persistence over time. Studies indicate that the lifetime prevalence of specific phobias around the world ranges from 3% to 15%, with fears and phobias concerning heights and animals being the most common. The developmental course of phobias, which progress from fear to avoidance and then to diagnosis, suggests the possibility that interrupting the course of phobias could reduce their prevalence. Although specific phobias often begin in childhood, their incidence peaks during midlife and old age. Phobias persist for several years or even decades in 10–30% of cases, and are strongly predictive of onset of other anxiety, mood, and substance-use disorders. Their high comorbidity with other mental disorders, especially after onset of the phobia, suggests that early treatment of phobias could also alter the risk of other disorders. Exposure therapy remains the treatment of choice, although this approach might be less effective in the long term than previously believed. This Review discusses the literature regarding the prevalence, incidence, course, risk factors, and treatment of specific phobias, and presents epidemiological data from several population-based surveys.

Introduction

Anxiety disorders, which include generalised anxiety disorder, panic disorder, agoraphobia, social phobia, and specific (simple) phobias, are more prevalent in adults than are other mental disorders. 1 In 1987, Marks 2 reviewed the existing literature and conceptualised the study of anxiety, which led to a surge in research on the epidemiology and natural history of the subcategories of panic and agoraphobia, 3 – 7 social phobia, 8 – 16 and generalised anxiety disorder. 17 – 20 However, less research has been done on the subcategory of specific phobias, 21 – 23 which is the subject of this Review. As many people with specific phobias do not seek treatment, the epidemiological aspects of this Review concentrate on population-based data, focusing on the prevalence, incidence, and natural history of specific phobias. We also discuss research on risk factors (including genetic epidemiology) and treatment modalities for specific phobias. We systematically reviewed the epidemiological research literature on any specific phobia, and eight specific phobias were assessed on the basis of three separate population-based surveys. The aim of this Review is to introduce researchers and clinicians to this relatively under-developed field, to highlight the importance of specific phobias, and to provide some guidance regarding treatment options.

The diagnosis of phobic reaction was described in two short paragraphs in the first edition of the American Psychiatric Association DSM in 1952, 24 which stated that “the commonly observed forms of phobic reaction include fear of syphilis, dirt, closed places, high places, open places, animals, etc. The patient attempts to control his anxiety by avoiding the phobic object or situation.” Since then, types of phobia (including social phobias, agoraphobia, and specific phobias) have been more narrowly specified, and subtypes of specific phobias (including phobias related to blood, injections, and injury) have been expanded. The diagnosis of a specific phobia requires unreasonable fear associated with a specific object or situation, avoidance of the object or situation, persistence of the fear over time, and clinically significant distress or impairment associated with the fear, or avoidance. 25 The definitions in the American and international classifications 26 are similar, which is important for our discussion of worldwide results.

The requirement that the individual recognises their phobia as unreasonable indicates that the presence of insight is important, and suggests that the interview or self-report method of assessment by a clinician or survey interviewer (as used in much of the research discussed herein) is probably a valid method of diagnosis. Specific phobias can be diagnosed with only a few questions. For example, the first question about specific phobias from the revised third edition of the Diagnostic Interview Schedule, 27 used in the Epidemiologic Catchment Area (ECA) study, 28 asks about the fear itself and avoidance (eg, for blood and injection phobia, “have you ever had such an unreasonable fear of seeing blood; getting an injection; or going to the dentist that you tried to avoid it?”). The second question asks about persistence (eg, “did any of these fears continue for months or even years?”), and is followed by a series of questions about possible resulting distress or impairment, such as seeing a doctor, taking medication, or staying away from work.

Prevalence and incidence

Our literature search identified 25 population-based studies of the prevalence of specific phobias in adults, done between 1984 and 2016 in populations around the world ( table 1 ). The median lifetime prevalence is 7·2% (IQR 4·0–10·4), and varies considerably among these reports, from 1·5% in Florence, Italy, 41 and 2·6% in China 50 to 14·4% in Oslo, Norway. 39 Although some of this variation is likely to be due to the use of different assessment procedures, many structured survey assessment procedures are similar, deriving from the Diagnostic Interview Schedule 53 (used in the ECA studies 28 ), which evolved into the University of Michigan Composite International Diagnostic Interview, 54 and then into the version used in the WHO World Mental Health Surveys. 55 Differences in survey responses or age ranges of the samples could also explain the variation. However, large variations are also present in studies striving to use identical methods, such as the high rate for Baltimore in the ECA study (14·5% for male participants and 23·5% for female participants) as compared with the New Haven (3·8% and 8·5%) and St Louis (4·0% and 9·4%) ECA sites, 56 and the large difference between two samples from different areas of Norway. 39 , 42 These differences could provide guidance about as-yet-unknown risk factors, and suggest different causes that might be amenable to prevention or treatment. In east Asian populations, geographical variation is low, confined within the low lifetime prevalence in these regions: 2·6% in China, 3·4% in Japan, and 3·8% in Korea. There is no obvious trend in prevalence by calendar period. The 25 WHO World Mental Health Surveys also showed less variation than did other population-based studies, presumably because the WHO surveys all used the same instrument. 57 However, low-income countries showed slightly lower prevalence in the WHO surveys, consistent with the pattern of results seen in the earlier individual studies. The large differences between populations suggest the importance of studying risk factors for specific phobias.

Lifetime prevalence of specific phobia in adults according to study and population

ECA=Epidemiologic Catchment Area. NCS=National Comorbidity Survey. NCS-R=National Comorbidity Survey Replication. NESARC=National Epidemiologic Survey of Alcohol and Related Conditions. MAPSS=Mexican American Prevalence and Services Survey. MNCS=Mexican National Comorbidity Survey. SPMMHS=São Paulo Megacity Mental Health Survey Sample. NEMESIS=Netherlands Mental Health Survey and Incidence Study. ESEMeD=European Study of the Epidemiology of Mental Disorders. MHS=Mental Health Survey. ECA-R=Epidemiologic Catchment Area Replication.

In all studies included in this Review, the lifetime prevalence of specific phobias was higher in female participants than in male participants. The greatest differences were observed in Chile, rural Norway, and Hong Kong, where prevalence in female participants was more than three times as high as in male participants, and the smallest differences were seen in two Latino populations: Mexicans in southern California 34 and Puerto Ricans ( table 1 ). 33 The higher prevalence in women was consistent with a Darwinian interpretation 58 (ie, that the process of selection favours groups in which the female members of the species were most avoidant of danger, especially during child-rearing years). 59 However, there was no obvious explanation for the variation in male:female ratios around the world.

The first occurrence of a specific phobia can happen at any time throughout the lifespan, as shown by data from the Baltimore ECA follow-up, 60 a cohort study designed to explore the life-course structure of mental disorders ( figure ). This study interviewed individuals selected probabilistically from the household-residing population in eastern Baltimore in 1981, with follow-up interviews of the same respondents in 1982, 1993–96, and 2004–05. 60 When asked about the first occurrence of a phobia, many participants responded that they had experienced the phobia since they were a child or since they could remember, or similar, resulting in peaks in incidence at or below 5 years of age ( figure ). These findings are consistent with those of the Early Developmental Stages of Psychopathology study in Germany (in which almost all of the sample of 3021 adolescents reported onset of specific phobia in childhood or adolescence), 62 the National Comorbidity Survey (NCS; in which the median age of onset in 8098 adults was 15 years), 31 and the World Mental Health Surveys (completed in 22 countries with a total sample size of 124 902, in which the median age of onset was 8 years). 57 The incidence of new specific phobias in girls during childhood was much higher than in boys, and gently declined thereafter until the beginning of adulthood (about 20 years of age), after which it rose until about age 30 years for women ( figure ). The peak incidence in women occurred during the years of reproduction and child rearing, possibly reflecting an evolutionary advantage. Men and women had an additional peak in incidence during old age that was much stronger for women, reaching nearly 1% per year. This pattern might reflect the new occurrence of physical conditions 63 or adverse life events (such as the unexpected death of a loved one) 64 during those years.

Data are from the Baltimore Epidemiologic Catchment Area follow-up study 61 of 1920 respondents followed up from 1981 through 1993 (adapted from Public Mental Health [Oxford University Press] with permission). Kernel smoothing was applied, averaging incidence over a 5-year window to reduce variation.

Fears of specific objects or situations are widespread in the population. For example, more than 70% of people in the USA report having one or more unreasonable fears. 23 The prevalence of these fears is much higher than that of the consequent diagnoses ( table 2 ), which require the presence of avoidance and impairment related to the fear. In publicly available datasets from the USA (the National Epidemiologic Survey of Alcohol and Related Conditions [NESARC] 23 and the NCS 31 ) and from the Netherlands Mental Health Survey and Incidence Study (NEMESIS) 38 —all of which included large probabilistic samples representing national populations and used structured, diagnostically oriented interviews—fears of animals and heights are the two most prevalent fears in all three samples, and the order of prevalence of the different specific fears is relatively constant, with the exception that fear of blood is less prevalent in NESARC than in the other two studies ( table 2 ). The conditional probabilities of meeting the diagnostic criteria for specific phobias given the presence of the fear are similar across all seven fears and across all three samples (about 25–30%). The lifetime prevalence estimates of particular specific phobias (about 2–6%; table 2 , rightmost columns) are of the same order of magnitude as many other, more broadly defined, psychiatric diagnoses. The baseline prevalence estimates for specific phobias in the Baltimore ECA ( table 3 , left column) are higher than the estimates from the NESARC, NCS, and NEMESIS studies ( table 2 ), suggesting Baltimore to be an outlier with particularly high prevalence (as also shown in table 1 ). Since phobias are, by definition, distressing or impairing, their effective prevention or treatment could have a non-trivial effect on the mental health of the population. For blood or injection phobia, prevention could also provide a physical health benefit, because people with this phobia presumably avoid contact with doctors who engage in preventive measures across the general health spectrum. Although there are a range of universal prevention programmes for early psychopathology in general, few of them have been examined specifically with respect to simple phobias. 66 , 67

Lifetime prevalence of specific fears, phobia given specific fears, and specific phobias

NESARC=National Epidemiologic Survey of Alcohol and Related Conditions (using the Alcohol Use Disorder and Associated Disabilities Interview Schedule). 23 NCS=National Comorbidity Survey (using the Composite International Diagnostic Interview). 31 NEMESIS=Netherlands Mental Health Survey and Incidence Study (using the Composite International Diagnostic Interview). 38

12-month prevalence and persistence of specific phobias in adults in three longitudinal studies

Baseline prevalence (in 12 months preceding initial interview) is shown as % (SE). Persistence is defined as occurrence in the 12-month period preceding the follow-up interview among patients who met the criteria for the disorder in the 12 months preceding the baseline interview. ECA=Epidemiologic Catchment Area. NCS=National Comorbidity Survey. NESARC=National Epidemiologic Survey of Alcohol and Related Conditions.

Clinical course

Specific phobias are not transient disorders, as shown by data from the ECA, NCS, and NESARC studies ( table 3 ). Persistence, reflecting the chronicity of the disorder, is measured by the percentage of patients with a past-year history of the disorder at the baseline interview who report an occurrence of the disorder within the 12 months preceding the follow-up interview. In the ECA sample, 6–20% of specific phobias were persistent at 1 year, and 6–28% at 12 years; in the NCS sample, persistence at 10 years ranged from 25% to 38%; and in the NESARC sample, persistence at 3 years ranged from 12% to 19% ( table 3 ). A similar estimate of persistence, 17·5% for any specific phobia, was observed after 8 years of follow-up in the Mexican Adolescent Mental Health Survey, 68 while persistence in the NCS sample after 10 years was greater, at about 25%. In all three samples shown in table 3 , one of the most persistent phobias was that of heights. This degree of persistence is similar to that of other common, non-psychotic mental disorders. 61

Specific phobias are strong predictors of other anxiety disorders and of mood and substance-use disorders ( table 4 ). In the NESARC study, 23 anxiety disorders were the most strongly predicted, as might be expected, with odds ratios (ORs) ranging from 5·60 to 7·41 (95% CIs 4·95–8·40), without much change after adjustment for sociodemographic factors (5·12 to 7·18 [4·50–8·11]). Even after adjustment for other common mental disorders, the ORs for any anxiety disorder were high (3·84 [3·46–4·27]; table 4 ). Mood disorders were also strongly predicted (4·05 [3·69–4·46]), and the OR remained high after adjusting for closely related mood disorders (eg, the ORs for specific phobias predicting major depressive disorder were 1·99 [1·80–2·20] after adjusting for the earlier occurrence of dysthymia and mania). The ORs for substance-use disorders were lower than those of anxiety disorders, but still non-trivial and statistically significant (1·83 [1·67–2·00]). 23 High cooccurrence of specific phobias and other mental disorders was also observed across the World Mental Health Survey samples, in which 61% of lifetime cases of specific phobia had at least one other mental disorder. 57 These data suggest that the incidence of other common mental disorders could potentially be reduced by effective treatment of specific phobias. 69 , 70

Lifetime specific phobia as a predictor of lifetime mood, anxiety, and substance disorders (National Epidemiologic Survey of Alcohol and Related Conditions [n=43 093]) 23

All associations are significant at p<0·001.

Risk factors

Risk factors for specific phobias have not been well studied. Most potentially pertinent studies group the anxiety disorders into one category in their presentation of even the most rudimentary risk factors. The most important demographic risk factor for specific phobias seems to be female sex ( table 1 ). We identified five studies in which the prevalence of specific phobias could be compared between rural and urban populations, 23 , 39 , 42 , 34 , 33 and found very little difference between the two groups, except in Norway, where the prevalence was 14% in the urban population and 7% in the rural population. 39 , 42

We estimated the association between the prevalence of specific fears and education, marital status, and residence in the NESARC sample, which was the only study to have this amount of detail for specific phobias of animals, heights, storms, and closed spaces ( table 5 ). 23 Lower educational attainment was associated with higher prevalence of any specific phobia (40% in people with less than high school education vs 29% in college graduates), as was formerly married status (38% in people who were separated or divorced, and 42% in widowed people, vs 35% in married people). The difference in prevalence between rural and urban areas was trivial, which is surprising given that exposures to fear stimuli presumably differ between those areas, with more exposure to animals in rural areas and heights in urban areas.

Lifetime prevalence of specific phobias by three demographic characteristics (National Epidemiologic Study of Alcohol and Related Conditions [n=43 093]) 23

Data are % (SE)

Data from the World Mental Health Surveys also indicate a higher prevalence of any specific phobia in people with lower educational attainment. 57 Lower educational attainment is an indicator of lower socioeconomic status in general, which is presumably associated with less control over the social and physical environment, especially in conditions of stress. Consistent with data from the USA, World Mental Health Survey data indicate a higher prevalence of any specific phobia among formerly married people (relative odds 1·3 in high-income countries and 1·1 in low-income or middle-income countries). 57 These data suggest that marital status as a risk factor for specific phobias might vary by geographical region, or according to other environmental characteristics. It seems reasonable that having a marital partner would alleviate fears somewhat in offering a protective element (ie, a spouse) to the environment; it is also possible that formerly married people are more likely to be depressed, which might be a risk factor for simple phobias.

Although genetic risk factors for specific phobias have been studied for at least three decades, 71 many of the existing studies involve overlapping samples. 72 Phobias are more likely to occur in people whose family members have phobias. Twin studies suggest that within-family resemblance is due to shared environmental factors in childhood, 73 – 75 whereas genetic factors influence familial resemblance in adulthood. 76 A meta-analysis of ten independent twin studies of specific phobias reported a mean heritability of about 30% for the three subtypes of phobias studied (animal, situational, and blood-illness). 72 Genetic epidemiological methods are also useful to elucidate how phobias relate to personality traits and other psychiatric disorders. Multivariate structural equation modelling of twin data suggests that genetic factors that influence animal and situational phobias are distinguishable from those that influence major depressive disorder, generalised anxiety disorder, panic disorder, agoraphobia, and social phobia. 77 Specific phobias also appear to be less genetically correlated with neuroticism and extraversion than are other anxiety and depressive disorders, including social phobia and agoraphobia. 78 , 79

Only about a tenth to a quarter of people with specific phobias eventually receive treatment, 30 , 57 possibly because avoidance can reduce stress and impairment. Predictors for receiving treatment include having more severe impairment, having particular phobias (eg, people with phobias of flying, closed spaces, or heights are more likely to seek treatment), and having a greater number of phobias. 57 To our knowledge, no studies have addressed the comparative effectiveness of different treatment options. Therefore, we discuss the evidence regarding the effectiveness of treatments relative to non-treatment control conditions, with a preference for published systematic reviews and meta-analyses.

Exposure therapy is the current treatment of choice for specific phobias. 80 , 81 The standard form of exposure therapy involves in-vivo or imaging approaches to phobic stimuli or situations. Virtual-reality exposure therapy was first introduced more than two decades ago to treat fear of heights 82 and remains a viable treatment option for other specific phobias. 83 Three decades ago, Öst pioneered a one-session treatment approach for specific phobias, with an average duration of approximately 2 h. 84 , 85 Subsequent studies by Öst and colleagues suggested that a single 3-h session of massed exposure therapy is as effective as multiple sessions (total 6 h) of more gradual exposure therapy for the treatment of phobias of flying, 86 blood and injections, 87 and claustrophobia. 88 The results of a 2008 meta-analysis indicate that multiple sessions might be somewhat more effective than the single-session approach, as measured by questionnaire-based functional outcomes at follow-up, 81 and careful consideration is needed when choosing the appropriate number and duration of sessions for patients; 89 however, the massed single-session approach could be considered a viable option for suitable patients.

Early studies of exposure therapies for specific phobias 90 were criticised for their various methodological limitations, including selection biases, the use of small, unrepresentative samples, and compromised control conditions. Although exposure therapy is much more widely studied and accepted now than it was in the early 1970s, systematic reviews suggest that the evidence base could still be improved. 80 , 81 Additionally, although the available evidence indicates moderately high short-term efficacy of psychological treatments for specific phobias, 80 most studies have only followed up patients for short durations. The assessment of long-term effectiveness is particularly important because treated phobias in patients (and extinguished fear responses in other animals) are susceptible to relapse. 91 – 96 One of the notable risk factors for relapse is context change, in which the individual reencounters the phobic stimulus or situation outside of the context in which extinction originally occurred. 93 , 96 Accordingly, studies have sought to extinguish conditioned responses to fear or phobic stimuli in multiple contexts, finding this approach to be comparatively more effective than extinction in a single context. 95 – 98

Pharmacotherapy is not a common treatment choice for specific phobias. However, within the past decade, studies have investigated pharmacological augmentation of exposure therapy in attempts to improve treatment outcomes. In one approach, clinicians administer the antibiotic D-cycloserine, which is thought to facilitate fear extinction learning through its role as an N-methyl D-aspartate receptor agonist. 99 , 100 The results of the first published, double-blind, randomised trial in humans indicated that oral administration of D-cycloserine (50 mg or 500 mg) before virtual-reality exposure therapy for phobia of heights was associated with substantially greater improvement than was placebo. 100 Results from a systematic review of placebo-controlled studies suggest that pre-exposure D-cycloserine administration (50 mg, 250 mg, or 500 mg) is associated with a small exposure augmentation benefit in patients with anxiety, obsessive-compulsive, or post-traumatic stress disorders (compared with pretreatment, d =–0·25 at post-treatment, d =0·19 at follow-up). 101 In another approach, clinicians administer glucocorticoids—which appear to have a role in fear extinction processing—before exposure therapy. In two randomised trials, participants in the treatment group were orally administered 20 mg cortisol 1 h before virtual-reality exposure therapy for fear of heights 102 or in-vivo exposure therapy for fear of spiders. 103 Both studies found that cortisol administration enhanced the efficacy of treatment relative to placebo-controlled exposure therapy.

Although specific phobias have a high prevalence, a low percentage of affected people seek treatment. Specific phobias begin early in life and persist over years or decades, and are associated with increased risk of various other mental disorders. The prevalence, incidence, course, and comorbidities of specific phobias are similar across the different subtypes, with the possible exception that fear of heights is more prevalent and more persistent than other subtypes. The consistent associations with some risk factors, such as female sex, education, and formerly married status, suggest the possible existence of causal pathways that could be altered to produce beneficial effects.

Future studies should more thoroughly examine barriers to treatment for specific phobias, and more high-quality studies assessing longer-term outcomes in patients treated with different forms of exposure therapy (eg, massed single-session vs more gradual multiple-session exposure, or single-context vs multiple-context exposure) are needed. The potential benefits of pharmacological augmentation of exposure also warrant further study. There is insufficient research regarding how the onset of related phobias is affected by the initial exposure to the feared object or situation, or the context of the exposure (such as the presence of social support or stress, and the magnitude of the exposure itself). Furthermore, little is known about the possibility of crossover from one type of specific phobia to another. Future research could illuminate these possibilities.

Search strategy and selection criteria

We searched PubMed on Oct 11, 2017, combining MeSH and open terms for phobias (“phobia*”[tw]) and epidemiology (“Epidemiologic Studies”[MeSH:NoExp] OR “Observational Study”[Publication Type] OR “Observational Study as Topic”[MeSH] OR “Cohort Studies”[MeSH] OR “epidemiologic study”[tw] OR “epidemiologic studies”[tw] OR “follow up”[tw] OR “longitudinal”[tw] OR “prospective*”[tw] OR “observational study”[tw] OR “observational studies”[tw]). The search was limited to studies in English and yielded 1536 records, which we assessed for their relevance to the prevalence, incidence, course, risk factors, or consequences of phobias. Citations included in reviews that did not meet the inclusion criteria were searched to identify relevant articles that the original search might have failed to capture.

Acknowledgments

WWE’s work is funded in part by a National Institute on Aging grant (U01AG052445).

Declaration of interests

We declare no competing interests.