How to recognise a phobia (and get help)

For weeks before she’s scheduled to fly, she feels intense worry and anxiety. The fear of flying developed a year ago, after an extremely turbulent flight. Now, every time she’s forced to take another trip for work, she has vivid and recurring images of her plane crashing. She’s hyperaware of any sound or unexpected movement of the plane, and she drinks excessively before the flight in an attempt to manage the anxiety.

Elsewhere, a young man feels panic whenever he’s exposed to the sight of blood or injection. He is not sure when or why these feelings first came about. But he’s started to avoid seeing his doctor, fearing that he might faint if he has to get a shot or have blood drawn. Just the thought of this possibility feels overwhelming.

These are only two examples of the various kinds of experiences faced by people with a specific phobia – a mental health condition that involves an intense fear or anxiety about a specific object or situation. For some, the reaction is prompted by planes or needles. For others, it’s seeing a spider, getting in an elevator, standing in a high place, or one of many other potential triggers. It’s estimated that about 7 per cent of people have a phobia at some point in their lives, and many experience more than one type.

If you have a recurring fear of your own, you might be wondering whether it qualifies as a phobia and what you can do about it. Too often, people who have a phobia don’t fully recognise what they are experiencing or choose to simply endure their symptoms. This can make life quite stressful, especially in situations where escaping or avoiding the feared thing is not an option. But research clearly shows that phobias can be treated effectively. In fact, they are among the most treatable disorders. As someone with more than 20 years of experience working with people who have phobias and other anxiety-related disorders, I know that evidence-based therapy can help even those with the most stubborn phobias overcome their excessive fear and avoidance.

What I aim to do is help you to think through whether you might indeed have a specific phobia and, if so, whether treatment is an option for you. This requires some understanding of what a phobia is and its variations.

What is a phobia?

Specific phobias are commonly sorted into five broad categories, based on the kind of object or situation that triggers an emotional response:

• animal type – usually animals such as snakes, spiders or mice;
• natural environment type – eg, heights, storms or water;
• blood-injection-injury type – eg, blood, needles or invasive medical procedures;
• situational type – eg, flying on an airplane, riding an elevator;
• other type – this involves a fear of something, such as choking or vomiting, that is not covered by the previous categories. (Some people have a fear of multiple types of situations in which they feel it might be difficult to escape; this is not a specific phobia, but a different anxiety disorder called agoraphobia.)

Importantly, a phobia is more than just ordinary fear. The capacity to experience fear in response to an immediate threat is natural and even essential to survival, because it mobilises the body’s response to genuine dangers. Similarly, a moderate amount of anxiety – feelings of uneasiness and tension about something anticipated in the future – is a normal experience, and might motivate you to prepare for what’s ahead (such as getting ready for a job interview). Part of what distinguishes a phobia is that the fear or anxiety is excessive, persistent and causes significant dysfunction – features we’ll explore in the next section.

Some people with a specific phobia also respond with disgust, which is typically evoked by objects or situations seen as repulsive or contaminated. Like fear, disgust can serve a protective function. But the ‘yuck’ factor can also play a significant role in the development of a phobia, especially one related to small animals or to blood, injection and injury.

When someone with a specific phobia encounters the feared object or situation, there is a well-coordinated bodily response. Often described as the body’s ‘fight-or-flight’ response, it’s characterised by rapid heartbeat, sped-up breathing and sweating, accompanied by a surge in stress hormones like epinephrine and norepinephrine. For many people with the blood-injection-injury type of phobia, the initial increase in heart rate and blood pressure is followed by a drop in both, which can lead to fainting.

These are just some of the basic characteristics of the phobia experience. In the rest of this Guide, I’ll help you look more closely at whether the hallmarks of a phobia apply to your own experiences – and describe what you can do next.

See if you show the signs of a phobia

When clinicians diagnose someone with a specific phobia, they commonly use a set of criteria from a standard guidebook, such as the Diagnostic and Statistical Manual of Mental Disorders (DSM). To get a formal diagnosis, you’ll have to meet with a qualified healthcare professional. For the moment, however, you can get a better sense of whether you might be dealing with a phobia by reflecting on your own experience and seeing if it shows the following key features, derived from the latest version of the DSM:

• Marked fear or anxiety about a specific object or situation. For example, you have an intense fear of snakes, including situations in which you think you are more likely to encounter snakes (such as going hiking). In contrast, someone who doesn’t have a phobia might not like snakes (or injections or flying on planes etc) but won’t feel more fear or anxiety about them than most people would.
• The object or situation almost always evokes immediate fear or anxiety. Do you experience fear or anxiety just about every time you come across the object or situation, or only sometimes? For example, you might have a sense of panic every time you see a spider in real life, or even something suggesting that a spider might be lurking (eg, a spider web). If you have a phobia, this fear will almost always show up right away (though there might be certain times when it doesn’t, such as when you’re distracted).
• The fear or anxiety is out of proportion to the actual danger posed by the specific object or situation, and to the sociocultural context. So, jumping out of your chair when you see a photo of a snake would be out of proportion to the actual danger (in this case, none). Similarly, declining an in-person job interview because it’s on the 100th floor of a skyscraper would suggest that your fear of heights is out of proportion to the (negligible) danger. In some social and cultural contexts, a particular threat can be dangerous, and so an intense fear of it might be regarded as reasonable. In the case of a phobia, your context does not account for your level of fear.
• The object or situation is actively avoided, or endured with intense fear or anxiety. For someone with a phobia, avoidance – which might mean looking away from an image, exiting a frightening situation or refusing to go near something – is often the most accessible way to reduce the fear and anxiety. But, as I’ll explain, this avoidance only worsens the phobia over time.
• The fear, anxiety or avoidance causes clinically significant distress or impairment. This impairment might happen at work, in your social life, or in other important areas of functioning. Someone who has a phobia of needles might avoid going to see the doctor for much-needed care. An individual who has panic attacks before or during a flight would also meet these criteria. Someone with emetophobia, or a specific phobia of vomiting, might avoid meals, which can lead to malnutrition.
• The fear, anxiety or avoidance is persistent, typically lasting for six months or more.

If you are not sure whether your experience fits all these criteria, there is another way to think about it. Simply ask yourself: are my fear and anxiety so distressing that I often avoid things or situations? And does that avoidance get in the way of me fully enjoying my life? If you answer ‘yes’ to those two questions, then I think it’s appropriate to seek help. In other words, if you believe that what you’re experiencing interferes with aspects of life that you find meaningful and important, then you should think about seeing a therapist. In the next sections, I’ll share some advice on how to do that.

Seek the most helpful treatment for phobias

For specific phobias, research shows that exposure therapy is the best treatment available. Exposure therapy is a form of cognitive behavioural therapy (CBT) in which you are gradually exposed to the object or situation that causes you fear, anxiety or disgust.

On the surface, the idea of exposing yourself to what you fear as a way to reduce that fear might sound counterintuitive and scary. It is true that confronting your fears is not easy. However, as a therapist who often delivers exposure therapy myself, I have seen that, despite the initial apprehension people feel, the treatment becomes easier the more someone engages with it.

Exposure therapy creates a safe environment where you can practise challenging the expectations you have about your triggers (eg, that you can’t handle the feelings or the uncertainty they provoke). Doing this, in turn, decreases the need to avoid those things.

Why do we want to decrease avoidance? Because it plays an important part in perpetuating fear and anxiety. For someone with a phobia, avoidance is what’s called a ‘safety behaviour’ – an unnecessary action taken to prevent, escape from, or reduce the severity of a perceived threat. Avoidance often provides short-term relief: for instance, if you have a phobia related to dogs, avoiding a leashed dog on the street temporarily reduces your fear. But doing this also maintains the phobia by preventing you from learning a critical lesson: that the feared situation is usually safe (eg, dogs don’t typically bite), and the uncertainty involved is something you can tolerate.

To address this problem, exposure therapy sometimes involves coming into direct contact with the feared thing or situation, such as a live spider for someone with a spider phobia. A good therapist will walk you through the exposure, providing clear instructions and guidance. They might also model the exposure by demonstrating that the feared outcome does not occur (eg, when they hold the spider, nothing bad happens). A therapist may also guide you in imaginal exposure, in which you imagine coming into contact with what you fear. Exposure therapy can even be done using virtual reality technology, allowing you to interact with a virtual representation of the feared object or situation.

In all of its forms, exposure therapy is typically delivered over time in a graded fashion. A therapist works with you to construct a hierarchy, in which feared objects, activities or situations are ranked, and then encountered, according to difficulty. For someone with a blood-injection-injury phobia, for example, a standard exposure hierarchy might look like this: 1) looking at pictures of needles; 2) holding a needle that is capped; 3) watching a video of someone getting an injection; 4) seeing a vial of blood; 5) having a mannequin ‘get an injection’ next to one’s bare arm; 6) getting a pretend injection with a needle that is capped; and finally, 7) having blood drawn for donation. This graded approach provides multiple opportunities to practise tolerating difficult emotions – and to learn that bad things don’t usually happen when we confront what we’re afraid of.

Another important aspect of treatment is called ‘response prevention’. Even when you start to face what you fear, it can be tempting to respond with ‘safety behaviours’ such as distracting yourself or dampening your feelings in some way (as the woman with flying phobia did when she drank before a flight). As with avoidance, these responses can interfere with learning that you can tolerate anxiety and uncertainty. With response prevention, a therapist will help you limit these habitual responses to gain the greatest benefit. This too can be carried out in a gradual way.

An essential part of this whole process is ‘homework’: continuing to confront feared objects and situations that are part of the hierarchy, outside of the treatment session. This is a way to gain real-world learning and increase your belief in your own capacity to face what you fear.

Exposure therapy for specific phobias typically requires six to 12 sessions. However, some therapists may provide a single-session treatment format in which a person is exposed to steps of the hierarchy over the course of a few hours. The one-session format may be best for those who are highly motivated, have a time crunch, and need quick symptom relief. Although this condensed treatment is not yet widely available, research suggests that it can be as effective as the traditional approach.

Non-exposure options

The more a person complies with the steps of treatment, the more effective exposure therapy can be. However, some people might find the treatment too distressing or just want to try something else. Although exposure therapy is currently the gold-standard treatment for phobias, cognitive therapy is an additional option. Cognitive therapy uses what’s called ‘cognitive restructuring’, along with other coping strategies, to treat some phobias (including claustrophobia). This approach helps people identify, challenge and then replace catastrophic thoughts – such as the thought I will get trapped and suffocate in the elevator – largely by considering the evidence for and against such thoughts. A therapist might use cognitive therapy alone or in combination with exposure therapy.

Medications such as beta blockers and sedatives might have limited, short-term use in specific situations (such as while flying on a plane). However, there is little evidence suggesting that medications are an effective long-term solution for specific phobias.

Find a qualified therapist

Many therapists have the training to effectively provide therapy for a specific phobia, but not all do. A good place to start is to search for a clinical psychologist near you, as they are more likely than some other mental health professionals to be trained in the delivery of exposure therapy.

To find a therapist who’s right for you, be willing to ask questions. (If you contact a therapist who is guarded or offended by your questions, you should probably move on to a different one.) For instance: what is their therapeutic orientation? If you’re seeking treatment for a phobia, then ‘cognitive behavioural therapy’ or ‘CBT’ is an appropriate answer. Often, you’ll be able to find information about a therapist’s treatment approach on their web page. Unfortunately, there are some practitioners who describe themselves as cognitive behavioural therapists but do not have the necessary training. If you’re not clear that a therapist has received training in CBT, you could ask them: what does therapy with a cognitive behavioural therapist look like? They should be able to tell you that the therapy is structured, present-focused, time-limited and goal-oriented, with an emphasis on teaching you skills.

You might also ask a therapist how much of their practice currently involves treating anxiety disorders, and specific phobias in particular. An important follow-up question is: what is your approach to such cases? Here is where, ideally, the therapist will describe exposure therapy as an approach they use.

Professional organisations in your country might provide sortable online listings that can help you find a therapist with experience treating phobias. In the US, for instance, the Anxiety and Depression Association of America has a useful ‘find your therapist’ tool that can help you locate exposure-therapy providers in particular cities and states. The Association for Behavioral and Cognitive Therapies offers its own directory that includes cognitive behavioural therapists who treat anxiety disorders (including phobias). If you’re feeling stuck in your search, you could also ask your doctor to refer you to a psychologist who has experience treating phobias.

Explore other options for support and self-help

You might wonder if dealing with a phobia requires going to see a therapist at all. Yes, you are probably better off seeing a therapist who is well trained in exposure therapy. However, effective internet- and mobile-based interventions are now available for a wide range of psychological disorders, including phobias. These alternatives to traditional face-to-face therapy often use images, audio and videos of feared objects or situations to deliver exposure therapy at home.

One of these interventions might be a good starting point if you are ambivalent about seeing a therapist, or if weekly appointments do not work with your busy schedule. It could be a way to dip your toes in the water to see what exposure therapy is about. A simple online search will turn up plenty of options, not all of them good ones. It’s best to ensure that any intervention you try uses exposure therapy principles and that the outcomes of the intervention have been published in a peer-reviewed scientific journal. While it’s too early to tell if any tech-based interventions are comparable with in-person exposure therapy (especially when it comes to long-term improvements), some of them do appear to be effective.

One option that I like is ZeroPhobia, a mobile app that provides a guided, gamified virtual self-help programme for some specific phobias – currently, fear of flying and fear of heights. The app has modules for education, goal-setting and exposure, allowing you to practise managing your fear in virtual-reality scenarios with the aid of a cardboard VR viewer. Studies have found that this was effective in reducing symptoms of acrophobia (fear of heights) and aviophobia (fear of flying), compared with not receiving the intervention.

Another option is the self-guided smartphone app called oVRcome, which is paired with a VR headset. The app teaches you how to manage phobic feelings using virtual environments that provide gradual exposure to your fears. One study of people who had a fear of flying, heights, needles, spiders or dogs showed a significant decrease in phobia symptoms after six weeks of the treatment programme.

Ultimately, you should still try to seek help directly from a qualified therapist. But if you’re waiting for an appointment, something else you can do in the meantime is some symptom monitoring. That is, start to pay attention to what, where, when and how you find yourself avoiding things related to your fear. Going further, you could even generate a list of these things, places or situations, and organise the list in terms of how much anxiety they provoke for you (going from least to most). If/when you’re able to see a therapist, this will make the job easier as you get started.

Are some people more likely to have phobias?

Specific phobias tend to run in families: if you have a family member with a phobia, it’s more likely that you will have some type of phobia yourself. Family and twin studies suggest that a person’s risk of having a phobia is moderately influenced by genetics, and that it’s more strongly related to genetics for certain phobia types (such as blood-injection-injury phobia).

Environmental influences could also increase the likelihood of developing a phobia. For example, overprotective parenting may communicate to a child that the world is dangerous, and reinforce the use of the very ‘safety behaviours’ that maintain phobic avoidance. There’s evidence that exposure to a traumatic event might raise the risk of having a phobia as well.

Although many people who have a specific phobia do not remember any initial event that gave rise to their symptoms, there are a number of pathways by which experience might lead to the development of a particular kind of phobia. One is direct experience: a child who is attacked by a dog might go on to develop a phobia of dogs. Another is modelling, where one acquires new behaviours or emotional responses by observing other people’s experiences. For example, a child who sees an older sibling cry when getting a vaccination might develop an injection phobia. A third possible pathway is through instruction or information: eg, some children who hear horror stories about going to the dentist may go on to develop a phobia.

Certain personality traits are also risk factors. One such trait is behavioural inhibition. Research suggests that a minority of children are predisposed to be fussy, irritable infants and shy, fearful toddlers. These behaviourally inhibited kids are the ones at greater risk of developing a specific phobia. Later in life, those with a high level of neuroticism – the disposition to experience negative emotions, self‐consciousness, irritability and emotional instability – are also more likely to have a specific phobia. There is some evidence that a proneness to experience disgust might put one at risk for certain phobias, such as animal phobia and blood-injection-injury phobias. There are a few reliable demographic risk factors for specific phobias, including female gender and younger age.

Although specific phobias often begin in childhood, they can persist for years. In fact, having a specific phobia often precedes the development of other disorders, especially anxiety, mood, and substance-use disorders. Given that phobias are a risk factor for these other conditions, getting treatment sooner rather than later might prevent not only the worsening of a phobia, but the development of other mental health challenges.

The website of the Exposure Therapy Consortium features resources explaining the rationale for using exposure therapy with specific phobias and what an exposure plan looks like. On this page, you’ll find some videos (both involving insect phobias) that illustrate how graded exposure works.

In an episode of the US video show The Good Stuff from PBS, a man opens up about – and faces – his own fear of heights, with a bit of humour.

The book-based programme Mastering Your Fears and Phobias: Workbook (2nd ed, 2006) by the clinical psychologists Martin Antony, Michelle Craske and David Barlow is grounded in the principles of CBT, and teaches readers about the nature of their fear and how to overcome it, both through exposures and by changing negative thoughts.

The Speaking of Psychology podcast has a conversation with Martin Antony about the impact of phobias and how treatment works.

If your fear relates to high places, the Psyche Guide ‘How to Overcome a Fear of Heights’ (2024) by Poppy Brown zooms in on acrophobia specifically.

Some people with intense fear of more than one situation – such as being in open spaces, riding public transportation or being outside of home alone – are facing not a specific phobia but a condition called agoraphobia. The Psyche Guide ‘How to Overcome Agoraphobia’ (2022) by Gila Lyons covers this in detail.