Most of us are none too eager to confront a spider or to be caught in a thunderstorm, but few of us have such dread as Marianne or Trisha:

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A phobia (from the Greek word for “fear”) is a persistent and unreasonable fear of a particular object, activity, or situation. People with a phobia become fearful if they even think about the object or situation they dread, but they usually remain comfortable as long as they avoid it or thoughts about it.

We all have our areas of special fear, and it is normal for some things to upset us more than other things (see MediaSpeak below). How do such common fears differ from phobias? DSM-5 indicates that a phobia is more intense and persistent and the desire to avoid the object or situation is stronger (APA, 2013). People with phobias often feel so much distress that their fears may interfere dramatically with their lives.

Most phobias technically fall under the category of specific phobias, DSM-5’s label for an intense and persistent fear of a specific object or situation. In addition, there is a broader kind of phobia called agoraphobia, a fear of venturing into public places or situations where escape might be difficult if one were to become panicky or incapacitated.

A specific phobia is a persistent fear of a specific object or situation (see Table 5-5). When sufferers are exposed to the object or situation, they typically experience immediate fear. Common specific phobias are intense fears of specific animals or insects, heights, enclosed spaces, thunderstorms, and blood. Here Andrew talks about his phobic fear of flying:

Each year around 12 percent of all people in the United States have the symptoms of a specific phobia (Kessler et al., 2012). Almost 14 percent of individuals develop such phobias at some point during their lives, and many people have more than one at a time. Women with the disorder outnumber men by at least 2 to 1. For reasons that are not clear, the prevalence of specific phobias also differs among racial and ethnic minority groups. In some studies, African Americans and Hispanic Americans report having at least 50 percent more specific phobias than do white Americans, even when economic factors, education, and age are held steady across the groups (Stein & Williams, 2010; Hopko et al., 2008; Breslau et al., 2006). It is worth noting, however, that these heightened rates are at work only among African and Hispanic Americans who were born in the United States, not those who emigrated to the United States at some point during their lives (Hopko et al., 2008).

The impact of a specific phobia on a person’s life depends on what arouses the fear (Costa et al., 2014; Gamble, Harvey, & Rapee, 2010). People whose phobias center on dogs, insects, or water will keep encountering the objects they dread. Their efforts to avoid them must be elaborate and may greatly restrict their activities. Urban residents with snake phobias have a much easier time. The vast majority of people with a specific phobia do not seek treatment (NIMH, 2011). They try instead to avoid the objects they fear.

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People with agoraphobia are afraid of being in public places or situations where escape might be difficult or help unavailable, should they experience panic or become incapacitated (APA, 2013) (see Table 5-6). This is a pervasive and complex phobia. In any given year, 1.7 percent of the population experience agoraphobia, women twice as frequently as men (Kessler et al., 2012). The disorder also is twice as common among poor people as wealthy people (Sareen et al., 2011). At least one-fifth of those with agoraphobia are currently in treatment (NIMH, 2011).

People typically develop agoraphobia in their 20s or 30s, as Veronica did:

It is typical of people with agoraphobia to avoid entering crowded streets or stores, driving in parking lots or on bridges, and traveling on public transportation or in airplanes. If they venture out of the house at all, it is usually only in the company of close relatives or friends. Some insist that family members or friends stay with them at home, but even at home and in the company of others they may continue to feel anxious.

In many cases the intensity of the agoraphobia fluctuates, as it did for Veronica. In severe cases, people become virtual prisoners in their own homes. Their social life dwindles and they cannot hold a job. People with agoraphobia may also become depressed, sometimes as a result of the severe limitations that their disorder places on their lives.

Many people with agoraphobia do, in fact, have extreme and sudden explosions of fear, called panic attacks, when they enter public places, a problem that may have first set the stage for their development of agoraphobia. Such individuals may receive two diagnoses—agoraphobia and panic disorder, an anxiety disorder that you will read about later in this chapter—because their difficulties extend considerably beyond an excessive fear of venturing away from home into public places (APA, 2013).

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Each of the models offers explanations for phobias. Evidence tends to support the behavioral explanations. Behaviorists believe that people with phobias first learn to fear certain objects, situations, or events through conditioning (Cherry, 2014; Field & Purkis, 2012; Gamble et al., 2010). Once the fears are acquired, the individuals avoid the dreaded object or situation, permitting the fears to become all the more entrenched.

Behavioral Explanations: How Are Fears Learned?Behaviorists propose classical conditioning as a common way of acquiring phobic reactions. Here, two events that occur close together in time become strongly associated in a person’s mind, and as you saw in Chapter 3, the person then reacts similarly to both of them. If one event triggers a fear response, the other may also.

In the 1920s, a clinician described the case of a young woman who apparently acquired a specific phobia of running water through classical conditioning (Bagby, 1922). When she was 7 years old she went on a picnic with her mother and aunt and ran off by herself into the woods after lunch. While she was climbing over some large rocks, her feet were caught between two of them. The harder she tried to free herself, the more trapped she became. No one heard her screams, and she grew more and more terrified. In the language of behaviorists, the entrapment was eliciting a fear response.

Entrapment → Fear response

As she struggled to free her feet, the girl heard a waterfall nearby. The sound of the running water became linked in her mind to her terrifying battle with the rocks, and she developed a fear of running water as well.

Running water → Fear response

Eventually the aunt found the screaming child, freed her from the rocks, and comforted her, but the psychological damage had been done. From that day forward, the girl was terrified of running water. For years family members had to hold her down to bathe her. When she traveled on a train, friends had to cover the windows so that she would not have to look at any streams. The young woman had apparently acquired a specific phobia through classical conditioning.

In conditioning terms, the entrapment was an unconditioned stimulus (US) that understandably elicited an unconditioned response (UR) of fear. The running water represented a conditioned stimulus (CS), a formerly neutral stimulus that became associated with entrapment in the child’s mind and came also to elicit a fear reaction. The newly acquired fear was a conditioned response (CR).

US: Entrapment → UR: Fear

CS: Running water → CR: Fear

Another way of acquiring a fear reaction is through modeling, that is, through observation and imitation (Bandura & Rosenthal, 1966). A person may observe that others are afraid of certain objects or events and develop fears of the same things. Consider a young boy whose mother is afraid of illnesses, doctors, and hospitals. If she frequently expresses those fears, before long the boy himself may fear illnesses, doctors, and hospitals.

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Why should one or a few upsetting experiences or observations develop into a long-term phobia? Shouldn’t the trapped girl see later that running water will bring her no harm? Shouldn’t the boy see later that illnesses are temporary and doctors and hospitals helpful? Behaviorists believe that after acquiring a fear response, people try to avoid what they fear. They do not get close to the dreaded objects often enough to learn that the objects are really quite harmless.

Behaviorists also propose that learned fears of this kind will blossom into a generalized anxiety disorder if a person acquires a large number of them. This development is presumed to come about through stimulus generalization: responses to one stimulus are also elicited by similar stimuli. The fear of running water acquired by the girl in the rocks could have generalized to such similar stimuli as milk being poured into a glass or even the sound of bubbly music. Perhaps a person experiences a series of upsetting events, each event produces one or more feared stimuli, and the person’s reactions to each of these stimuli generalize to yet other stimuli. That person may then build up a large number of fears and eventually develop generalized anxiety disorder.

How Have Behavioral Explanations Fared in Research?Some laboratory studies have found that animals and humans can indeed be taught to fear objects through classical conditioning (Miller, 1948; Mowrer, 1947, 1939). In one famous report, psychologists John B. Watson and Rosalie Rayner (1920) described how they taught a baby boy called Little Albert to fear white rats. For weeks Albert was allowed to play with a white rat and appeared to enjoy doing so. One time when Albert reached for the rat, however, the experimenter struck a steel bar with a hammer, making a very loud noise that frightened Albert. The next several times that Albert reached for the rat, the experimenter again made the loud noise. Albert acquired a fear and avoidance response to the rat.

Research has also supported the behavioral position that fears can be acquired through modeling. Psychologists Albert Bandura and Theodore Rosenthal (1966), for example, had human research participants observe a person apparently being shocked by electricity whenever a buzzer sounded. The victim was actually the experimenter’s accomplice—in research terminology, a confederate—who pretended to feel pain by twitching and yelling whenever the buzzer went on. After the unsuspecting participants had observed several such episodes, they themselves had a fear reaction whenever they heard the buzzer.

Although these studies support behaviorists’ explanations of phobias, other research has called those explanations into question (Gamble et al., 2010). Several laboratory studies with children and adults have failed to condition fear reactions. In addition, although most case studies trace phobias to incidents of classical conditioning or modeling, quite a few fail to do so. So, although it appears that a phobia can be acquired by classical conditioning or modeling, researchers have not established that the disorder is ordinarily acquired in this way.

A Behavioral-Evolutionary ExplanationSome phobias are much more common than others. Phobic reactions to animals, heights, and darkness are more common than phobic reactions to meat, grass, and houses (see MediaSpeak). Theorists often account for these differences by proposing that human beings, as a species, have a predisposition to develop certain fears (Cherry, 2014; Lundqvist & Ohman, 2005; Seligman, 1971). This idea is referred to as preparedness because human beings, theoretically, are “prepared” to acquire some phobias and not others. The following case makes the point:

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Where might such predispositions to fear come from? According to some theorists, the predispositions have been transmitted genetically through an evolutionary process. Among our ancestors, the ones who more readily acquired fears of animals, darkness, heights, and the like were more likely to survive long enough to reproduce and to pass on their fear inclinations to their offspring (Cherry, 2014; Hofer, 2010; Ohman & Mineka, 2003).

Every theoretical model has its own approach to treating phobias, but behavioral techniques are more widely used than the rest, particularly for specific phobias. In addition, research has shown such techniques to fare better than other approaches in most head-to-head comparisons. Thus we shall focus here primarily on the behavioral interventions.

Treatments for Specific PhobiasSpecific phobias were among the first anxiety disorders to be treated successfully. The major behavioral approaches to treating them are systematic desensitization, flooding, and modeling. Together, these approaches are called exposure treatments because in all of them people are exposed to the objects or situations they dread (Gordon et al., 2013; Abramowitz, Deacon, & Whiteside, 2011).

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People treated by systematic desensitization, a technique developed by Joseph Wolpe (1987, 1969), learn to relax while gradually facing the objects or situations they fear. Since relaxation and fear are incompatible, the new relaxation response is thought to substitute for the fear response. Desensitization therapists first offer relaxation training to clients, teaching them how to bring on a state of deep muscle relaxation at will. In addition, the therapists help clients create a fear hierarchy, a list of feared objects or situations, ordered from mildly to extremely upsetting.

Then clients learn how to pair relaxation with the objects or situations they fear. While the client is in a state of relaxation, the therapist has the client face the event at the bottom of his or her hierarchy. This may be an actual confrontation, a process called in vivo desensitization. A person who fears heights, for example, may stand on a chair or climb a stepladder. Or the confrontation may be imagined, a process called covert desensitization. In this case, the person imagines the frightening event while the therapist describes it. The client moves through the entire list, pairing his or her relaxation responses with each feared item. Because the first item is only mildly frightening, it is usually only a short while before the person is able to relax totally in its presence. Over the course of several sessions, clients move up the ladder of their fears until they reach and overcome the one that frightens them most of all.

Another behavioral treatment for specific phobias is flooding. Therapists who use flooding believe that people will stop fearing things when they are exposed to them repeatedly and made to see that they are actually quite harmless. Clients are forced to face their feared objects or situations without relaxation training and without a gradual buildup. The flooding procedure, like desensitization, can be either in vivo or covert.

When flooding therapists guide clients in imagining feared objects or situations, they often exaggerate the description so that the clients experience intense emotional arousal. In the case of a woman with a snake phobia, the therapist had her imagine the following scene, among others:

In modeling it is the therapist who confronts the feared object or situation while the fearful person observes (Bandura, 2011, 1977, 1971; Bandura et al., 1977). The behavioral therapist acts as a model to demonstrate that the person’s fear is groundless. After several sessions many clients are able to approach the objects or situations calmly. In one version of modeling, participant modeling, the client is actively encouraged to join in with the therapist.

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Clinical researchers have repeatedly found that each of the exposure treatments helps people with specific phobias (Antony & Roemer, 2011; Rosqvist, 2005). The key to greater success in all of these therapies appears to be actual contact with the feared object or situation. In vivo desensitization is more effective than covert desensitization, in vivo flooding more effective than covert flooding, and participant modeling more helpful than strictly observational modeling. In addition, a growing number of therapists are using virtual reality—3D computer graphics that simulate real-world objects and situations—as a useful exposure tool (Dunsmoor et al., 2014; Antony, 2011).

Treatments for AgoraphobiaFor years clinicians made little impact on agoraphobia, the fear of leaving one’s home and entering public places. However, approaches have now been developed that enable many people with agoraphobia to venture out with less anxiety. These new approaches do not always bring as much relief to sufferers as the highly successful treatments for specific phobias, but they do offer considerable relief to many people.

Behaviorists have again led the way, this time by developing a variety of exposure approaches for agoraphobia (Gloster et al., 2014, 2011). Therapists typically help clients to venture farther and farther from their homes and to gradually enter outside places, one step at a time. Sometimes the therapists use support, reasoning, and coaxing to get clients to confront the outside world. They also use more systematic exposure methods, such as those described in the following case study:

Exposure therapy for people with agoraphobia often includes additional features—particularly the use of support groups and home-based self-help programs—to motivate clients to work hard at their treatment. In the support group approach, a small number of people with agoraphobia go out together for exposure sessions that last for several hours. The group members support and encourage one another, and eventually coax one another to move away from the safety of the group and perform exposure tasks on their own. In the home-based self-help programs, clinicians give clients and their families detailed instructions for carrying out exposure treatments themselves.

Between 60 and 80 percent of agoraphobic clients who receive exposure treatment find it easier to enter public places, and the improvement persists for years after the beginning of treatment (Craske & Barlow, 2014; Gloster et al., 2014, 2011; Klein et al., 2011). Unfortunately, these improvements are often partial rather than complete, and as many as half of successfully treated clients have relapses, although these people readily recapture previous gains if they are treated again. Those whose agoraphobia is accompanied by a panic disorder seem to benefit less than others from exposure therapy alone. We shall take a closer look at this group when we investigate treatments for panic disorder.