Fear Not!

By Jeffrey Kluger

It's not easy moving through the world when you're terrified of electricity. "Donna," 45, a writer, knows that better than most. Get her in the vicinity of an appliance or a light switch or--all but unthinkable--a thunderstorm, and she is overcome by a terror so blinding she can think of nothing but fleeing. That, of course, is not always possible, so over time, Donna has come up with other answers. When she opens the refrigerator door, rubber-soled shoes are a must. If a light bulb blows, she will tolerate the dark until someone else changes it for her. Clothes shopping is done only when necessary, lest static on garments send her running from the store. And swimming at night is absolutely out of the question, lest underwater lights electrocute her. When there's a possibility that lightning may strike, she simply shuts off everything in her house and sits alone in a darkened room until the danger passes.

There is a word--a decidedly straightforward one--for Donna's very extreme condition: electrophobia, or a morbid fear of electricity. You will find it listed right below eisoptrophobia (fear of mirrors) and not far above enetophobia, eosophobia and ereuthrophobia (fear of pins, daylight and blushing, respectively). And those are just some of the Es.

For every phobia the infinitely inventive--and infinitely fearful--human mind can create, there is a word that has been coined to describe it. There's nephophobia, or fear of clouds, and coulrophobia, the fear of clowns. There's kathisophobia, fear of sitting, and kyphophobia, fear of stooping. There are xanthophobia, leukophobia and chromophobia, fear of yellow, white and colors in general. There are alektorophobia and apiphobia, fear of chickens and bees. And deep in the list, lost in the Ls, there's lutraphobia, or fear of otters--a fear that's useful, it would seem, only if you happen to be a mollusk.

The list of identified phobias is expanding every day and is now, of course, collected online www.phobialist.com) where more than 500 increasingly quirky human fears are labeled, sometimes tongue-in-cheek, and cataloged alphabetically. Some have more to do with neology than psychology. (It's one thing to invent a word like arachibutyrophobia, another thing to find someone who's really afraid of peanut butter sticking to the roof of the mouth.) Other phobias, however--like acrophobia (fear of heights), claustrophobia (fear of enclosed spaces) and agoraphobia (a crushing, paralyzing terror of anything outside the safety of the home)--can be deadly serious business.

If the names of phobias can be found online, the people who actually suffer from at least one of them at some point in their life--about 50 million in the U.S. by some estimates--are everywhere. They may be like "Beth," a pseudonym, a middle school student in Boston whose hemophobia, or fear of blood, was so severe that even a figure of speech like "cut it out" could make her faint. Or they may be like "Jean," 38, an executive assistant in New Jersey who is so terrified of balloons that just walking into a birthday party can make her break out in a sweat.

For most people, the treatment of phobias has been a cope-as-you-go business: preflight cocktails for the fearful flyer, stairways instead of elevators for the claustrophobe. But such home-brew tactics are usually only stopgaps at best. Happily, safe and lasting phobia treatments are now at hand. In an era in which more and more emotional disorders are falling before the scythe of science, phobias are among the disorders falling fastest.

Researchers are making enormous progress in determining what phobias are, what kinds of neurochemical storms they trigger in the brain and for what evolutionary purpose the potential for such psychic squalls was encoded into us in the first place. With this understanding has come a magic bag of treatments: exposure therapy that can stomp out a lifetime phobia in a single six-hour session; virtual-reality programs that can safely simulate the thing the phobic most fears, slowly stripping it of its power to terrorize; new medications that can snuff the brain's phobic spark before it can catch. In the past year, the U.S. Food and Drug Administration approved the first drug--an existing antidepressant called Paxil--specifically for the treatment of social phobias. And just last week the Anxiety Disorders Association of America held a four-day seminar in Atlanta on a wide range of topics, including how to recognize and overcome social phobias, how to spot phobia and anxiety disorders in children and how to help patients maintain gains achieved in treatment.

"There's been nothing like this in the field of mental health," says psychologist David H. Barlow, director of the Center for Anxiety and Related Disorders at Boston University. "In the past few years, we've had a complete turnaround in the treatment of phobic disorders."

For something that can cause as much suffering as a phobia, it's remarkable how many people lay claim to having one--and how many of them are wrong. Self-described computer phobics are probably nothing of the kind. They may not care for the infernal machines and may occasionally want to throw one out the window, but that's not the same as a full-fledged phobia. Self-described claustrophobics often misdiagnose as well. The middle seat on a transatlantic flight may be something you approach with dismay, but unless you also experience a racing heart and ragged breath, you are probably not phobic. Drawing the distinction between distaste and the singular terror of a phobia is not always easy--and it's made all the harder by the fact that fear in some circumstances is perfectly appropriate. If flying into a storm or easing into weaving traffic isn't the right time to go a little white knuckled, what is?

Experts, however, say a true phobic reaction is a whole different category of terror, a central nervous system wildfire that's impossible to mistake. In the face of the thing that triggers fear, phobics experience sweating, racing heart, difficulty breathing and even a fear of imminent death--all accompanied by an overwhelming need to flee. In addition, much of the time that they are away from the feared object or situation is spent dreading the next encounter and developing elaborate strategies intended to avoid it. "Jeanette," 44, a teacher's assistant, is so terrified of cats that she sends her daughter, 21, into an unfamiliar store to scout around and sound a feline all clear before she enters. The daughter has been walking point this way since age five. "Nora," 50, a social worker, will circumnavigate a block with a series of right turns rather than make a single left, so afraid is she of facing the stream of traffic that a left turn requires.

Most psychologists now assign phobias to one of three broad categories: social phobias, in which the sufferer feels paralyzing fear at the prospect of social or professional encounters; panic disorders, in which the person is periodically blindsided by overwhelming fear for no apparent reason; and specific phobias--fear of snakes and enclosed spaces and heights and the like. Of the three, the specific phobias are the easiest to treat, partly because they are the easiest to understand.

The human brain may be a sophisticated thing, but there is an awful lot of ancient programming still etched into it. For "Martin," 21, a dental student in London, Ontario, his fear of snakes is so overwhelming that he stapled together pages in a textbook to avoid flipping to a photo of a snake. He often wakes with nightmares that he is sitting in a bar or a stadium and suddenly sees a snake slithering toward him. "It's odd," he says, "because I'm not in situations where I would ever see snakes."

His brain, however--or at least the oldest parts of it--may have been. One of the things that helped early humans survive was a robust fear-and-flight response: an innate sense of the places and things that represent danger and a reflexive impulse to hightail it when one of them is encountered. When the species became top predator a few million years later, those early lessons were not easy to unlearn.

Contemporary researchers believe it's no coincidence that specific phobias usually fall into one of four subcategories, all of which would have had meaning for our ancient ancestors: fear of insects or animals; fear of natural environments, like heights and the dark; fear of blood or injury; and fear of dangerous situations, like being trapped in a tight space. "Phobias are not random," says Michelle Craske, psychologist at UCLA's Anxiety and Behavioral Disorders Program. "We tend to fear anything that threatens our survival as a species." When times change, new fears develop, but the vast majority still fit into one of the four groups.

It turns out that we process the fear of these modern menaces in the same area of the brain our ancient ancestors did--the paralimbic region, which mediates a whole range of primal responses, including anger and sexual arousal. "It seems that contemporary people learned from their ancient ancestors what to be afraid of and how to handle it," Barlow says.

Not all of us, however, parlay that ancient history into a modern-day phobia. It may be our distant ancestors who predispose us to phobias, but it's our immediate ancestors--specifically our parents--who seal the deal. As many as 40% of all people suffering from a specific phobia have at least one phobic parent, seemingly a clue that phobias could be genetically influenced. In recent years, a number of scientists have claimed to have found the phobia gene, but none of those claims have held up to scrutiny. If phobias are genetically based at all, they almost certainly require a whole tangle of genes to get the process going.

But genetics doesn't even have to be involved as long as learning is. A childhood trauma--a house fire, say, or a dog bite--may be more than enough to seize the brain's attention and serve as a repository for incipient fears. "Temperament also seems to be critical," says Craske. "Two people can go through the exact same traumatic event, but the high-strung, emotionally sensitive person is more vulnerable to the fear." Even secondhand fears--watching Mom or Dad react with exaggerated terror to a cockroach or a drop of blood, for example--may play a role. The journal Nature last week reported a study in which researchers performed scans on the fear centers of volunteers' brains and found that when the subjects were merely told to expect an electric shock, the neurological reaction to the anticipated jolt was as powerful as fears based on actual experience. "There is a lot of legitimacy to the idea that phobias can be learned," says Edna B. Foa, professor of psychology and psychiatry at the University of Pennsylvania. "We respond to what we see or experience."

In many cases, the brain may think it's doing the child's psyche a favor by developing a phobia. The world is a scary place, and young kids are inherently fearful until they start to figure it out. If you are living with a generalized sense of danger, it can be profoundly therapeutic to find a single object on which to deposit all that unformed fear--a snake, a spider, a rat. A specific phobia becomes a sort of backfire for fear, a controlled blaze that prevents other blazes from catching. "The thinking mind seeks out a rationale for the primitive mind's unexplained experiences," says psychologist Steven Phillipson, clinical director of the Center for Cognitive-Behavioral Psychotherapy in New York City.

But a condition that is so easy to pick up is becoming almost as easy to shake, usually without resort to drugs. What turns up the wattage of a phobia the most is the strategy the phobics rely on to ease their discomfort: avoidance. The harder phobics work to avoid the things they fear, the more the brain grows convinced that the threat is real. "The things you do to reduce anxiety just make it worse," says Barlow. "We have to strip those things away."

And that's what doctors do. A patient visiting Barlow's Boston clinic is first assessed for the presence of a specific phobia and then guided through an intensive day or two of graduated exposure. People who are afraid of syringes and blood, for example, may first be shown a magazine photo with a trace of blood depicted in it. Innocuous photos give way to graphic ones, and graphic ones to a display of a real, empty syringe. Over time, the syringe is brought closer, and the patient learns to hold it and even tolerate having blood drawn.

None of this is remotely easy for the phobic person, and the body's anxiety Klaxons may go off the instant the therapy begins. Gradually, however, as each exposure level is reached, the alarms start to quiet; they sound again only when the intensity of the exposure is turned up. "Just as people become habituated to the noise of traffic or background chatter, so too can phobics become nonresponsive to the thing that once frightened them," says Phillipson.

With that habituation comes profound recovery. In studies recently conducted by Lars Goran Ost, a psychology professor at Stockholm University and one of the pioneers of one-day phobia treatments, a staggering 80% to 95% of patients get their phobias under control after just one session. And when symptoms disappear, they usually stay gone. Patients, he says, rarely experience a significant phobic relapse, and almost never replace the thing they no longer fear with a fresher phobia object.

Given the apparent simplicity of exposure therapy, phobics may be tempted to try it themselves. That can be a mistake. It is important that exposure take place under the care of a professional, since it takes a trained person to know when patients are being pushed too far and when it's safe to go further. For some situations impossible to re-create in a doctor's office--like heights and flying in airplanes--virtual-reality programs are available to provide simulated exposure under professional supervision. Software for other fears is being written all the time. "Not all people respond to virtual reality," says Barlow, "but on average, it's just as effective for treating certain phobias." If specific phobias were the only type of phobias around, things would be decidedly easier for doctors and patients. But the two other members of the phobia troika--social phobias and panic disorders--can be a little trickier.

Of the 50 million Americans who have experienced or will someday suffer from a phobia (and many will have more than one), 35 million will suffer from social phobia, and the battle they fight is a harrowing one. Richard Heimberg at Temple University's Adult Anxiety Clinic often thinks of the 50-year-old patient who talked frequently about getting married and having a family--a reasonable dream, except that his terror of rejection had kept him from ever going out on a date. After much encouragement and counseling, he finally screwed up his courage enough to ask a woman out. The next day, when Heimberg asked him if he'd had a good time, he said yes. But when asked if he were going to invite her out again, the patient slumped and said no. "She's only going to give to charity once," he explained.

For this patient, the problem wasn't mere low self-esteem but outright terror. To a social phobic, the mere prospect of a social encounter is frightening enough to cause sweating, trembling, light-headedness and nausea, accompanied by an overwhelming feeling of inadequacy. For some sufferers, the disorder is comparatively circumscribed--occurring only at large parties, say--making avoidance strategies seem easy. But social phobias can encroach into more and more areas of life, closing more and more doors. As sufferers grow increasingly isolated, they grow increasingly hopeless and risk developing such conditions as depression and alcoholism.

But things don't have to be so bleak. While social phobias do not respond to a single intensive exposure session as specific phobias do, therapy can still be relatively straightforward. A successful treatment regimen may involve no more than a dozen sessions of cognitive-behavioral therapy, in which patients slowly expose themselves to the places and circumstances that frighten them and reframe the catastrophic thinking that torments them. They are taught to tone down their "attentional bias," a tendency to stress their supposed social stumbles, and their "interpretation bias," a habit of picking up neutral cues from other people and interpreting them as evidence of failing socially. Often group therapy works better than one-on-one therapy. It provides more than a supportive circle of fellow sufferers: the very act of gathering with other people can serve as a first, critical rebellion against the disorder.

If such therapy doesn't help social phobics, drugs can. Ever since the popularization of Prozac in the early 1990s, the family of modern psychopharmacological drugs has grown steadily. Most of these medications are selective serotonin reuptake inhibitors--or SSRIs--which, as the name implies, selectively block the brain's reabsorption of the neurotransmitter serotonin, helping produce feelings of satisfaction and kick-start recovery. Last year the drug manufacturer SmithKline Beecham asked the Food and Drug Administration to take a second look at the popular SSRI Paxil and consider approving it specifically for the treatment of social-anxiety disorder. The FDA agreed, making Paxil the first drug ever to be formally endorsed for such use.

While the flood of marketing tends to overstate the case, the fact is, Paxil works--not by eliminating anxiety entirely but by controlling it enough for traditional therapy to take hold. And with the pharmacological door now open, makers of similar drugs like Luvox, Prozac and Celexa will probably seek the same certification. "Paxil is not unique among these drugs," says Barlow. "It was just first in line."

Progress in treating social-anxiety disorder is also providing hope for the last--and most disabling--of the family of phobias: panic disorder. Panic disorder is to anxiety conditions what a tornado is to weather conditions: a devastating sneak attack that appears from nowhere, wreaks havoc and then simply vanishes. Unlike the specific phobic and the social phobic who know what will trigger their fear, the victim of panic attacks never knows where or when one will hit. Someone who experiences an attack in, say, a supermarket will often not return there, associating the once neutral place with the traumatic event. But the perceived circle of safety can quickly shrink, until sufferers may be confined entirely to their homes. When this begins to happen, panic disorder mutates into full-blown agoraphobia. "For some people, even the house becomes too big," says Fordham University psychology professor Dean McKay. "They may limit their world to just a few rooms."

The treatment for agoraphobia is much the same as it is for social phobia: cognitive-behavioral therapy and drugs. In many cases, recovery takes longer than it does for social phobias because agoraphobic behavior can become so entrenched. Nonetheless, once therapy and drug treatments get under way, they sometimes move surprisingly quickly. "The best way to treat agoraphobia," says Ost, "is by individual therapy, once a week for 10 or 12 weeks."

If science has so many phobias on the run, does that mean that the problem as a whole can soon be considered solved? Hardly. Like all other emotional disorders, phobias cause a double dip of psychic pain: from the condition and from the shame of having the problem in the first place. Over the years, researchers have made much of the fact that the large majority of phobia sufferers are women--from 55% for social phobias and up to 90% for specific phobias and extreme cases of agoraphobia. Hormones, genes and culture have all been explored as explanations. But the simplest answer may be that women own up to the condition more readily than men do. If you don't come forward with your problem, you can't be included in the epidemiologists' count. Worse, you can never avail yourself of the therapists' cure.

Making things even tougher, phobias are often hard to distinguish from other anxiety disorders. A person who feels compelled to wash or shower dozens of times a day may have a phobic's terror of germs, but a clinician would easily peg the problem as obsessive-compulsive disorder, not a specific phobia. The survivor of an airline crash may exhibit a phobic's panic at even a picture of a plane, but likely as not, the fear is one component of a larger case of post-traumatic stress disorder. Different conditions require different treatments, and without the right care, the problem is unlikely to clear up.

The fact that phobias, of all the anxiety disorders, can be overcome so readily is one of psychology's brightest bits of clinical news in a long time. Phobias can beat the stuffing out of sufferers because the feelings they generate seem so real and the dangers they warn of so great. Most of the time, however, the dangers are mere neurochemical lies--and the lies have to be exposed. "Your instincts tell you to escape or avoid," says Phillipson. "But what you really need to do is face down the fear." When you spend your life in a cautionary crouch, the greatest relief of all may come from simply standing up.

--With reporting by Dan Cray/Los Angeles, Brad Liston/New Orleans, Ulla Plon/Copenhagen and other bureaus

TIME.com ON AOL Take the phobia self-test online at www.time.com/health and if you're still not too scared, send an e-mail to letters@time.com about your own phobias. To chat with Jeffrey Kluger, go to AOL Live at 7 p.m. (E.T.) Wednesday.

With reporting by Dan Cray/Los Angeles, Brad Liston/New Orleans, Ulla Plon/Copenhagen and other bureaus