Supervised by: Ellen Froustis MA, MSc. Ellen Froustis is a DPhil. Education candidate at the University of Oxford. She has a Master’s of Education-Special Emphasis School Counselling and a Master’s in Clinical Psychology. As the founder and director of EIMAI, and regional director of Peace Jam Greece, Ellen provides youth leadership development programs, bringing together youth with Nobel Peace Laureates and university students to create positive change in themselves and their communities. Ellen has served as General Secretary of the Greek Adlerian Psychological Association (2012-2016) and Vice President of Habitat for Humanity, Greater Athens (2006-2010). Ellen’s work with youth and schools has been awarded by the Near East Council of Overseas Schools, The Loukoumi Make A Difference Foundation, The Nobel Peace Laureate’s Billion Acts of Peace and Character.Org for best practices in character education.
Abstract
This research paper is a review of literature that was conducted by a team of psychology interns at Oxford Scholastica. The team collected and analyzed various research and scholarly articles that studied treatment interventions for a range of phobias. Treatments for the following phobias were explored: Mysophobia (Germophobia), Glossophobia, Atychiphobia, PTSD due to the trauma of gun violence, Agoraphobia, Apeirophobia, social anxiety disorder/social phobia, Autophobia (Monophobia), and Gelotophobia. The team evaluated and assessed findings from 15 academic journal articles and determined that Cognitive Behavioral Therapy (CBT), Trauma-Focused CBT, Virtual Reality CBT, Exposure Therapy (desensitization), Cognitive Control Training (CCT), Exposure Response Prevention (ERP), attention control interventions and medication are the most common methods and strategies used to treat fears and phobias. Cognitive Behavioral Therapy, in comparison to other treatment methods, was reported to have the most consistent outcomes. However, time constraints and limited access to some psychology journal databases did not enable the team to conduct a full systematic review, which may have revealed other effective treatment methods; this was a limitation of this study.
Introduction
The overall prevalence of phobia in children and adolescents is estimated at 19.7%. Among children with phobias, females tend to have significantly higher rates (62.4% vs 37.6%) than males. Nearly half of the total sufferers are in the 12-15 year age group (46.3%) (NIH, 2011). There is a diverse range of fears that young people experience, such as fear of spiders (Arachnophobia), being alone (Autophobia), public speaking (Glossophobia), enclosed spaces (claustrophobia), heights (acrophobia), germs (Mysophobia). In some cases, they become phobias. One of the most common phobias found in teenagers is social phobia, a fear of being amidst a lot of people or being in social situations. This can result in social anxiety disorder, where one experiences intense feelings of anxiety in social settings and during interactions (Monroe, 2022). It is important to differentiate between real and perceived fears and phobias to address treatment.
Fear is a triggered response to danger or stimulus predicting danger. It is a common emotion that is experienced by most people and can be characterized by nervousness, anxiety, discomfort, and distress. Fear on its own cannot be overcome by medical treatment as it often does not require this type of intervention (Garcia, 2017). It is an innate mechanism to protect individuals from real harm. An individual will experience fear as a result of external or internal inputs. As preparation to face the perceived danger, the brain will invoke what is commonly known as a “freeze, flight, fight, or fright” response to counter these inputs (Bracha 2004).
Phobia, on the other hand, is a more extreme version of fear that can hinder one’s life. It is known as an extreme or irrational fear of or aversion to a specific object or situation. A phobia is a form of anxiety disorder characterized by a persistent, excessive fear of something that may not carry a real threat.
Phobias have been categorized into three broad areas: social phobias (fear of social or professional encounters); panic disorders (experiencing overwhelming fear without a specific reason); and specific phobias (i.e. fear of spiders, spaces, heights) (Kluger et al., 2001). A phobia can be experiential specific, meaning that it originated from a lived experience of a traumatic event, or non-experiential specific, meaning that it was experienced vicariously through others or through one’s thinking about possible threatening outcomes (Garcia, 2017). Interacting with the source of one’s phobia may cause physical symptoms of panic, including tachycardia, diarrhea, shortness of breath, vomiting, nausea, or dizziness. Physical symptoms brought on by a crisis in relation to one’s phobia may require medical intervention, while the phobia itself can be treated with various forms of therapy or medication. Specific phobias are said to be easier to treat because they can be understood better (Kluger et al., 2001).
Like phobias, fear can be categorized as experiential or non-experiential and viewed as a learned or associated behavior. Non-experiential fear can be caused by a variety of factors – genetic, familial, environmental, and developmental – although it often begins with an initial period of sensitization (Garcia, 2020). Sensitization is an exaggerated emotional response to a specific situation or stimuli, which may create a learned behavior of fear associated with that stimuli in the future.
From a neurobiological perspective, sensitization is related to dysfunctional “learning-independent” fear circuits, which can trigger an exaggerated activation of the amygdala (Amano et al., 2010). Habituation is another natural neurobiological response to fear, in which the brain becomes desensitized to certain stimuli over time, eventually decreasing its fear response to such situations. Essentially, it serves as a decrement in the emotional reaction, controlled by amygdala activation with repeated stimuli (Denny et al., 2014). A lack of functionality of such a mechanism may result in persistent, non-experiential fears. Experiential phobias are triggered by an initial traumatic event, causing a repeated pattern of fear and avoidance when in contact with similar situations in the future (Lonsdorf et al., 2017). The brain responds to neurological cues, such as certain sounds, views, scents, and tastes that are associated with the original event, creating a learned behavior of fear in response to that stimulus (Garcia, 2020).
In terms of how fear initiates the process that the brain neurobiologically undergoes, the brain will neurally evaluate the stimulation caused by the fear on an unconscious basis before it will begin conscious evaluation of the stimulus. Specifically, the amygdala has a role of intervention between the corporal responses to emotion and the areas of the brain concerned with conscious feeling. There is an evolutionary standpoint to examine that also influences the neurobiological process; humans have developed an established tendency to materialize the irrationality inherent within assuming harm to be associated with the stimulation fear (Subramaniam, 2019). If the stimulus provides a sensation that is too dull in its nature to trigger a response from the emotional brain or too unrealistic to the cognitive brain, then an individual’s response to fear will biologically be suppressed due to the inaction of the amygdala to initiate fear-based behavior (Subramaniam, 2019).
In addition to the biological actions of the amygdala, through repeated exposure to a stimulus associated with a present fear which will directly vivify the amygdala, and then by experiencing the stimulus without being able to tangibly acknowledge the fear, one will be able to practice “fear-extinction” (Subramaniam, 2019). This results in the amygdala transferring the memories associated with the stimulus attached to the tangible fear into higher processing centers of the brain, specifically the medial prefrontal cortex, for storage. Furthermore, these memories will end up overriding the fear memories in the amygdala upon the successful management of one’s response to their fear. The reason for this is related to the brain’s intention to mitigate the use of neural resources when a stimulus of fear is experienced (Subramaniam, 2019). Understanding fear from a neurobiological perspective helps to identify effective methods of treatment.
Common Forms of Treatment
Cognitive Behavioral Therapy is one of the most common forms of treatment for psychological distress, including phobias. Fear, on the other hand, isn’t necessarily a condition, but rather a form of significantly less severe psychological distress. This makes fear a point of concern when tackling phobias in any form of treatment, but not necessarily the main target, as the meaning that people make of that fear is an important target of therapy. CBT is a form of psychotherapy where one talks to a therapist. Working with a mental health counselor allows such patients to manage problems by looking at them through a new mindset that is crafted in meetings together. CBT is a more cognitive approach to addressing mental health issues, targeting the irrational thoughts that can create paralyzing emotions that often lead to behaviors that do not benefit the person. Irrational thoughts are often referred to as “cognitive distortions”. CBT is helpful for understanding one’s irrational thoughts, exploring alternative ways of thinking about a situation or finding solutions, which often defuses intense emotions, and generates new responses or behaviors toward the stressful situation (Mayo Clinic, 2019).
Exposure Therapy, a type of behavioral therapy, is a form of Cognitive Behavioral Therapy. It focuses on exposing a person to situations that one has attached an abnormal amount of anxiety to, with a goal of desensitizing one’s emotional response and changing the behavioral reaction to these uncomfortable feelings (Lakin, 2018). Exposure Therapy places the person in the heart of the situation or object by confronting it head-on, which can be a bit more stress-inducing at first but can be very effective once a person has been desensitized to their fears or phobia.
Moreover, medication is a common treatment that is most effective when offered side by side with psychotherapy. Since therapists are unable to treat their patients with medication, people usually have to see a psychiatrist too in order to have support from both treatments. Psychiatric counseling is the first step when treating phobias, but medication is sometimes necessary, and it can be a long process to find the right form and dose. Phobias are treated with medications aimed at relieving anxiety, one of the largest effects on these patients. SSRIs are most commonly used, starting at a low dosage and combining it with talk therapy for the best outcome (National Health Service, 2018). Medication induces a more calming effect so that clients can think more clearly and benefit from therapy and getting to the root issues of their phobia or problem.
Whether real or imagined, fears and phobias can have a real and debilitating effect on the lives of young people. Therefore, this review of literature aims to identify the most common forms of treatment for fears and phobias and compare the effectiveness of these treatment methods. The question that will be investigated in this research endeavor is: “What are the most common forms of treatment for fears and phobias and what is their effectiveness?”
Literature Review
In this review of literature, psychology interns researched a specific phobia and the treatment methods that are most common in combating it. The goal was to understand each phobia and compare and contrast the effectiveness of treatment methods across the 9 different phobias that were examined, which included: Atychiphobia, Mysophobia (Germophobia), Glossophobia, PTSD due to trauma of gun violence, Agoraphobia, Apeirophobia, social anxiety disorder/social phobia, Autophobia (Monophobia), and Gelotophobia.
Atyichiphobia is an intense, irrational, and persistent fear of experiencing failure or feeling a sense of inadequacy. It can arise from an individual’s desire to achieve success while being concerned about societal views and negative reactions that can be competitive, judgmental, and belittling. An individual who has this fear will often deliberately attempt to avoid a situation that has any possibility of failure or self-imposed humiliation (Moline, 2015). As an example, one would avoid taking an exam due to the fear of achieving a score that cannot be deemed as a passing grade and, therefore, end up failing the course in its entirety. This emphasizes the challenging and impactful nature of Atychiphobia, as well as how it is a multifaceted response from a neurobiological standpoint. There are many aspects of failure that cause fear. One such component is related to a psychodynamic conceptualization of the fear of failure.
There is a tendency for the brain to forget the tangible situation of an incident. Still, there is, alternatively, an ability to retain emotions, especially one that has negative connotations such as humiliation or despair, for a much lengthier amount of time than the incident itself (Benninger, 2019). One particular influence on Atychiphobia is mindset and the degree to which someone has a fixed mindset versus a growth mindset as a criterion for judgment of one’s own behaviors and beliefs. The reason behind this is related to the notion that an individual with a fixed mindset will likely view a setback or inability to overcome hardship as a finished outcome as opposed to seeing it as a continual work in progress. In other words, an individual with Atychiphobia does not direct their aspirations in a way that creates an opportunity to improve themselves because they focus on their fear of failure rather than their success. Inevitably, deconstructive criticism and unproductive and self-interfering mentalities can form, leading to a decreased efficacy or belief that they can achieve their goals or that their life can be happy, fulfilling and prosperous. Despite this hindrance, it is a largely prevalent phobia due to the unattainable expectations established by the societal requirement of an individual’s contribution to civilization; One study discovered that out of 1083 adults tested, 31% responded with having Atychiphobia, which is, in its totality, larger than any other individual fear that was provided (Moline, 2015). In order to overcome the fear of failure, one needs to strive towards being able to thoroughly clarify their motivations, aspirations, and what success and failure definitively mean to them in order to achieve self-actualization that will act as a catalyst for segregating their beliefs; specifically, beliefs that revolve around the idea that gratuitous challenges are not of substantial weight to the point of causing distress and harm to one’s emotional and social health (Benninger, 2019).
A study on Atychiphobia by Bergh, Vermeersch, Hoorelbeke, Vervaeke, de Raedt and Koster explored the impact of Cognitive Control Training (CCT) as an Augmentation Strategy to CBT in the Treatment of Fear of Failure in Undergraduates (2020). The aim and objective of this study was to determine whether Cognitive Control Training can combat negative, maladaptive emotional regulation such as rumination. However, it was previously determined that as an isolated method of intervention for an individual who has Atychiphobia, CCT does not have a pronounced effect of measurable improvement of emotional regulation and psychopathology symptoms. Thus, it was questioned and examined in this study whether traditional intervention programs for the fear of failure, such as CCT, would improve these pertinent characteristics of emotional regulation and psychopathology symptoms when combined with CBT. The method and procedure that was utilized for this study involved 102 participants who were students aged 18 to 28; 56 of them reported themselves as having prior experience with psychotherapy, and they were collectively diverse in terms of their fields of study (Vermeersch et al., 2020). The participants were randomized in one of two experimental environments: one group experienced CCT and followed by ten 15-minute sessions of an adaptive Paced Auditory Serial Addition Task (PASAT). Alternatively, the second group were placed under active placebo conditions for the same amount of time (ten 15-minute sessions), while performing an adaptive speed-of-response task (SRT) (Vermeersch et al., 2020). This study had a very deliberate focus in terms of the outcomes that were intended to be analyzed; one possible outcome of the two groups relates to Repetitive Negative Thinking (RNT) and symptoms related to stress, anxiety, and depression, and the other outcome relates to determining adaptive cognitive emotion regulation strategies. The results of the study found that in both conditions, RNT and the symptoms shown were reduced. However, despite the original predictions and initial hypotheses made by the study, the CCT condition did not show a significant difference in comparison to the active placebo conditions when used solely on its own (without combining other treatment options/programs), specifically in terms of the effect of the treatments used. However, when these various methods of CCT and CBT were used in combination as a treatment for the fear of failure, symptoms were reduced by 40%, which was “unexpectedly” larger than the symptom reduction rate of 25%, as seen with only the usage of CBT, and a rate of 30% with CCT used as an alternative to CBT. As a result, it was concluded that CCT augments/enhances the effects of a CBT-related treatment for Atychiphobia when they are both used in conjunction with one another (Vermeersch et al., 2020).
Mysophobia, also known as Germophobia, is the extreme fear of contaminated microbes. In order to handle this phobia, mysophobics develop and perform certain practices that maintain cleanliness greater than the average person. Mysophobia typically develops from Obsessive-Compulsive Disorder (OCD), where mysophobics excessively repeat specific routines. Some other causes of Germophobia can be linked to genetics or a traumatic event. When exposed to germs, one may undergo a panic attack and experience irregular heartbeat, shaking, nausea, or sweating (Olsen, 2020).
In order to overcome Mysophobia, CBT and Exposure Therapy are typically used. For instance, a CBT approach would be when a patient is asked to state how their thoughts about germs affect their emotions and how it influences their behavior. It might include a psychoeducational component about OCD, germs and immunity to understand they are not in danger when they use basic hygiene and asked to track their daily response to germs. On the other hand, Exposure Therapy would expose mysophobics to germs. They would have to learn how to remain calm in a ‘contaminated environment’ (Olsen, 2020). During a 2016 study examining the effectiveness of Exposure Response Prevention (ERP), there were 10 participants, both male and female, with a median age of 13.6. First, the children and their parents attended an education session where they were educated on OCD, symptoms, Exposure Therapy and the role of family accommodation. In the first hour of session 1, the participants were taught strategies on how to combat OCD, such as ‘talking back’ to irrational thoughts. The second and third hours used ERP tasks and repeated them until the child’s anxiety decreased by at least 50%. Between the sessions, the participants were also given ERP tasks to practice. During the second session, the child spent 3 hours doing ERP exercises. These sessions varied from patient to patient, depending on their pace. Over the course of each session, a minimum of 3 tasks targeted a child’s OCD symptoms. These took place at home and in public spaces. After the sessions, the families took part in an e-therapy program where they would call the therapist over Skype. They would then discuss the progress, and the therapist would assign homework. Following the program, there was a 1-month follow-up where families completed diagnostic interviews, the CY-BOCS OCD severity interview, self-report questionnaires, and CY-BOCS-SR ratings. This same process reoccurred during the 6-month follow-up. This study found that during the 6-month follow-up, 8/10 participants showed a reliable change based on the CY-BOCS total score. 8/10 children also “improved” based on the diagnostic reviews. Once again, 8/10 children displayed clinically significant “improvement” on the basis of CSR ratings. ERP appears successful in reducing Mysophobia and addressing symptoms of OCD (Farrel et al., 2020).
Glossophobia, more commonly known as the fear of public speaking, is a phobia which affects approximately 75% of the population to some extent. It is also the most common form of social phobia, affecting 40% of those with this disorder (Klinger et al., 2005). Sufferers of Glossophobia have an immense fear of social performance, often within an academic setting. Due to this fact, this phobia often develops in young students as they are tasked with oral assignments such as presentations and in-class discussions. This phobia has the potential to impact one’s academic performance, interpersonal relationships, and communication skills. If left untreated, it may manifest in areas such as the workplace in which an individual may find it difficult to further their career goals due to the prevalence of meetings and conferences in this environment (Ambit and Pandayan, 2020). Another area in which this phobia manifests is in language learning due to a fear of negative perception by native speakers or misspeaking (Santos and Kunso, 2021). Glossophobia is often fueled by societal factors of close-mindedness and discrimination. Researchers believe that if a definitive cure for the fear of public speaking is achieved, it will create a cultural shift in which individuals are more comfortable stating their opinions and speaking up for themselves (Ambit and Pandayan, 2020).
A study by Safir, Wallach, and Bar-Zvi (2011) compared the long-term effectiveness of Virtual Reality Cognitive Behavioral Therapy (VRCBT) and standard Cognitive Behavioral Therapy (CBT) in treating public speaking anxiety. VRCBT refers to Cognitive Behavioral Therapy using an active computer-generated virtual environment that can simulate difficult and diverse real-world environments and situations. As such, this is a topic that is being widely researched as an alternative for psychotherapies that require contact with real-world stimuli as exposure in-vivo can be an insurmountable difficulty for some sufferers (Troendle, 2014). In the original study, 88 participants who suffered from Glossophobia were assigned to one of three groups: VRCBT (28), CBT (30), and WLC (30). WLC referred to the wait list control group in the experiment. Subjects in the VRCBT and CBT groups received 12 individual one-hour treatment sessions. After a year, subjects then completed a follow-up questionnaire sent by mail. The study concluded that VRCBT is an effective alternative to CBT as positive results were maintained in both testing groups (Safir, Wallach, and Bar-Zvi, 2011).
Trauma, both ongoing and past, can cause a fear response that inhibits daily movement and activity. Ongoing traumas, such as domestic and community violence, and past traumas, such as that of war veterans or refugees, hold equally debilitating effects on their sufferers, creating a learned behavior of fear toward similar situations (Cohen et al., 2011). This may result in severe phobias of general trauma reminders, such as certain smells or graphic imagery. One example of such a phobia would be in survivors of gun violence, who may develop a fear of loud noises and triggering sounds. A train whistle, for instance, may cause people with this phobia to cower away or try to make themself as invisible as possible as they did when hiding from their perpetrators. Fear inspired by trauma may create symptoms such as anxiety, rapid heartbeat, tense body language, and extreme flinching. Nearly 7% of the general population suffers from PTSD, although 60% of males and 50% of females have experienced at least one traumatic event in their lifetime. (Pacella et al., 2012)
Many studies have been done to make Trauma-Focused CBT as effective and individualized as possible. One such study by Jensen (2013) focused on comparing the effects of Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) to normal therapy methods (TAU). In a randomized trial of 156 traumatized youth between the ages of 10 and 18, each child was assigned to either TF-CBT or TAU as a treatment method. The results of this experiment showed that youth who were treated with TF-CBT showed “significantly lower levels of posttraumatic stress symptoms” and showed more signs of improvement in functional impairment, with an overall downward trend in mental illnesses such as depression and anxiety. The study showed the efficacy of TF-CBT as a treatment option for youth suffering from PTSD and opened up pathways for it to be implemented in community clinics worldwide (Jensen et al., 2013). More studies were done to focus on improving the effectiveness of TF-CBT, with one implementing the following strategies for youth who experience complex traumas, both ongoing and past: (1) dedicating a proportionally larger part of the TF-CBT model towards coping skills and mechanisms; (2) emphasizing the safety proponent of the TF-CBT model early on in treatment; and (3) begin exposure to general reminders in small increments (Cohen, et al., 2012).
Another study looked into restructuring the trauma narrative and processing component of TF-CBT to include the following for youth with ongoing traumas: (a) increasing parental awareness and acceptance of the extent of the youths’ ongoing trauma experiences; (b) addressing youths’ unhealthy coping mechanisms ongoing traumas; and (c) helping youth differentiate between real danger and generalized trauma reminders (Cohen et al., 2011). The results of these studies show that these strategies are effective when implemented into TF-CBT for youth patients.
Agoraphobia is often a severe and chronic disorder. It’s also one of the most prevalent known anxiety disorders. It is often associated with an existing panic disorder, with about a third of people with Agoraphobia having one. Panic disorders cause intense attacks of fear. Agoraphobia was originally thought of as an avoidance of public places, crowds, queues, and open spaces, using public transport, standing in line, etc. Eventually, it leads to being anywhere outside of the house. Recently, however, the focus of the disorder has shifted, even though it can occur alone, to studying panic attacks themselves, as that is believed to be the underlying root of what leads Agoraphobia to really develop. Also, most people who seek treatment for Agoraphobia are those who have panic attacks. The attacks are so bad they lead people to get out of the house and go get help, so those are the patients with the disorder that researchers have the most access to (clevelandclinic, 2020).
Medication and CBT were both tested as treatments for Agoraphobia in a study conducted by Dunn (2020). A significant difference was shown between the factors of information, effectiveness, and usefulness. There were 29 people in this group who experienced one form of treatment each. There was an observable difference between how CBT treatment was more helpful than medication. In a survey conducted before and after treatment, CBT was shown to have a great positive effect on helping people overcome or at least lessen the gravity of this disorder in their lives. While both medication and CBT were important in treatment, comparing the two shows a clear difference. Means for information (2.32x), usefulness (1.73x) and effectiveness (1.74x) in treatment with CBT were all much greater than that of medication. This was further confirmed with a calculated p-value of literally 0 for both information and usefulness and only 0.01 for effectiveness (The p-value calculates the probability of the data occurring under the null hypothesis). The calculated t-value, [info (5.68), effect (2.69) and useful (4.28), all being clearly far from 0], further showed greater effectiveness in CBT treatment (t-values close to 0 would prove a null hypothesis, numbers past 2 prove a treatment is working). Since numbers calculated for both the t and p values were at ‘no chance’ numbers, the treatments truly worked. The power of CBT clearly outweighs medication as a form of treatment. The next step is to combine the two so that even greater progress can be made (Dunn, 2020).
Infinity is a hard thing to wrap one’s mind around and in a few cases, is impossible to understand. Apeirophobia, the fear of eternity, stems from the lack of knowledge and control we have over time and space. The idea of heaven could be devastating; the continuation of life after death forever. Considered an anxiety disorder, Apeirophobia is much more common than one might believe, which has led to a lack of information and studies on the phobia (Azarian, 2016). Usually starting at a young age, everlasting life can be even scarier than death to some. At least with death, there is a conclusion; but heaven and the principles of our universe are founded in contrast to this concept, causing feelings of helplessness. One of the toughest pills to swallow for those who suffer from this phobia is that no matter how long they think about it and no matter how many studies are done, our never-ending galaxy and universe will never be tangible (Olesen, 2017). Coming to terms with the inability to manage the afterlife and the fact that existence is ruled by the science and nature of something much bigger than humanity is the only productive path. Not necessarily ignoring the threatening concept, but understanding that humans are powerless in this situation can end up being a comfort over time.
There is no treatment that specifically exists for an anxiety disorder like Apeirophobia, but CBT, specifically Exposure Therapy and Existential Psychotherapy, can be extremely helpful. Desensitization is a very impactful method of Exposure Therapy; this allows the patient to experience their fears and eventually get used to them. Exposure to different forms of infinity, such as numbers, death, and an infinite amount of other properties of life, causes clear anxiety in patients, but the goal is that over time it will not affect them as much (Psych Times). It is impossible to get rid of invasive thoughts and anxieties, but one can learn to live with them. Anti-anxiety medication or antidepressants, only in addition to CBT, can also be beneficial for those who suffer from Apeirophobia. The rarity and ambiguity that comes with this disorder make it very hard to conduct a study since there really is no clear treatment. However, programs like Mindfulness-Based Stress Reduction, consisting of intensive mindfulness training, have been proven to help relieve some of the existential dread that comes with Apeirophobia (Psychiatric Times). Moreover, a theory has been proposed that could explain some of the behaviors that come with the disorder. Terror Management Theory states that when one is either uncomfortable with a religious practice or scientific fact, denial is usually one’s immediate safety blanket. For some, in a desperate search for a new, right answer, their minds become stuck on this idea, never being able to live with the discomfort of existential thoughts. Such a theory makes a lot of sense for Apeirophobia and also demonstrates the unlikeliness of an actual cure (Theodore, 2022). Exposure Therapy is the best option for people who suffer from such thoughts, allowing them to find relief even when intrusive thoughts fill their minds.
Recognized as one of the most common and disabling mental disorders among adolescents, social phobia (SP) or social anxiety disorder (SAD) is defined as the unreasonable, overwhelming or excessive fear or anxiety in social situations and interactions with other people, with intense emotional suffering expressed by feelings of self-consciousness, judgment, evaluation, and inferiority (Klinger et al., 2005; Spain D et al 2018; Zhang X, 2022). Typically emerging between the ages of fifteen and twenty, SP is the result of a multifaceted interplay between biological, psychological and social factors; moreover, a genetic predisposition to heightened anxiety sensitivity combined with an aberrant, over-assessment of fear and negative life expectancies, abnormal overactive amygdala and brain cortex, widespread resting-state dysconnectivity in cortico-striato-thalamo-cerebellar circuitry with a widespread pattern of gray matter of cortical, subcortical and cerebellum areas, as well as behavioral inhibition together with familial history, adverse social experiences during formative years and childhood traits may increase the susceptibility to develop SP (Guyer et al., 2012; Zhang et al., 2022; Svihra et al., 2004; Spain et al., 2018; Klinger et al., 2005). Also, excessive self-criticism and self-focused attention with fear of negative evaluation may result in anxiety and SP, as well as overestimation of the threat associated with social situations, negative beliefs about the self, biases in information, attention and emotion processing, and ‘safety behaviors’ such as avoidance, mental rehearsal and post-event processing, which indirectly reinforce anxiety over time (Cox, 2002; Jakymin et al., 2012; Spain et al., 2018).
Generalized SP represents the main subtype of SP, characterized by fear in almost all social situations that typically manifests as anticipatory anxiety, worry, indecision, depression, embarrassment, feelings of inferiority, and self-blame involved in most life situations; all of these interfere with relationships, daily routines, work, school and disrupt patient’s life (Klinger et al., 2005). In fact, each of the four domains of fear, including performance anxiety (speaking in public), intimacy anxiety (establishing connections, small talk), assertiveness anxiety and observation anxiety (acting while being under scrutiny), is clearly affected in SP and results in significant emotional distress accompanied by behavioral symptoms and physical manifestations (intense fear, racing heart, blushing, excessive sweating, dry throat and mouth, trembling, difficulty swallowing, muscle twitches) (Klinger et al., 2005).
Management alternatives of SP include medication (antidepressant drugs aiming to help reduce anxiety and discomfort), psychotherapy, or a combination of the two. Cognitive Behavior Therapy (CBT), acting in three different ways – Exposure Therapy, Cognitive Therapy and Assertiveness Therapy – is among the treatments of choice for social phobia, as graded exposure to feared social situations is one of the fundamental approaches (Klinger et al., 2005). On the other hand, Virtual Reality Cognitive Behavior Therapy (VRCBT), a human-computer interaction paradigm based on exposure to virtual environments that are designed to recreate four situations dealing with social anxiety (performance, intimacy, scrutiny, and assertiveness), is an interesting alternative to the standard exposure (Klinger et al., 2005; Wu et al., 2021). The possibility to control the intensity of the stimuli addresses the full spectrum of SP, with patients being able to learn adapted cognitions and behaviors in order to reduce anxiety in the corresponding real situations (Klinger et al., 2005; Wu et al., 2021).
An interesting meta-analysis and systematic literature review recently published explored the effectiveness and long-term efficacy of VRCBT compared to CBT in the treatment of anxiety and depression in patients with anxiety disorders (Wu et al., 2021). The authors concluded that VRCBT is beneficial in anxiety disorders including social phobia, with similar therapeutic results as CBCT (Wu et al., 2021). Another important point is related to the role of mindfulness meditation training and self-referential processing in SP from behavioral and neural effects perspectives (Goldin et al., 2009). It seems that mindfulness-based stress reduction (MBSR) may result in increased self-esteem and decreased anxiety, increased positive and decreased negative self-endorsement, increased brain activity related to attention regulation and reduced activity in brain systems implicated in conceptual-linguistic self-view as reported by authors from Stanford University (Goldin et al., 2009). Self-referential processing could be the functional behavioral target to assess the effects of MBSR, and post-MBSR changes in maladaptive/distorted social self-view in SP occur as a consequence of self-processing conceptual modulation as well as regulation of attention (Goldin et al., 2009).
Fear of social interactions and situations with social and communication difficulties classically describes social phobia, but also can be found in other conditions such as autism (Farahi et al., 2022); thus, interpersonal sensitivity including interpersonal awareness, separation anxiety, timidity, fragile inner self, and a need for reassurance are typically more deeply related to SP, while fragile inner self and a need for approval are more commonly related to autistic traits (Farahi et al., 2022). On the other hand, social anxiety may co-occur with autism spectrum disorders (ASD), prompting those with ASD to withdraw from social interaction (Spain et al., 2018). A systematic review of social anxiety in ASD emphasized that SP may be associated with socio-communication impairments, specific social skills and diminished social motivation, while ASD patients commonly experience anxiety and worry about social interactions (Spain et al., 2018). Although there is a significant overlap between SP and autism, it is vital to understand the differences, particularly when they co-occur, including differences in gaze avoidance, social motivation, body posture, social cues and body language (Guy-Evans, 2022). Furthermore, differences in brain functioning, as supported by neuroimaging studies, clearly underpin that autistic people are even more different than those with social phobia (Guy-Evans, 2022).
Autophobia, also known as Monophobia, is the fear of being alone no matter how many loved ones or friends you have. This is different from feeling lonely because loneliness makes an individual feel downhearted and unhappy due to low social connections and/or poor quality of life. On the other hand, the fear of being alone makes one feel anxious or even scared when one is physically alone or even at the thought of being in that state. It is hard to know for sure how many people have this kind of phobia because many people keep it to themselves or fail to realize they have it. However, it is estimated that 1 in 10 American adults and 1 in 5 American teenagers deal with this phobia at some point . Many phobias often start in childhood which is why many people can trace their fear of being alone to a negative or traumatic experience they had early in their life. Things like being ignored, feeling abandoned, loss of a parent, and no support during hard times can all cause this irrational fear (Cleveland Clinic.Org).
There are many ways to treat this fear such as attention control, Exposure Therapy, and Cognitive Behavioral Theory. There hasn’t been a study done on how CBT or other forms of therapy help people with Autophobia. However, a study was conducted by Anthony C. James (2020) and others to see if CBT is effective in treating anxiety disorders in children and adolescents. There were 5,964 participants who were all younger than 19 and met the diagnostic criteria for an anxiety disorder diagnosis. One group got attention control, while the other got CBT. There was also a waitlist group to serve as the control study. After the study was done, they saw that there was a difference in effectiveness between attention control and CBT, where CBT was more effective. Surprisingly, the study showed that the waitlist group also improved, and there was only a slight difference in effectiveness between no treatment and CBT. This could be because time and situations that come and go can make phobias subside temporarily. Another reason could be the placebo effect, because the participants knowing that they were in the study could itself help with dealing with the phobia. Since Autophobia is classified as an anxiety disorder, this study shows that CBT appears more effective than attention control in comparison to no treatment (James, et al., 2020).
Gelotophobia is the pathological and irrational fear of appearing to others as an object of ridicule. It stems from the unshakable belief that you yourself appear ridiculous to others and causes an inability to perceive and appreciate laughter or even smiling in a positive way. This leads Gelotophobes to refuse to show themselves in social settings because they believe that others are continuously scrutinizing them as a source of humor. Some other signs of this phobia include that those who suffer appear “cold as ice”, have low self-esteem and social competence and may even manifest the “Pinocchio syndrome” (stiff, wood-like movements, lack of expression). Gelotophobia may be confused or classified with shame-based neurosis, but it is its own category. This phobia is most likely caused by the repeated trauma of not being taken seriously or being laughed at during childhood, but may also result from intense traumatic experiences as an adult (e.g. mobbing). Therefore, the social environment and especially parents play a monumental role in the potential development of this phobia in young children and even adolescents (Ruch; Proyer, 2013). It has also been found that culture greatly influences the incidence of Gelotophobia in a country. For example, in the UK, 13% of people experience this phobia with 1% having it to such an extent that it is debilitating, while in Denmark, only 2% (the lowest percentage in the world) of people have Gelotophobia. This is largely due to the difference between “British humor” and the taboo of making fun of another that is part of Danish culture (Oxford CBT, 2022).
Gelotophobia in and of itself does not have any specific type of treatment or therapy. However, as it can be classified as a social phobia, it should be treated as such. Its severity can be influenced by comorbidities associated with social phobias, such as anxiety, depression or psychoactive substance dependence (Ito LM et al., 2008). For treatment, it has been found that CBT is the most effective method, with an 84% success rate after one year, compared to the 42% success rate of Exposure Therapy. Patients are also given social skills training (SST) and assertiveness training (AT), which teaches them a variety of socially acceptable behaviors and skills to help reduce their perceived impotence in social gatherings. They first practice these skills in familiar environments before being assigned to practice them in social settings. Also, studies have been made to see whether Group Cognitive Behavioral Therapy (GCBT) or Individual Cognitive Behavioral Therapy (ICBT) is more successful. While no empirical consensus has been reached, GCBT has presented greater practical promise by not only reducing cost but most importantly by providing in vivo exposure to social settings. These groups are created to be well-balanced (age, gender, severity of SP) and are usually around six people and led by one or two therapists. These sessions use typical CBT methods of restructuring the negative outlook on laughter or themselves and last for at least 12 weeks (Ito LM et al., 2008).
A study conducted on Taiwanese students found that people with autism spectrum disorder (ASD) and anyone who is a natural introvert have a much higher risk of developing Gelotophobia as opposed to their extroverted counterparts. It concluded that Gelotophobia does not arise in any way from ASD, but from repeated traumatic experiences coupled with a low level of extraversion. This study also found that how agreeable a person was correlated with their level of katagelasticism, or the psychological condition where one excessively enjoys laughing at others, and those with ASD had generally high risk of Gelotophobia, but with close to no tendency towards katagelasticism (Tsai et al., 2018). Both studies agreed that CBT was the best mode of treatment for people with Gelotophobia and other social phobias, with both showing a preference for GCBT as it helps reinforce and even teach social behaviors and intrapersonal relationships.
Methods
This research paper is a review of studies that treated fears and/or phobias. Studies were identified from the following databases: Frontiers in Psychology, Research Gate, Google Scholar and Social Science Research Network. The following search terms were used: “fears”, “phobias”, “adolescent fears”, “adolescent phobias”, “Mysophobia”, “Agoraphobia”, “Aperiophobia”, “Autophobia”, “social phobia”, “Gelotophobia”, “Atychiphobia”, “Glossophobia”, “treatment for fears”, “treatment of phobias”, “Exposure Therapy”, “CBT and phobias”, “CBT for treatment of trauma and fear”, “amygdala”, “Trauma-Focused Cognitive Behavioral Therapy”, “TF-CBT”, “PTSD symptoms”.
Fifteen articles were reviewed in Table 1 below to compare treatment methods across 9 fears/phobias.
Table 1: Studies reviewed can be found in the following table. https://docs.google.com/spreadsheets/d/1Jv4Zq3csdTAiteyw_DljI12CpQ1KEAOP5PZ3-wY4Kf0/edit?usp=sharing
Discussion
This research paper explored the question: How effective is CBT in treating the range of fears/phobias often experienced by young people? After examining 9 research studies on a range of phobias, the following was assessed:
Throughout this study, it has been identified that those who received Cognitive Behavior Therapy or other therapeutic treatments such as Exposure Therapy or medication were able to make measurable progress in overcoming their phobia. This outcome is particularly positive when compared to those on the wait list control group who generally made no progress or even experienced a worsened condition due to a lack of treatment. An exception to this statement was found within the study reviewed regarding Autophobia in which CBT was not shown to be significantly effective. It has been observed in the literature review that medication can manage a chemical imbalance within the brain while CBT tackles the core problems which create a phobia.
CBT can be categorized three different ways – Exposure Therapy, Cognitive Therapy, and Assertiveness Therapy – and is among the treatments of choice for different types of phobias, including social phobia, since a graded exposure to feared social situations is one of the fundamental approaches. Virtual Reality Cognitive Behavioral Therapy (VRCBT) is another method of CBT based on exposure to virtual environments that are designed to recreate situations; it offers the possibility to control the intensity of the stimuli and is quite promising as it is a more recent intervention.
Self-help methods such as Mindfulness-Based Stress Reduction (MBSR) used during CBT sessions improved the condition of some patients, especially those with social phobia. MBSR and VRCBT are recent therapeutic inventions which have become more widely researched due to their accessibility. A major disadvantage that had been previously identified in traditional CBT is that it often requires payment that may not be realistic for those living in poverty. In addition to this, those in rural or less urban areas may not have access to an in-person treatment facility. This issue is addressed by treatments such as VRCBT as the equipment is relatively cost-effective and can be conducted without the oversight of a therapist. However, as this form of therapy is quite recent and is still considered to be in the stage of development, further research is required to solidify the ability of VRCBT to be as effective as CBT. This is imperative when considering the notion that results of single studies can be impressionable, but may be due to the dynamics of patients or other conditions of an experiment and may not be applicable to a greater population.
Within the literature review, the idea that therapy is an extensively personal and specific experience has been of significant focus. It cannot always be confined to traditional methods such as CBT or the usage of medication as it is often the combination of various treatments that allow one to finally experience a sense of progress. However, this progress is not always linear and the root causes of a phobia can often haunt one for an extended length of time. Effective treatment for a particular individual can shift and change as they grow. Despite all of this, CBT can be confidently categorized as a successful, gold-standard treatment that has helped millions of people worldwide. Combined with elements of Exposure Therapy and a variety of different strategies based on one’s specific needs, it can be incredibly effective.
One such modification in CBT that has been substantially effective is utilizing a trauma-based approach for adolescents experiencing Post Traumatic Stress Disorder (PTSD). The specific study that was analyzed within the literature review identified that this trauma-focused method of CBT was even more efficacious in reducing symptoms of PTSD than the traditional treatment. Furthermore, many therapists have gravitated towards utilizing parental involvement as part of their course of treatment to ensure understanding and acceptance of their child’s mental health issues. This has allowed parents to help foster a safe and nurturing home environment for their children to thrive as they improve their mental health condition with therapy.
Strengths and Limitations
The complex and multifaceted approach of exploring a variety of different phobias experienced by adolescents and young people represents the main strength of this article. We were focused not only on different phobias, but we also comprehended a detailed clinical presentation and we were inclusive of all treatments. Furthermore, we underpin the complex interrelationships between specific phobias and psychiatric disorders such as OCD, autistic spectrum disorders, and narcissistic personality disorder. While this is not a systematic review, it gave us the opportunity to examine what treatments are applied across 9 fears and phobias and how they compared with CBT which, in most cases, was more effective than other treatments or more effective in combination with other treatments.
Another limitation was that accessing full-length journal articles was limited to open-access databases, and therefore it is possible that other treatment methods were not explored. Exploring 1-2 studies for each fear/phobia also does not make findings representative.
Future Considerations
In the future, more studies could be done to get a better understanding of the effectiveness of CBT as a treatment. Currently, the amount of studies done with modified CBTs are limited, with little research done on the full scope of options such as Virtual Reality and computer-aided self-help forms of treatment. Additionally, research done on CBT has been greatly limited to the USA. With few studies evaluated in other countries, there is less data collected on how its effectiveness may change when implemented in other places. Culture and society can have a large impact on therapy, and depending on the environment in which CBT is performed, it may have other outcomes. Furthermore, therapist training for CBT differs by country, often depending on the standard of education where they live and other factors such as access to medical literature and previous CBT trials. Because each professional receives distinct training, the way they execute CBT may differ. Further studies should be done to solidify conclusions of CBT effectiveness, and how it may vary worldwide.
Conclusion
Everyone has experienced fear, but a phobia is far more than that. Phobias are a pertinent issue in about 20% of children and young people and can have a huge negative impact upon their entire lives, sometimes even debilitating. Therefore, it is essential to their well-being that they receive some kind of help to overcome this phobia. This literature review has found that Cognitive Behavioral Therapy coupled with other methods of treatment such as medication or Exposure Therapy, MBSR are an effective way to help young people overcome or cope with their phobia (or phobias). Alongside CBT, a supportive environment and especially a supportive home environment supplements and aids in the overcoming of irrational fears. Overcoming these phobias can provide patients a freedom that they’ve never experienced before. While it does take much work and time to break down the iron grip a phobia has over a person, CBT offers an effective solution to combating phobias.
References
Amano, T., Unal, C. T., Paré, D. (2010). “Synaptic Correlates of Fear Extinction in the Amygdala.” Nature News, Nature Publishing Group, https://www.nature.com/articles/nn.2499.
Ambit, A.G. and Pandayan, M.R.O. (2020). Can’t Say A Word With You: Glossophobia. SSRN. Retrieved from. http://dx.doi.org/10.2139/ssrn.3826958
Azarian, B. (2016). Apeirophobia: The fear of eternity. The Atlantic. https://www.theatlantic.com/science/archive/2016/09/apeirophobia-the-fear-of-eternity/498368/
Beninger, M. (2019). The psychology behind your fear of failure. Blog. Mind and Body. Retrieved from: https://www.blinkist.com/magazine/posts/psychology-behind-fear-failure#
Bracha, H. S. (2004). Freeze, flight, fight, fright, faint: adaptationist perspectives on the acute stress response spectrum. CNS spectrums, 9(9), 679-685. https://doi.org/10.1017/s1092852900001954
Cleveland Clinic(n.d.). Autophobia (Fear of being alone). Cleveland Clinic. Retrieved from: https://my.clevelandclinic.org/health/diseases/22578-autophobia-monophobia-fear-of-being-alone
Cohen, J.A., Mannarino, A.P. Kliethermes, M. Murray, L.A. (2012) Trauma-focused CBT for youth with complex trauma, Child Abuse & Neglect, 36(6), 528-541. https://doi.org/10.1016/j.chiabu.2012.03.007.
Denny, B. T., Fan, J., Liu, X., Guerreri, S., Mayson, S. J., Rimsky, L., New, A. S., Siever, L. J., & Koenigsberg, H. W. (2014). Insula-amygdala functional connectivity is correlated with habituation to repeated negative images. Social cognitive and affective neuroscience, 9(11), 1660-1667. https://doi.org/10.1093/scan/nst160
Farrell, L. J. F., Oar, E. L. O., Waters, A. M. W., McConnell, H. M., Tiralongo, E. T., Garbharran, V. G., & Ollendick, T. O. (2020). Brief Intensive CBT for Pediatric OCD with E-Therapy Maintenance, 86-92.
Garcia R. (2017). Neurobiology of fear and specific phobias. Learning & Memory. 24(9), 462-471. https://doi.org/10.1101/lm.044115.116
Guyer, A. E., Choate, V. R., Detloff, A., Benson, B., Nelson, E.E., Perez-Edgar, K., Fox, N. A., Pine, D. S., & Ernst, M. (2012). Striatal functional alteration during incentive anticipation in pediatric anxiety disorders. Am J Psychiatry, 169(2), 205-212.
Hasper Jay R. Santos, & Fhajema M. Kunso. (2021). “I Speak Not”: Accounts of English Language Learners With Glossophobia. Modern Journal of Studies in English Language Teaching and Literature, 3(2), 15–28. https://doi.org/10.56498/322021136
Ito, L. M., Asbahr, F. R., Kendall, P. C., Tiwari, S., & Roso, M. C. (2008). Cognitive-behavioral therapy in social phobia. Bras Psiquiatr. 30. 96-101 Retrieved from: https://www.scielo.br/j/rbp/a/8jL85kwBNNpFkYv5w5DDnKq/?format=pdf
James, A. C., Reardon, T., Soler, A., James, G., & Creswell, C. (2020). Cognitive behavioral therapy for anxiety disorders in children and adolescents. National Center for Biotechnology Information. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8092480/
Jenson, T. K., Holt, T., Ormhaug, S. M., Egeland, K., Granly, L., Hoaas, L. C., Hukkelberg, S. S., Indregard, T., Stormyren, S. D., Wentzel-Larson, T., (2013). A Randomized Effectiveness Study Comparing Trauma-Focused Cognitive Behavioral Therapy with Therapy as Usual for Youth. Neuroscience & Biobehavioral Reviews. 43(3), 703-728. https://www.tandfonline.com/doi/full/10.1080/15374416.2013.822307.
Klinger, E., Bouchard, S., Légeron, P., Roy, S., Lauer, F., Chemin, I., & Nugues, P. (2005). Virtual reality therapy versus cognitive behavior therapy for social phobia: a preliminary controlled study. Cyberpsychology & Behavior, 8(1), 76-88. https://doi.org/10.1089/cpb.2005.8.76
Lonsdorf, Tina B., and Christian J. Merz. (2017). More than Just Noise: Inter-Individual Differences in Fear Acquisition, Extinction and Return of Fear in Humans – Biological, Experiential, Temperamental Factors, and Methodological Pitfalls. Neuroscience & Biobehavioral Reviews. 80, 703-728.
Monroe, J. (2022). Types of phobias: Where they come from & how to treat them. Newport Academy. https://www.newportacademy.com/resources/mental-health/types-of-phobias/
Olesen, J. (2020). Fear of germs phobia – Mysophobia or misophobia. Fear of.Net. Retrieved from: https://www.fearof.net/fear-of-germs-phobia-Mysophobia/
Oxford CBT. (2022). Gelotophobia: The fear of laughter. Retrieved from: https://www.oxfordcbt.co.uk/Gelotophobia/
Pacella, M.L., Hruska,B., Delahanty, D.L. (2013). The physical health consequences of PTSD and PTSD symptoms: A meta-analytic review. Journal of Anxiety Disorders, 27, (1), 33-46.
Psychiatric Times,(n.d.). Apeirophobia (Fear of Infinity). https://psychtimes.com/apeirophobia-fear-of-infinity/
Ruch, W., & Proyer, R. T. (2008). The fear of being laughed at: Individual and group differences in Gelotophobia. Humor 21-1, 47-67. Retrieved from: https://www.zora.uzh.ch/id/eprint/3635/5/humor.2008.002.pdf
Safir, M. P., Wallach, H. S., & Bar-Zvi, M. (2011). Virtual reality Cognitive-Behavior therapy for public speaking anxiety: One-Year Follow-Up. Behavior Modification, 36(2), 235-246. https://doi.org/10.1177/0145445511429999
Spain, D., Sin, J., Linder, K. B., McMahon, J., & Happé, F. (2018), Social anxiety in autism spectrum disorder: A systematic review. Research in Autism Spectrum Disorders, 52, 51-68.
Subramaniam, A. (2019). The Neurobiology of Fear. Psychology Today. Retrieved from: https://www.psychologytoday.com/ca/blog/parenting-neuroscience-perspective/201910/the-neurobiology-fear
Svihra, M. & Katzman, M.A. (2004). Behavioral inhibition: A predictor of anxiety. Pediatric Child Health, 9 (8), 547-550.
Troendle, A. (2014). The use of virtual reality in psychotherapy for anxiety disorders, the State-of-the-Art and the evaluation of its effectiveness (Bachelor Thesis). University of Basel. https://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.715.6312&rep=rep1&type=pdf
Tsai, M.-N., Wu, C.-L., Tseng, L.-P., An, C.-P., & Chen, H.-C. (2022). Extraversion is a mediator of Gelotophobia: A study of autism spectrum disorder and the big five. Frontiers. Retrieved from: https://www.frontiersin.org/articles/10.3389/fpsyg.2018.00150/full
Zhang, X., Suo, X., Yang, X. Lai, H., Pan, N., Ho, M., LI, Q., Kuang, W., Wang, S., et Gong, Q. (2022). Structural and functional deficits and couplings in the cortico-striato-thalamo-cerebellar circuitry in social anxiety disorder. Translational Psychiatry, 12, (26) 1-11.
