Step 1: A Trigger

First there is something that “triggers” or signals a threat to a person. It can be external as in seeing someone th**w up or internal as in imagining yourself vo**ting. It could be external like a disgusting smell or internal as a gagging feeling. Any of the senses; sight, smell, taste, hearing and touch, could be involved in triggering the fear. This trigger or triggers could have been part of the initial onset of the phobia or part of the ongoing problem if the phobia is already present.  

A trigger isn’t inherently something bad. It is just information. Two people can experience the exact same trigger, but one person is fine and the other gets excessively alarmed. It is the next steps that give meaning to the trigger that make it part of an anxiety cycle.

Step 2: Misinterpretation

In the case of a phobia the trigger is misinterpreted as far more threatening than it is in actuality. For example, thr**ing up is viewed not as unpleasant but as catastrophic. This threat seems so real or possible to the person because of how they mentally construct it.

There is an important point to be made here. Fear of actual danger is rarely a problem needing treatment. No one gets therapy because they ran in the house after lightning stuck nearby. They get treatment because they get extremely anxious, for example, when there are just dark clouds and that it interferes with their lives.

Human beings learn fear FAST and generalize the sense of threat to anything similar or related. I only have to step on a nail once to forever be careful walking through construction debris. This is a good thing. There a biological favoritism for learning to be afraid. It isn’t hard to imagine that same process going a bit too far. 

However, a problem begins when the fear spreads to things associated to the specific threat that are imagined as far more dangerous than they are in reality. The key word is imagined. It is a mental movie about something that might happen. In the case of emetophobia, vo**ting is misinterpreted as a threat. (Sometimes, embarrassment of vo**ting in public is more of the imagined threat.) Then the mind spreads it to anything that might lead to vomiting like an uncomfortable feeling in the stomach or the “contaminated” desk of someone who got sick. 

This is still all normal. We misinterpret things all the time. Everyone imagines distressing things like this, but it only occasionally leads to a phobia. There are more steps involved before it becomes a phobia.

Step 3: Anxiety, Fear, Distress

So there is a trigger, then misinterpretation, followed by intense anxiety. In the early stages of a phobia the anxiety may not be that strong. In fact, lots of people can remember getting sick before the phobia and not being that alarmed at all. However, once the phobia has developed the anxiety will get very intense.

Although the imagined danger is not real, the experience of distress is real. Sometimes when I watch TV there is a scene that is so vivid to me that I can actually feel what it would be like. I recently saw a scene where someone base jumped (parachuted) off a building and I felt something like what I imagine the feeling would be and it is NOT on my to-do list. Our body will create a simulated feeling for something that scares us. I think it wants to make sure we fully understand the problem! That simulated feeling can be part of the phobia. That makes the misinterpretation seem much more plausible. When a threat is perceived the body prepares – dramatically.

This process is often called the fight or flight response. Without going into too much detail, it is the body’s way of responding to danger – real or imagined. In the right circumstances this process instantly optimizes your body to defend itself. In the wrong circumstances it can become part of an anxiety disorder. Panic while running from a charging rhinoceros is extremely useful. Panic while sitting in a classroom, not so much. It is similar physiology but interpreted differently.

Anxiety disorders are incongruence between what a person is thinking and feeling compared to the actual situation. Using our previous example, the anxiety about being hit by lightning is evoked by dark clouds. As mentioned earlier, the fear becomes associated with more and more things. The physical reaction is just as strong (if not stronger) for the imagined problem as for the actual situation. For emetophobia there is extreme distress at the possibility of vo**ting. The anxiety leaps (associates) to anything that might lead to vo**ting. (In one of life’s great ironies, anxiety causes stomach distress and then that evokes more anxiety.) The belief that it is a serious threat leads to the next step. This is the tipping point of something becoming a phobia.,,,

Step 4: Avoidant Coping

This step may be the key element in why someone develops an anxiety disorder. Everyone experiences the first 3 things but not everyone develops an anxiety disorder. The tipping point is when someone acts consistently with the misinterpretation. In other words, they behave as if the imagined fear is truly a threat. The main thing people do is avoid or escape the “danger” in a desperate attempt to get relief. When you are terrified, relief is AWESOME. People come back over and over. Then it becomes a powerful habit and even a compulsion. Because it does give relief it is very hard NOT to do it. Unfortunately, these kinds of behaviors interfere with living a normal life. At first it might not be that disruptive. But it gets bigger. For example, if you are afraid of getting sick first you may want to avoid a classroom but then you will want to avoid school. Getting to stay home gives relief. We all know how big a problem that becomes. Less dramatically, if the fear is contamination causing illness there could be extreme hand washing and cleaning. The urge to escape, avoid or fix can become ferocious. If you have tried to stop a terrified child from doing something to avoid the fear, you know what I mean.

Let me state again that avoiding authentic, genuine, and certified danger is NOT a problem. (Well, okay it is big problem but not regarding anxiety disorders.) Anxiety disorders only happen when there is not a literal threat, only the possibility, however unlikely. Because the anxiety “feels” real and the avoiding “feels” better this becomes enormously influential. Because this becomes the pattern, the next step seals the deal. (As a side note, even if the sufferer knows that he or she is overreacting, that is still unlikely to be enough to stop the cycle. That is why it is extremely unlikely you can talk someone out of a phobia with just logic. A different kind of knowledge is needed.)