Acrophobia
Fear of Heights
What is Acrophobia?
Acrophobia is an extreme fear of heights. Fear of heights is actually a very common thing- roughly one in five individuals will show at least some level of anxiety while in high places (Curtis et al. 1998). While some level of fear when in high places is normal, and even sensible, acrophobia goes beyond what would be considered normal fear and becomes an extremely debilitating and distressing phobia.
Phobia of heights is a relatively common condition, with most research finding a prevalence rate of around 4.7% in countries such as the United States, Australia and Germany (Curtis, Magee, Eaton, Wittchen, &Kessler, 1998).
Fear of heights, or acrophobia, is a long-lasting disorder that can seriously impact people’s lives. In severe cases it can drastically limit a person’s ability to perform everyday tasks like climbing sets of stairs, standing near ledges of balconies, working or living in high-rise buildings and preventing many forms of recreational activity.
Acrophobic patients will often seek to avoid any situation which places them high up- stairs, terraces, high rise buildings, elevators and bridges amongst many others. Given how commonplace many of these situations are, people with acrophobia often feel extremely impaired and have to make drastic changes to their lives to avoid high places. Avoiding all situations involving heights can have severe social impact on patients, leaving them isolated and restricted in where they can go.
Acrophobia is different from vertigo. Acrophobia is an excessive fear of heights or falling, while physiological vertigo is a more physical sensation- a feeling of destabilisation which occurs when the distance between you and the nearest stationary object becomes very large (such as when looking down from a great height).
How Does Acrophobia Form?
Acrophobia can form at any time in a person’s life, but most commonly begins in adolescence or in the mid-twenties (Antony and Barlow 2002). Phobia of heights is equally common between genders, and can often form without any direct negative experience involving heights (Poulton et al. 2001).
Measuring Phobia of Heights
The Acrophobia Questionnaire (AQ) is used to measure and assess fear of heights (Cohen, 1977). The AQ is a 20 item test which assesses levels of fear and avoidance in different heights-related situations. The scale is used to measure both fear and avoidance.
To complete the AQ, read each item on the list and indicate how afraid each item would make you if you were in that situation now, on a scale from 1 (not at all afraid) to 7 (extremely afraid). Then read each item again and rate how likely you would be to avoid it now. Enter a 0 if you would not avoid doing it, a 1 if you would try to avoid doing it, and a 2 if you would avoid doing it at all costs.
Patients with acrophobia typically score between 48 and 60 on the anxiety subscale and between 10 and 14 on the avoidance subscale (Baker, Cohen, and Saunders 1973).
- Diving off the low board at a swimming pool
- Stepping over rocks crossing a stream
- Looking down a circular stairway from several flights up
- Standing on a ladder leaning against a house, second story
- Sitting in the front of a second balcony of a theatre
- Riding a Ferris wheel
- Walking up a steep incline while country hiking
- Airplane trip (eg to San Francisco)
- Sitting next to an open window on the third floor
- Walking on a footbridge over a highway
- Driving over a large bridge (eg the Golden Gate bridge)
- Being away from the window in an office on the 15th floor
- Seeing window cleaners ten feet up on a scaffold
- Walking over a sidewalk grating
- Standing on the edge of a subway platform
- Climbing up a fire escape to the third floor landing
- Being on the roof of a ten story apartment building
- Riding an elevator to the 50th floor
- Standing on a chair to get something off a shelf
- Walking up the gangplank of an ocean liner
Treatment
As with all phobias, the most effective treatment is exposure: facing the situations that cause you fear in a controlled and systematic way. Often this involves creating a fear hierarchy of anxiety-provoking situations, from least to most frightening. Patients then work their way up this hierarchy- exposing themselves to each situation in turn until it no longer provokes any strong fear. Exposure is highly effective in treating all phobias, including acrophobia.
Self-Help Treatment
Exposure therapy does not necessarily require a therapist- it is perfectly possible to learn the principles of exposure yourself and then conduct your own exposure exercises without any professional help. Self-help therapy- either online or though written material- has been shown to be just as effective as therapist directed therapy (Baker et al,1973; Bourque and Ladouceur, 1980).
Medication
Various attempts have been made to enhance exposure treatment by proscribing medication alongside it. While conventional wisdom suggests that anxiety medication alongside therapy can enhance recovery, research around fear of heights suggests that use of anxiety medication during treatment has no effect and can sometimes even be detrimental to treatment outcome (Barlow, Gorman, Shear, & Woods, 2000).
Other forms of medication may have more positive effects on the exposure process. The memory enhancing drug D-cycloserine (DCS), for example, has been shown to enhance the effects of exposure in two small studies (Ressler et al., 2004). Exposure in combination with this form of medication resulted in significantly larger reductions in acrophobia symptoms than placebo pills or exposure alone.
Safety Behaviours in Acrophobia Treatment
During exposure, patients often make use of safety behaviours- actions or mental processes designed to reduce the fear they are feeling. These actions can prevent a person from feeling the full extent of their anxiety in a feared situation- thereby making them slower to overcome this fear (Powers et al., 2004; Sloan & Telch, 2002; Telch, 2004).Examples of safety behaviours relating to fear of heights include:
- Remaining firmly holding on to the handrail at all times when on a high balcony
- Remaining a fixed distance from the edge at all times
- Only being willing to enter high places with a supportive friend present, or even wanting to hold on to the friend (or therapist during exposure)
- Avoiding looking down
- Adopting a fixed, stabilised stance
- Tensing of the muscles
- Breathing exercises to keep calm
During exposure it is often beneficial to engage in actions which are in direct opposition to these safety behaviours. Instead of trying to mitigate the fear you are feeling, exposure works best when you lean into it and face it head on. For example, instead of spending your time on a balcony gripping the hand rail, stand up straight and place your hands behind your back. This may increase the anxiety you feel in that moment, but in doing so you not only get to see that being up on the balcony is safe, you get to see that remaining affixed to the handrail is not necessary for your safety. Thus you learn to overcome the feared situation and you learn that safety behaviours are not required to do so.
Examples of other oppositional actions could include (still using the example of being up on a high balcony with a secure railing on the edge):
- Placing your feet directly on the edge
- Moving your head around rather than fixing it in place to induce dizziness
- Running towards the edge and leaning over it
- Walking or running backwards towards the edge
- Moving towards the edge with your eyes closed
Please note that these exercises should only be attempted if you are certain it is safe to do so. Asking a friend to assess the safety of these action, or to stay with you during them, is a good idea.
This process of augmenting exposure practice with safety-opposing actions is not the same as the technique known as flooding. Flooding is a form of “jumping in the deep end” exposure in which the patient is immediately confronted with their most feared situation- for example a tall cliff or the balcony on the twentieth floor of an apartment block. Flooding has been shown to be effective in reducing anxiety, but is definitely a hard concept for most phobic patients to agree to given the intensity of the situations they will be thrown in to. Rather, this technique of nullifying or counteracting safety behaviours can be fitted into a normal exposure hierarchy where patients work their way up the list of feared situations.
References
Antony, M. M., & Barlow, D. H. (2002). Specific phobias. In D.H. Barlow (Ed.) Anxiety and its disorders (2nd ed., pp. 380-417): The nature and treatment of anxiety and panic.
Arroll, B., Wallace, H. B., Mount, V., Humm, S. P., & Kingsford, D. W. (2017). A systematic review and meta‐analysis of treatments for acrophobia. Medical Journal of Australia, 206(6), 263-267.
Baker, B. L., Cohen, D. C., & Saunders, J. T. (1973). Self-directed desensitization for acrophobia. Behaviour Research and Therapy, 11(1), 79-89.
Barlow, D. A., Gorman, J. M., Shear, M. K., & Woods, S. W. (2000). Cognitive-behavioral therapy, imipramine, or their combination for panic disorder: A randomized clinical trial. Journal of the American Medical Association, 283, 2529–2536
Bourque, P., & Ladouceur, R. (1980). An investigation of various performance-based treatments with acrophobics. Behaviour Research and Therapy, 18(3), 161-170.
Coelho, C. M., & Wallis, G. (2010). Deconstructing acrophobia: physiological and psychological precursors to developing a fear of heights. Depression and Anxiety, 27(9), 864-870.
Curtis, G., Magee, W. J., Eaton, W. W., Wittchen, H. U., & Kessler, R. C. (1998). Specific fears and phobias: Epidemiology and classification. The British Journal of Psychiatry, 173(3), 212-217.
Otto, M. W., Smits, J. A. J., & Reese, H. E. (2005). Combined psychotherapy and pharmacotherapy for mood and anxiety disorders in adults: Review and analysis. Clinical Psychology: Science and Practice, 12, 72–86.
Poulton, R., Waldie, K. E., Menzies, R. G., Craske, M. G., & Silva, P. A. (2001). Failure to overcome ‘innate’fear: A developmental test of the non-associative model of fear acquisition. Behaviour research and therapy, 39(1), 29-43.
Ressler, K. J., Rothbaum, B. O., Tannenbaum, L., Anderson, P., Zimand, E., Hodges, L., & Davis, M. (2004). Facilitation of psychotherapy with D-cycloserine, a putative cognitive enhancer. Archives of General Psychiatry, 61, 1136–1144
Telch, M. J., & Lucas, R. A. (1994). Combined pharmacological and psychological treatment of panic disorder: Current status and future directions. In B. E. Wolfe, & J. D. Maser (Eds.), Treatment of panic disorder: A consensus development conference (pp. 177–197).Washington, DC: American Psychiatric Association.
Wiederhold, B. K., & Bouchard, S. (2014). Fear of Heights (Acrophobia): Efficacy and Lessons Learned from Psychophysiological Data. In Advances in Virtual Reality and Anxiety Disorders (pp. 119-144). Springer, Boston, MA.