What is acrophobia

Acrophobia is an extreme, irrational fear of heights that poses little or no real danger. Acrophobia is also called height phobia. Acrophobia is a type of anxiety disorder, which is defined as a specific phobia with symptoms of a panic attack leading to avoidance behavior and psychological and/or psychosocial impairment ¹.

According to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders: DSM-5 ², the life-time prevalence of acrophobia was 6.4 % (women 8.6 %, men 4.1 %), and the point prevalence was 2.0 % (women 2.8 %; men 1.1 %).

The diagnosis of acrophobia is defined in the ICD-10 ³ and DSM-5 ² by the following criteria:

• An intense fear;
• Avoidance of exposure to heights;
• One of the vegetative symptoms like trembling, palpitation, sweating, inner agitation;
• And two other symptoms from the diagnostic symptom list.
• A time criterion of at least 6-month duration is required.

People with acrophobia try to avoid high places. If they cannot, they may experience:

• Panic and fear
• Rapid heartbeat
• Shortness of breath
• Trembling
• A strong desire to get away

Acrophobia usually start in children or teens and continue into adulthood. The causes of acrophobia is not known.

Treatment options include medicines, psychotherapy or both.

What causes acrophobia

Much is still unknown about the actual cause of acrophobia. Causes may include:

• Negative experiences. Many phobias develop as a result of having a negative experience or panic attack related to a specific object or situation.
• Genetics and environment. There may be a link between your own specific phobia and the phobia or anxiety of your parents — this could be due to genetics or learned behavior.
• Brain function. Changes in brain functioning also may play a role in developing specific phobias.

Risk factors for developing acrophobia

These factors may increase your risk of acrophobia:

• Your age. Specific phobias can first appear in childhood, usually by age 10, but can occur later in life.
• Your relatives. If someone in your family has a specific phobia or anxiety, you’re more likely to develop it, too. This could be an inherited tendency, or children may learn specific phobias by observing a family member’s phobic reaction to an object or a situation.
• Your temperament. Your risk may increase if you’re more sensitive, more inhibited or more negative than the norm.
• A negative experience. Experiencing a frightening traumatic event, such as being trapped in an elevator or attacked by an animal, may trigger the development of a specific phobia.
• Learning about negative experiences. Hearing about negative information or experiences, such as plane crashes, can lead to the development of a specific phobia.

Acrophobia symptoms

Acrophobia is an extreme, irrational fear of heights that poses little or no real danger.

People with acrophobia try to avoid high places. If they cannot, they may experience:

• Panic and fear
• Rapid heartbeat
• Shortness of breath
• Trembling
• A strong desire to get away

Acrophobia test

Screening Question: Have you already experienced visual height intolerance while looking from a height? (distressing instability when standing or moving)

• Yes continue to Question 1 (continue to fill out the rest of the questionnaire only if you answered “yes”)
• No – end of test

Question 1: Because of your visual height intolerance, how much difficulty did you recently have doing sports?

• 0 = No difficulty
• 1= Any difficulty (a little/moderately/quite a lot/very much)

Question 2: Because of your visual height intolerance, how much difficulty did you recently have in your daily activities?

• 0 = No difficulty
• 1 = A little
• 2 = Moderately/quite a lot/very much

Question 3: Because of your visual height intolerance, how much is your quality of life affected?

• 0 = Not at all
• 1 = A little
• 2 = Moderately/quite a lot/very much

Question 4: I have visual height intolerance when exposed to heights

• 0 = Occasionally
• 1 = Often/frequently/always

Question 5: Now I have visual height intolerance that is…

• 0 = Less strong than before
• 1 = Just as strong as before
• 2 = Stronger than before

Question 6: I have/had visual height intolerance for longer than 6 months

• 0 = No
• 1 =  Yes

List A

Question 7: What bodily symptoms do you feel when exposed to heights? (multiple answers possible)

• a. Trembling
• b. Palpitations (fast heart beat)
• c. Inner agitation
• d. Sweating/moist hands
• e. Light-headedness
• f. Postural (to-and-fro) dizziness
• g. Weakness in the knees
• h. Instability of stance and gait
• i. Malaise/queasy feeling in the stomach
• j. Oppression
• k. Fearfulness
• l. Mental image of falling
• m. Gait disorder
• n. Others ………
• None of the above

List B

Question 8: Visual height intolerance is induced by my … (multiple answers possible)

• Standing on or climbing up a tower
• Standing on or walking over a bridge
• Standing on or walking up steps
• Standing on or climbing up a ladder
• Standing on or walking on a balcony
• Looking out of a window
• Standing or walking on a scaffolding
• Standing or walking on a roof
• Riding on a carousel or a Ferris wheel
• Riding in a ski lift or gondola
• Hiking/mountain climbing
• Rock climbing
• Other situations. If yes, please name
• …………………………………

Additional questions for the diagnosis of acrophobia

Question 9: Do you feel very intense fear or extremely strong fear when exposed to heights?

• Yes
• No

Question 10: I try in advance to avoid exposure to heights

• Yes
• No

Scoring instructions for the Visual Height Intolerance Severity Scale ⁴.

The scale is based on a set of eight questions for determining the severity of visual height intolerance. Two of the questions are lists: one of symptoms and one of triggers. Two additional questions are for the assessment of acrophobia.

1. Severity of visual height intolerance.

• Sum up the score of items 1–6.
• Add up the number of symptoms reported from List A (item 7). If there are less than 4 symptoms, add 0 to the total score; if there are 4 or more symptoms, add 1 to the total score.
• Likewise, add up the number of triggers from List B (item 8). If there are less than 4 triggers, add 0 to the total score. If there are 4–6 triggers, add 1 to the total score. For 7–9 triggers, add 2 to the total score. For 10 or more triggers, add 3 to the total score.

The sum of items 1–6, plus items of List A plus items of List B yields the total severity score.

Severity score: 1 2 3 4 5 6 7 8 9 10 11 12 13

2. Diagnosis of acrophobia.

To meet DSM-5 criteria for the diagnosis, one must have

• At least one of the vegetative symptoms (a.–d.) from List A.
• Two other additional symptoms from List A.
• A positive response to item 6 (duration of at least 6 months) of the severity scale (yes).
• A positive response to items 9 and 10 (yes).

To establish the diagnosis of acrophobia, questions 9 and 10 have to be added to the basic eight-question questionnaire. These questions are concerned with the symptoms of intense fear and an overt-behavioral avoidance when exposed to certain height stimuli.

The questionnaire has not been tested for its robustness in short-term repeated use or for its longitudinal validity, which is particularly important in follow-up and treatment studies ⁴.

Acrophobia treatment

The best treatment for acrophobia is a form of psychotherapy called exposure therapy. Sometimes your doctor may also recommend other therapies or medication. Understanding the cause of acrophobia is actually less important than focusing on how to treat the avoidance behavior that has developed over time.

The goal of treatment is to improve quality of life so that you’re no longer limited by your acrophobia. As you learn how to better manage and relate to your reactions, thoughts and feelings, you’ll find that your anxiety and fear are reduced and no longer in control of your life.

Psychotherapy

Talking with a mental health professional can help you manage your acrophobia. Exposure therapy and cognitive behavioral therapy are the most effective treatments.

• Exposure therapy focuses on changing your response to the object or situation that you fear. Gradual, repeated exposure to the source of your specific phobia and the related thoughts, feelings and sensations may help you learn to manage your anxiety. For example, if you’re afraid of elevators, your therapy may progress from simply thinking about getting into an elevator, to looking at pictures of elevators, to going near an elevator, to stepping into an elevator. Next, you may take a one-floor ride, then ride several floors, and then ride in a crowded elevator.
• Cognitive behavioral therapy (CBT) involves exposure combined with other techniques to learn ways to view and cope with the feared object or situation differently. You learn alternative beliefs about your fears and bodily sensations and the impact they’ve had on your life. CBT emphasizes learning to develop a sense of mastery and confidence with your thoughts and feelings rather than feeling overwhelmed by them.

Medications

Generally psychotherapy using exposure therapy is successful in treating acrophobia. However, sometimes medications can help reduce the anxiety and panic symptoms you experience from thinking about or being exposed to the object or situation you fear.

Medications may be used during initial treatment or for short-term use in specific, infrequently encountered situations, such as flying on an airplane, public speaking or going through an MRI procedure.

• Beta blockers. These drugs block the stimulating effects of adrenaline, such as increased heart rate, elevated blood pressure, pounding heart, and shaking voice and limbs that are caused by anxiety.
• Sedatives. Medications called benzodiazepines help you relax by reducing the amount of anxiety you feel. Sedatives are used with caution because they can be addictive and should be avoided if you have a history of alcohol or drug dependence.

How to overcome acrophobia

Professional treatment can help you overcome your specific phobia or manage it effectively so you don’t become a prisoner to your fears. You can also take some steps on your own:

• Try not to avoid feared situations. Practice staying near feared situations as frequently as you can rather than avoiding them completely. Family, friends and your therapist can help you work on this. Practice the techniques you learn in therapy and work with your therapist to develop a plan if symptoms get worse.
• Reach out. Consider joining a self-help or support group where you can connect with others who understand what you’re going through.
• Take care of yourself. Get enough rest, eat healthy and try to be physically active every day. Avoid caffeine, as it can make anxiety worse. And don’t forget to celebrate successes as things get better.
• Mindfulness strategies may be helpful in learning how to tolerate anxiety and reduce avoidance behaviors.
• Relaxation techniques, such as deep breathing, progressive muscle relaxation or yoga, may help cope with anxiety and stress.
• Physical activity and exercise may be helpful in managing anxiety associated with specific phobias.

1. Acrophobia impairs visual exploration and balance during standing and walking. Brandt T, Kugler G, Schniepp R, Wuehr M, Huppert D. Ann N Y Acad Sci. 2015 Apr; 1343():37-48. https://www.ncbi.nlm.nih.gov/pubmed/25722015
2. American Psychiatric Association, DSM-5 Task Force. Diagnostic and Statistical Manual of Mental Disorders: DSM-5. 5th ed. American Psychiatric Association: Arlington, VA; 2013.
3. World Health Organization. The ICD-10 Classification of Mental and Behavioural Disorders. Geneva: WHO; 1993.
4. Huppert D, Grill E, Brandt T. A New Questionnaire for Estimating the Severity of Visual Height Intolerance and Acrophobia by a Metric Interval Scale. Front Neurol. 2017;8:211. Published 2017 Jun 1. doi:10.3389/fneur.2017.00211 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5451500