Edited by: Gianluca Serafini, San Martino Hospital, University of Genoa, Italy
Reviewed by: Yuki Yamada, Kyushu University, Japan; Zheng JIN, Zhengzhou Normal University, China
Specialty section: This article was submitted to Mood and Anxiety Disorders, a section of the journal Frontiers in Psychiatry
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In this article, we describe the case of a girl who suffers from a phobia to repetitive patterns, known as trypophobia. This condition has not yet been recognised by diagnostic taxonomies such as the Diagnostic and Statistical Manual of Mental Disorders. Trypophobia usually involves an intense and disproportionate fear towards holes, repetitive patterns, protrusions, etc., and, in general, images that present high-contrast energy at low and midrange spatial frequencies. It is commonly accompanied by neurovegetative symptoms. In the case we present here, the patient also suffered from generalised anxiety disorder and was treated with sertraline. After she was diagnosed, she showed symptoms of both fear and disgust towards trypophobic images. After some time following treatment, she only showed disgust towards said images. We finish this case report presenting a comprehensive literature review of the peer reviewed articles we retrieved after an exhaustive search about trypophobia, we discuss how this case report contributes to the understanding of this anxiety disorder, and what questions future studies should address in order to achieve a better understanding of trypophobia.
Fear is the normal response to danger, while phobias are characterised by excessive, unconscious, and persistent fear that constantly triggers anxiety. Therefore, in the Diagnostic and Statistical Manual of Mental Disorders (DSM)-5 (
We hereby present a case of an infant who suffers from trypophobia. After obtaining informed consent from her proxy for publishing this report, we hereby report and comment her morbid records, evolution, and response to the treatment. We also present a comprehensive literature review about the condition. Due to the scarce available literature, this case report represents an opportunity to ponder upon the clinical presentation and potential underlying aetiology of this phobia. Finally, we pose some questions about trypophobia for future studies.
A 12-year-old patient, female and Caucasian, schooled (sixth grade), brought by her mother consulting about her feelings of discomfort when observing or approaching some sorts of surfaces and objects. The patient had a normal pregnancy history and her school performance was outstanding, being above the 90th percentile of her class.
The patient currently lives with her mother and a younger sister. Although she has never lived with her father, she visits him twice a month, keeping a close relationship. Her mother suffered from generalised anxiety disorder (GAD) and has additionally developed three depressive episodes successfully treated with sertraline.
At the age of 9, the patient consulted a psychiatrist due to physical complaints, e.g., recurrent abdominal pain and nausea. The psychiatrist attributed them to be caused by her parents’ divorce, diagnosing her with separation anxiety disorder. She was treated with 50 mg of daily oral sertraline for 6 months, which yielded a positive response.
The patient’s symptoms began 3 months before her medical appointment. They included intense, disproportionate, and uncontrollable fears, which were associated with the sight of dotted objects, holes, or particularly bright or conspicuous protruding elements. Such fear was always associated with neurovegetative symptoms, e.g., increased heart and breathing rate, choking, nausea, pallor, dry mouth, sweating, and agitation. She described herself experiencing fear during daily activities, e.g., when looking at sliced or seed-covered bread,
The attending psychiatrist kept seeing the patient monthly over the course of a year, where he could determine that her fear was triggered by objects with repetitive clusters. When the patient was asked to draw her fear, she did it as shown in Figure
While the main complaints revolved around her phobic symptoms, the patient also expressed uncertainty regarding the future, highlighting an exacerbated aversion to change and risk situations, and excessive worries about her academic and social performance, despite the fact that her academic functioning was optimal and her relationship with adults and peers was positive.
Furthermore, she showed a strong pessimistic bias, desire to have everything under control, e.g., closing windows and doors to prevent the entry of thieves, devoting many hours to study, etc. The patient also manifested insomnia and anxious dreams.
Regarding depression and anxiety dimensions, she scored 7 in the Kovacs Questionnaire for Child Depression (
The psychiatrist diagnosed phobia of repetitive patterns and GAD, discarding any other categorical disorder. After diagnosis, she underwent outpatient therapy with 25 mg of daily oral sertraline in single dose in the morning, increasing to 50 mg after a week, along with cognitive behavioural therapy (CBT).
At the 5-week control, she was asked to assess her phobic symptoms, which she described as a 20% improved when compared to the first consultation. The mother described critical events during that month: first, the girl grasped to her at the supermarket when seeing a set of breads covered with sesame seeds, and second, she reacted similarly when passing by polished stones mounted on a concrete wall. In both events, she showed fear, but without neurovegetative symptoms. Regarding GAD, she showed a substantial improvement on her sleeping disturbances, anxious expectation, and excessive worries; thereby, her behaviour became more suitable to the school obligations she must regularly fulfill. The CGI-S score was 4 (“moderately ill”) and CGI of Clinical Improvement (CGI-I) score was 3 (“slightly better”). Subsequently, sertraline dose was increased to 75 mg.
Nine weeks after starting treatment, the phobia’s intensity had been halved, achieving adequate fear control and facing in a more adequate manner certain situations. The mother provided the health staff with a set of pictures of the objects that had triggered phobic reactions in the patient (see Figures
Sidewalks with surface patterns which triggered phobic reactions according to the patient’s mother.
Objects with surface patterns which triggered phobic reactions according to the patient’s mother:
At the last regular medical appointment, the mother referred some situations: since the patient was 4 years old, she has refused certain kinds of foods, throwing tantrums when being forced to eat. The patient referred she felt no fear, but disgust for some kinds of food. In her words: “I could not eat bread with holes, word noodles soup, or drink raspberry juice, because the texture of the seeds generates disgust in me, and I still feel chill when I remember it.” She avoids consuming fruit marmalades due to the feeling of the granules on her tongue, nor has ever eaten strawberries because she perceives them as visually disgusting. During the interview, an image of a strawberry was shown to the patient. She manifested progressive anguish as the image was expanded; the same happened to the image of vents; however, fear was not incipient, although it emerged when the image was amplified.
The understanding of trypophobia is still limited and the number of peer-reviewed articles is low. We searched for publications on PubMed and EMBASE using and combining the free terms: “trypophobia,” “fear*,” “phobi*,” “visual discomfort,” “repetitive patterns,” “holes,” “cluster of holes,” and “stripped pattern.” Only 10 publications met our criteria. They are reviewed below.
“Visual discomfort” was described by Wilkins as an umbrella term describing a spectrum of adverse events triggered by visual stimuli, such as striped pictures, cluster images, repetitive patterns, and even text lines. It is common in individuals suffering from migraine and epilepsy, but it has been mostly studied from the point of view of visual perception rather than the underlying cognitive mechanisms of a phobic phenomenon (
Twenty years ago, Rufo (
Le et al. (
A couple of years ago, Chaya et al. (
Imaizumi et al. (
Vlok-Barnard and Stein (
Recently, Can et al. (
Recently, Kupfer and Le (
Sasaki et al. (
More recently, Yamada and Sasaki (
In summary, the evidence so far suggests people show aversion towards images with high-contrast energy both at low (
Summary of studies, instruments, and contributions about trypophobia.
Reference | Type of sample | Instruments employed | Main findings and contributions |
---|---|---|---|
Rufo ( |
Case report | Psychiatrist’s report | First available description about a girl who expressed panic when facing any image of repetitive patterns, specially holes |
Cole and Wilkins ( |
General population of adults and adults who claim to suffer from trypophobia | Rating scales, spectral analysis | All trypophobic images possess high-contrast energy in midrange spatial frequencies, a feature also shared by images of poisonous animals. People in general experience discomfort when looking at trypophobic images |
Le et al. ( |
General population of adults and adults who claim to suffer from trypophobia (Facebook group) | Rating scales, questionnaire | The construction of the TQ and the presentation of its psychometric properties. They confirm that people who suffer from high levels of trypophobia are more sensitive to images with high-contrast energy in midrange spatial frequencies. Both images of holes and bumps can trigger trypophobic symptoms. Also, the bigger the cluster, the higher the trypophobic response |
Chaya et al. ( |
General population of adults (recruited online) | TQ, Liebowitz Social Anxiety (SA) Scale, Discomfort Rating Score | SA has a significant indirect effect on the discomfort associated with eye clusters, which was mediated by trypophobia. The same happens with clusters of faces. The results suggest both SA and trypophobia contribute to the discomfort some people experience when gazed by many people |
Imaizumi et al. ( |
General population of adults (recruited online) | TQ, Disgust Scale-Revised, Interpersonal Reactivity Index | Trypophobia proneness is predicted by core disgust sensitivity, personal distress, and proneness to visual discomfort |
Vlok-Barnard and Stein ( |
Adults who claim to suffer from trypophobia (Facebook group) | Self-report questionnaire, Kessler Psychological Distress Scale, Sheehan Disability Scale, and items from Zohar–Fineberg Obsessive–Compulsive Screen and Diagnostic and Statistical Manual of Mental Disorders -5 criteria for Specific phobias | Trypophobic symptoms are chronic and persistent and cause significant distress. The most common co-morbidity diagnoses are major depressive disorder and generalized anxiety disorder. The most common trypophobic symptom is disgust rather than fear when confronted with trypophobic images |
Can et al. ( |
4-year-old children randomly recruited | Self-report, categorization task | Trypophobic stimuli are associated with discomfort in children due the visual features of said stimuli. The results suggest that such discomfort is due to an instinctive response to the stimuli visual features rather than the result of a learned but non-conscious association with venomous animals |
Kupfer and Le ( |
General population of adults and adults who claim to suffer from trypophobia (Facebook group) | Fear and disgust self-report scales, Three Domain Disgust Scale, Neuroticism subscale (from Big Five Inventory) | Both people who suffer from trypophobia and who did not report aversion towards disease-relevant cluster stimuli, but only the trypophobic group reported aversion towards objectively harmless cluster stimuli that had no relevance to disease. Aversive responses were predominantly based on disgust |
Sasaki et al. ( |
General population of adults | TQ, Discomfort scale | Trypophobic discomfort can be caused both by mid- and low-frequency visual components |
Yamada and Sasaki ( |
General population of adults (recruited online) | Discomfort surveys | Discomfort evoked by trypophobic images is higher amongst participants with history of skin problems |
First, most trypophobic people show disgust instead of fear as main symptom. The most common response in phobias is disproportionate fear, which this patient suffered along with disgust before treatment. After treatment, she communicated experiencing mostly significant disgust. This could mean trypophobic symptoms make the individual vulnerable to suffer from anxiety due to negative reinforcements in operant conditioning, e.g., individuals more sensitive to trypophobic images may try to avoid them and, thus, avoid the concomitant discomfort. This could increase anxious expectation with time, as it appears to happen with specific phobias (
It has been reported sertraline plus CBT would achieve greater effects in children anxiety (
The origin of phobias has been attributed to evolutionary principles (
The approach taken in this case report presents some limitations that need to be explained and some considerations that should be taken. First, as described before, Le et al. (
Second, the fact that the patient responded positively to sertraline and CBT as treatments does not mean that sertraline should be necessarily regarded as a standard treatment method for trypophobic symptoms. The rationale for choosing sertraline here lies on the fact that the patient’s mother suffered from GAD and depressive episodes in the past, having yielded a very positive response for both ailments when treated with sertraline. Taking into consideration that, of course, both mother and daughter share a strong genetic background, and also the fact that GAD and trypophobia are both anxiety disorders with allegedly common underlying neurobiological mechanisms, it seemed justified to prescribe sertraline and CBT to the patient.
Finally, it is necessary to state to what extent we can take this case report as a representative case of trypophobia. To answer this question, we first need to answer what is the relation between the trypophobic symptoms presented by the patient and trypophobic disgust and fear described in previous articles. As described before, the patient has exhibited aversive discomfort towards trypophobic stimuli from very early age. This discomfort became worse with time until the phobic symptoms triggered by trypophobic images began to significantly affect her daily life. The similarities between this case report and previous descriptions in the literature lie upon the discomfort presented towards trypophobic stimuli, as defined by Cole and Wilkins (
Trypophobia has been described as a phobia to images with high-contrast energy at low and midrange spatial frequencies, such as holes and repetitive patterns, and two theories, both evolutionary, have been posed: trypophobia could be a product of evolution, an aversion to poisonous animals that possess high-contrast energy at midrange spatial frequencies in their skin, or due to an aversion to clusters of pustules or roughly circular shapes on human skin, thus helping humans to avoid ectoparasites and infectious diseases. A third and more recent theory about trypophobia as an involuntary reaction towards dermatosis has also been posed. Neither of these theories has been supported by substantial evidence yet. However, multiple aspects of trypophobia have been partially determined, such as socio-demographic variables, clinical features, co-morbidities, levels of distress, associated psychological traits, and visual features of the stimuli. Moreover, a symptom scale has been developed and validated for the study of trypophobia. One of the mysteries that have not been solved yet is that there are people who express disgust, while others express fear or both to trypophobic images. Assuming trypophobia is due to evolution, then it makes sense to ask why some people react with disgust while others react with fear? This problem is key for the clinical understanding of trypophobia as a specific phobia and it has not been answered yet.
This study involves a case report, for which a written informed consent was obtained from the parents of our patient in order to publicly describe her case, in accordance with CIOMS guidelines and the Declarationof Helsinki.
JM-A: conception of the work, acquisition and interpretation of the data, critical revision of the work, and final approval of the version to be published. RL, MA, ES, and EM: conception of the work, interpretation of the data, critical revision of the work, and final approval of the version to be published.
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.