1

The Fear of Clusters of Holes: A Review of the Recent Literature on

Trypophobia
Lulu Zhang
Department of Biology, Northeastern University, Boston, Massachusetts 02115; email :
zhang.is@husky.neu.edu

Keywords
Trypophobia, phobia, fear of holes, clusters of holes
Abstract
Trypophobia has increased in prominence over recent years. It is generally known as an irrational fear of
clusters of holes where there is typically a strong aversion to specific visual stimuli Trypophobia is
usually compared between the diagnostic criteria for specific phobia and obsessive-compulsive disorder,
but is not recognized as an official phobia as of now. Specific phobias, including trypophobia, are
currently classified as a type of anxiety disorder. The etiology for trypophobia is unknown, but for
phobias in general, it is thought to stem from learning or intrinsic evolutionary systems, and previous
studies on neural responses to trypophobic stimuli suggest trypophobia may result from cognitive and
physical triggers in visual stimuli. The majority who suffer from trypophobia do not seek out treatment,
but online support groups has emerged in proving to be helpful. Currently, there is little in the literature
about trypophobia and it is difficult to study, but by understanding the underlying mechanisms and
getting a clearer understanding of the workings of trypophobia will eventually allow for a more
informed decision on how to classify it as an official disorder.
Introduction
Trypophobia is an unofficial phobia that has recently emerged in popularity with thousands of people
claiming to have. It generally refers to a fear of holes, clusters of holes, or images and objects that
resemble clusters of holes (Vlok & Stein 2017). It is currently not recognized by the medical or
psychological community as a legitimate phobia because the medical field has been unable to
characterize it and it has been difficult to study. As a result, there are few studies in the literature on
trypophobia, and the majority have inconclusive results. This article reviews the current literature from
2016-2017 on trypophobia and discusses the findings for the studies. Visual stimuli can induce
trypophobia and these images possess distinctive spatial frequencies that differ from natural images.
People with trypophobia experience many responses, with disgust and fear being the most common, as
well as general anxiety. Many trypophobic individuals experience several comorbidities with other
disorders and phobias. The tentative etiology presented in the literature is discussed and current
treatment options are explored.
Features
Trypophobia is generally known as an irrational fear of clusters of holes where there is typically a strong
aversion to specific visual stimuli. However, studies show that the pattern of the visual image and its
spectral properties is what drives trypophobia rather than the objects themselves (Le et al. 2015).
Evidence suggests that a stronger trypophobic response occurs if the holes are found on human skin
(Cole & Wilkins 2013). The stimuli found to be associated with trypophobic response has a spectral
composition where at mid-range spatial frequencies has a high-contrast energy. This relationship
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between the composition of trypophobic stimuli has not been proven to cause fear in people, but it has
been accepted that trypophobia can be caused in part by images with specific visual features (Can et al.
2017). Trypophobia is unique in that the visual stimuli that trigger aversion is usually innocuous and not
harmful.
Studies show that images of holes, rather than the actual holes are what people fear. This is due to an
unconscious association between the association with venomous organisms and images of clustered
holes (Can et al. 2017). One of the most common images linked to trypophobia is the seed head of the
lotus flower (Fig. 1). The images themselves typically are not dangerous, such as a honeycomb, but can
cause aversion in people with trypophobic tendencies (Le et al. 2015). This unusual association between
aversion and generally non-threatening images makes it difficult to explain and understand trypophobia.
Although clusters of holes is usually the most dominant feature associated with trypophobia, clusters of
bumps can also generate aversion. This means that what the actual images are do not cause trypophobia,
but rather a specific property the image contains (Le et al. 2015). People who have trypophobia have
shared that it is not just an aversion to holes. Clusters of bumps or a mix of holes and bumps have been
reported to cause more discomfort in individuals than just images of cluster of holes which suggests
trypophobia may not be a fear of clusters of holes but instead aversion to images with unnatural spectral
qualities (Le et al. 2015).
Based off self-report questionnaires, people report
feeling anxious, nervous, uneasy and repulsed when
shown trypophobic images. For some individuals, the
aversion to trypophobic stimuli can be strong enough to
induce nausea (Vlok & Stein 2017). For others, it is
more severe where people have reported that the
trypophobia can be so severe in some cases where it
affects their ability to go to work or carry on in their
everyday lives (Le et al. 2015). Due to the visual nature
of trypophobia, it is suggested that those who
Figure 1. A lotus seed head is a common image experience trypophobia have a greater sensitivity to the
cited to induce trypophobia (from Cole & visual characteristics preset in trypophobic images, and
Wilkins 2013) this extreme sensitivity is partly what gives rise to
trypophobia (Le et al.2015). The level of impairment
caused by the psychological distress of trypophobic stimuli varies by the individual but the majority
experiences a high or moderate level of impairment (Vlok & Stein 2017). For some, trypophobia causes
people to be unable to fulfill work or social obligations, go about their normal daily life, or operate at a
productive level because the anxiety is too extreme.
Fear and disgust are the two main responses when people are presented trypophobic stimuli. Disgust
seems to be the more common response when people are presented with trypophobic and control images
(Kupfer & Le 2017, Vlok & Stein 2017). People who report disgust as the response also tend to be more
likely to experience mild, moderate, and severe anxiety attacks compared to those who predominantly
experience fear (Vlok & Stein 2017). Despite these differences, the level of impairment does not seem to
differ between the disgust and fear response groups (Vlok & Stein 2017). Most individuals who
experience mostly fear as a response meet the Diagnostic and Statistical Manual of Mental Disorders
(DSM-V) criteria for obsessive-compulsive disorder, with some of these individuals also meeting the
criteria for specific phobia (Vlok & Stein 2017). The proportion of individuals that meet each DSM-V
criteria is smaller for individuals who predominantly felt disgust in response to trypophobic images
(Vlok & Stein 2017).
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For people with trypophobia, most people meet most of the criteria for specific phobia except for having
the distress or impairment, but a smaller portion of individuals do meet all of the criteria the DSM-V
states that constitute a specific phobia. This contrasts with obsessive-compulsive disorder where the
proportion of individuals experiencing trypophobia and meet the criteria for obsessive-compulsive
disorder is very small (Vlok & Stein 2017).
Contenders in Characterizing Trypophobia
Specific Phobia Clinical Features
Specific phobias are currently classified as a type of anxiety disorder in the (DSM-V) and are recognized
as the third most common psychiatric disorder in adults in the United States (Le et al. 2015). Specific
phobias have several criteria that need to be met in the DSM-V which includes having a persistent and
marked fear about a specific object or situation that causes immediate anxiety or fear that is not
proportional to the actual danger caused by the object or situation. Studies have shown that the lifetime
prevalence of specific phobias can reach as high as 15.6% in the United States (Rudaz et al. 2017). The
DSM-V splits specific phobias into five subgroups which are blood-injection-injury, natural
environment, situational, zoophobia, and other with animal phobia being one of the most common types
(Rudaz et al. 2017; Zsido 2017). Avoidance of the cause of the phobia is another criterion of specific
phobia (Rudaz et al. 2017).
Obsessive Compulsive Disorder Clinical Features
Trypophobia is usually compared between the diagnostic criteria for specific phobia and obsessive-
compulsive disorders in the DSM-V to see which it matches more with. Obsessive-Compulsive Disorder
(OCD) is characterized by unwanted thoughts, urges, or images that cause anxiety or distress in an
individual and can lead to compulsions that form as an attempt to counter the anxiety felt by the
individual about a certain event (Grant 2014). OCD is the fourth most common psychiatric illness,
behind specific phobias, and has a lifetime prevalence of up to 3% (Grant 2014). For OCD to be
diagnosed, the individual must have obsessive thoughts that happen for longer than an hour each day,
with obsessions that do not start and stop suddenly with a specific event (Grant 2014).
Etiology
For phobias in general, two main theories have emerged as possible explanations, one which involves
learning and the other which considers intrinsic evolutionary systems (Le et al. 2015). To support this
theory, studies have shown that phobias can be a result of the selection process during evolution that
were associated with survival (Le et al. 2015). Disgust is an important reaction for avoidance, and can
aid in avoiding disease or dangerous situations. Trypophobia could be explained as a hyperactive
sensitivity to disgust which would result in extreme reactions to trypophobic stimuli.
The DSM-V does not list trypophobia as an official specific phobia and the name trypophobia was not
in use until 2005 (Can et al. 2017). This condition has only recently acquired prominence with the rise of
the Internet and little is known about it. Studies have considered possible origins for trypophobia, one of
which is an extended innate disgust toward sores and poisonous animals with spots which could help
prevent contact with germs and disease (Imaizumi et al. 2016). The natural adaptive reaction humans
have towards possible disease and parasitic risk could be amplified and exaggerated in people who
experience trypophobia (Kupfer & Le 2017).
Recent evidence shows that certain spectral compositions of images tend to cause the most aversion.
This can be described as a more perceptual cause of trypophobia where visual discomfort is associated
with trypophobia (Imaizumi et al. 2016). Any visual image can be broken down into several
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components, including luminance, chromatic, contrast, and spatial frequency. Spatial frequency is how
detailed or sharp an image is, and in nature, as contrast levels increase, spatial frequency decreases (Cole
& Wilkins 2013, Fig. 2). The level of detail in the image does not affect the spatial frequency, and there
is a particular spatial frequency present in natural images (Cole & Wilkins 2013). Images that are
uncomfortable to look at possess a high-spatial -frequency and higher contrast levels compared to
natural images (Cole & Wilkins 2013). Highly poisonous animals have been found to contain similar
spectral compositions that is a distinct feature of trypophobic images (Cole & Wilkins 2013). The
unnaturalness of the spatial frequencies that are stressful for humans is found to induce visual
discomfort and proneness to trypophobia (Imaizumi et al. 2016).
Trypophobic images do not just cause aversion in those who
experience trypophobia, the general population also has
aversive reactions to trypophobic image even if the
individual does not experience trypophobia (Cole & Wilkins
2013). When comparing responses to images with
trypophobic characteristics to those without, the general
population that does not experience trypophobia respond
Figure 2. An image with a high spatial more negatively to trypophobic images (Le et al. 2015). This
frequency is shown on the left. An image aversion trend is also present in children, where when shown
with low spatial frequency is shown on trypophobic images, children experienced discomfort (Can
the right (from Borst 2013). et al. 2017). The difference between adults and young
children is there is no association between trypophobic
images and poisonous animals, whereas in adults it is
suggested that there is an unconscious association between the two which gives rise to fear (Can et al.
2017).
Biological Response
Previous studies on neural responses to trypophobic stimuli suggest trypophobia may result from
cognitive and physical triggers in visual stimuli. The basal ganglia and insula are associated with disgust
responses and the visual cortices are associated with visual discomfort (Imaizumi et al. 2016). Occipital
cortical areas have also been found to show increased negativity when an individual is shown
trypophobic or venomous animal images (Pipitone et al. 2016). These findings support the notion that
aversion to holes comes from an innate and unconscious association with dangerous animals and
disease. The literature is incomplete however, and suggests there may be more psychological factors that
are responsible for trypophobic responses. One possibility is neuroticism which has been linked to
disgust sensitivity (Imaizumi et al. 2016). This link suggests individuals who have strong disgust
sensitivity are more sensitive to emotional stimuli and psychological distress (Imaizumi et al. 2016).
Individuals have increased physiological responses in EDA levels when shown trypophobic images
compared to control images which suggests a fear response (Pipitone et al. 2017). This fear response
would strengthen the argument that trypophobia originates from an adaptive survival response (Pipitone
et al. 2017). There is not enough evidence to make a definitive statement about the association, more
research still needs to be done before proclaiming a significant relationship between EDA response and
trypophobic images.
Comorbidities
For individuals who experience trypophobia, the most common psychiatric comorbidity is major
depressive disorder with generalized anxiety disorder close behind. The degree of anxiety can range
from mild to panic attacks and seems to be more common among individuals who experience disgust in
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response to trypophobic stimuli, rather than fear (Vlok & Stein 2017). Other comorbidities include
social anxiety disorder, and bipolar disorder, obsessive-compulsive disorder, but these are less prevalent,
with few individuals actually being diagnosed (Table 1). An unexpected find is the low comorbidity rate
of social anxiety disorder with trypophobia (Vlok & Stein 2017). Using a screen for other specific
phobias in individuals experiencing trypophobia, many fit all the criteria for specific phobia in the DSM-
V which zoophobia being the most common (Vlok & Stein 2017).
Table 1. A. Table of comorbidities with other disorders and with specific phobias (Vlok & Stein 2017).

Comorbidities (most Comorbidities with

prevalent to least specific phobias (most
prevalent) prevalent to least
prevalent)
Major depressive Animals
disorder
General anxiety Blood injections
disorder
Social anxiety disorder Specific situations
(enclosed spaces,
planes, elevators)
Panic disorder Other specific things
Bipolar disorder
Obsessive-compulsive
disorder

Predictors
Questionnaires used to measure and assess trypophobia also investigate predictors and proneness to
trypophobia (Table 2). Predictors found include Core disgust sensitivity, Personal Distress and visual
discomfort, but no association between trypophobia with gender. The predictor of Core disgust was
found to be stronger with females and the average age of onset has been observed to be 17.5 years
(Imaizumi et al. 2016, Vlok & Stein 2017). Core disgust is one domain of disgust sensitivity and it
measures the disgust of disease threats and offensiveness and appears to be the most relevant of the three
disgust sensitivity domains regarding trypophobia (Imaizumi et al. 2016). There have been no
significant findings that show family history or previous aversive experiences as predictors of
trypophobia (Vlok & Stein 2017).
Table 2. Table of tests used to assess trypophobia, their methods, population, and results of various studies
Test Methods Population Results
Self-report Children shown 2 images 94 native Chinese The children had a
side by side and asked to preschoolers; 44 girls, 55 negative response towards
pick which side they liked boys (Can et al. 2017) trypophobic images and
more; images contained venomous animal photos,
trypophobic and non- but a neutral response at
trypophobic, venomous venomous animals
and non-venomous without patterns (Can et
images arranged in 16 al. 2017)
pairings for 16 trials (Can
et al. 2017)

Test Methods
Single category implicit Participants categorize
association test (IAT) four ideas into 2 response
groups that contain 2
concepts each; measures
nonconscious association
between trypophobic
features and threat; has
been adapted for
preschoolers (PS-IAT);
the test had 2 stages each
with 28 practice trials and
56 test trials (Can et al.
2017)
Open-ended responses After trypophobic
individuals were shown
disease-relevant and
disease-irrelevant cluster
images, they were told to
describe how they felt
when looking at those
kinds of images (Kupfer
& Le 2017)
Trypophobic Measure comfort levels
Questionnaire (TQ) and general anxiety levels
when viewing
trypophobic and control
images (Pipitone et al.
2016)
Assess trypophobia
proneness and responses
to trypophobic stimuli
(Imaizumi et al. 2016)
Physiological response Measure EDA and BPM
tests levels in subjects
(Pipitone et al. 2016)
6
Population Results
94 native Chinese Found that there was no
preschoolers; 44 girls, 55 association of trypophobic
boys (Can et al. 2017) features with the threat of
venomous animals (Can
et al. 2017)
376 participants age 18- Found a greater
69, 88 males and 288 percentage of participant
females; All responded to had pathogen avoidance
a study advertisement in 2 related responses than
trypophobic support fear-related responses; the
groups on Facebook and a pathogen avoidance
student population of 304 response often includes
was used as a comparison disgust feelings related to
group with 257 females skin and several responses
and 47 males aged 18-51 included both disgust and
(Kupfer & Le 2017) skin contact (Kupfer & Le
2017)
37 undergraduates from a Found significant
southern Colorado correlation between high
university; 16 males, 21 discomfort and
females (Pipitone et al. trypophobic images and
2016) no significant correlation
between comfort levels
126 adults with Japanese and control images, but
as the first language, 83 no significant correlation
males, 43 females between TQ scores and
(Imaizumi et al. 2016) general anxiety scores
(Pipitone et al. 2016)
Identified Core disgust
sensitivity, Personal
Distress, and visual
discomfort proneness as
significant predictors; no
gender difference in
trypophobic proneness;
association between
visual discomfort and
trypophobic proneness
(Imaizumi et al. 2016)
37 undergraduates from a No significant
southern Colorado relationship between EDA
university; 16 males, 21 and BPM levels when
viewing trypophobic and
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Test Methods Population Results

females (Pipitone et al. control images and no
2016) correlation between
physiological scores and
TQ scores (Pipitone et al.
2016)
General population survey Obtain 50 images from 20 undergraduate students Responses show
trypophobia website and at the University of Essex, trypophobic images are
50 images of holes from none reported being uncomfortable to
Google and present in a trypophobic (Cole & individuals in the general
random order in a Wilkins 2013) population and not just
PowerPoint presentation those who have
where participants rate trypophobia (Cole &
discomfort levels (Cole & Wilkins 2013)
Wilkins 2013)
Three Domain Disgust 21 items in 3 domains 376 participants age 18- Significant relationship
Scale (TDDS) were presented and 69, 88 males and 288 between pathogen disgust
disgust and neuroticism females; All responded to sensitivity and aversion to
were rated using two a study advertisement in 2 disease-relevant cluster
different scales (Kupfer & trypophobic support images; no significant
Le 2017) groups on Facebook and a relationship between
student population of 304 pathogen disgust
was used as a comparison sensitivity and disease-
group with 257 females irrelevant cluster images;
and 47 males aged 18-51 significant difference
(Kupfer & Le 2017) between trypophobic
group mean pathogen
disgust sensitivity and the
comparison group
(Kupfer & Le 2017)
Aversion test Obtain 16 images of 376 participants age 18- Significant interaction
clusters from trypophobia 69, 88 males and 288 found between image type
website and 16 control females; All responded to and disease relevance for
images presented and a study advertisement in 2 trypophobic group;
rated pleasantness or trypophobic support significant interaction
unpleasantness, and rate groups on Facebook and a found between image type
levels of fear and disgust student population of 304 and disease relevance for
(Kupfer & Le 2017) was used as a comparison comparison group; overall
group with 257 females cluster images were rated
and 47 males aged 18-51 more unpleasant than
(Kupfer & Le 2017) non-cluster images; more
disgust was reported than
fear in both the
trypophobic and
comparison group
(Kupfer & Le 2017)
Online survey Gather sociodemographic 195 individuals aged 18- Trypophobia was found to
information, course, 80, from all over the be associated with
duration, severity, world with the majority significant distress and
comorbidity with other residing in the US and impairment with chronic
disorders, distress and UK; part of a Facebook and persistent symptoms;
impairment levels (Vlok support group for majority experienced
& Stein 2017) disgust over fear as a
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Test Methods Population Results

trypophobia (Vlok & response, and major
Stein 2017) depressive disorder and
generalized anxiety
disorder were the most
prevalent comorbidities;
most individuals met
criteria for specific phobia
instead of OCD (Vlok &
Stein 2017)

Treatment Options
Studies show that most people with trypophobia do not seek treatment for it. Treatments vary where
some only take medication, some only undergo cognitive-behavioral therapy or other therapy, and some
people opt to do a combination of medication and therapy (Vlok & Stein 2017). Self-help appears to be
a more popular method among those experiencing trypophobia with online support groups becoming a
popular choice for many affected. This is a different approach from what treatment tends to be for
specific phobias, where exposure based treatment has been proven to be more effective than alternative
treatments options (Rudaz et al. 2017).
Summary
This review examines the features associated with trypophobia, triggers, potential origins, comorbidities
with other disorders, biological influences, and current treatments available for this disorder. Most
individuals that report having trypophobia have comorbidities with other specific phobias or disorders at
various intensity levels. Several areas in the brain associated with disgust are activated when
trypophobic images are presented which supports the idea that trypophobia stems from an evolutionary,
innate response to disease and danger. A physiological response was found when viewing trypophobic
images and images of dangerous animals which supports the adaptive evolutionary theory. Individuals
that self-report having trypophobia have comorbidity with other psychiatric disorders and other specific
phobias. Individuals tended to fit the DSM-V criteria for specific phobia more than OCD, but there is
still no official clinical recognition or diagnosis for trypophobia.
Future Directions
There is little in the literature about trypophobia as of now and it is difficult to study. Most of the recent
studies all rely on self-report tests and questionnaires and some studies have shown normal and
trypophobic stimuli to subjects to measure levels of aversion, disgust, fear, and other responses. There is
limited data on physiological and psychiatric factors involved with trypophobia which is needed to
understand and explore its origins and mechanisms. Trypophobia is commonly measured using self-
report questionnaires and self-diagnosis due to the lack of an established clinical diagnosis. More
longitudinal studies with a sample that represents the general population need to be done to gain a better
understanding of the prevalence and features of the phobia. In understanding more about the underlying
causes and responses, clinicians will be able to establish standard clinical diagnosis and official
classification and recognition as a disorder.
Acknowledgements
I would like to thank Rebecca Hoffman, Benjamin Freiman, and Yihong Zhang for looking over my
annotated bibliography and providing helpful advice on my sources. I would also like to thank my peer
 9

reviewers, Rebecca Hoffman and Kang Min Kim for their useful feedback on areas to work on for my
review.
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