Why do tiny holes freak me out?

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Q: Seeing tiny holes – like the kind on some fruits or plants – makes my skin crawl. What’s going on with me?

A: Some people have negative reactions to tiny, clustered holes. This is known as trypophobia. Visual triggers include lotus seed pods, bubbles surfacing on a pancake on the griddle and even the iPhones with clustered camera lenses.

Around 10 to 15 percent of people find these images uncomfortable to look at, said Nate Pipitone, an associate professor of psychology at Florida Gulf Coast University, who has been studying trypophobia for several years.

The images can cause feelings of repulsion and disgust as well as itching and nausea. It happens to adults and children, even at 4 or 5 years old.

Researchers have studied two main evolutionary theories about why this aversion exists. Some venomous creatures exhibit trypophobic patterns – like the eight eyes of a tarantula – and several skin diseases, such as smallpox, create clusters of circular lesions.

While tiny circles in any context may be disturbing enough to some, Pipitone found that reactions are particularly strong when superimposed upon images of dangerous animals – and even more so upon images of human skin such as on the hand.

“This suggests that the extreme discomfort seen among those who are bothered by trypophobic images may be an adaptive response to avoid infectious diseases,” he said.

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What causes trypophobia?

Pipitone thinks trypophobia relates to how certain people process basic visual information. Studies have shown the images of holes that make people most uncomfortable tend to have a characteristic visual property: high contrast.

Think dark holes against a light background. Holes that look more washed out don’t usually cause discomfort.

The circular pattern is also a critical component, Pipitone added. Images of palm fronds, for example, have similarly sized swaths of light and dark, but don’t freak people out.

Many venomous creatures, such as the blue-ringed octopus, have the characteristic visual property, leading some researchers to argue the reaction stems from a subconscious reflex rather than a learned fear response.

Because of this, Pipitone isn’t confident trypophobia would be amenable to psychological interventions like cognitive behavioral therapy.

The easiest solution is simply to avoid these images whenever possible. In fact, Pipitone told me that students in his lab have opted out of trypophobia projects because of their own reactions.

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So is trypophobia real?

Another theory about trypophobia is a bit less Darwinian and instead relates to the power of suggestion: If you’re primed to search for a supposedly trypophobic image after I imply it’ll make you itchy, you may feel itchy simply because you were primed to do so.

Had you seen the image in another context, maybe you wouldn’t have blinked an eye.

Also, calling this phenomenon a phobia isn’t quite accurate.

Trypophobia, which first appeared in the medical literature 10 years ago, is most often associated with disgust, rather than fear.

It doesn’t fit neatly into any psychiatric diagnosis. To be diagnosed with a phobia by the standards of the Diagnostic and Statistical Manual of Mental Disorders – a guide used by clinicians to diagnose mental health disorders – fear or anxiety around a certain trigger has to be strong enough to cause significant distress or functional impairment.

“For most people, even though they may find trypophobic images repulsive to look at, they can still go about their daily routine,” Pipitone said.

It does have implications for all of us, though.

Researchers are working to decipher specific configurations of clusters, texture or color to help positively inform the design of items like clothes or even buildings. On the flip side, some filmmakers appear to lean into the effect trypophobic patterns have on people.

Take the horror series “Friday the 13th” villain Jason Voorhees, for example. He wears a hockey mask with tiny holes, which is oddly disturbing. And 2018’s “Black Panther” antagonist, Killmonger, displayed tiny keloid scars on his torso that some people reported triggered their trypophobia.

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What I want my patients to know

Trypophobia is a great example of a way all of us perceive and process the world differently. The same visual input causes distress in some people, but not others. Now think of the many medical conditions that may not be outwardly apparent – like migraines or long covid – where triggers in the daily environment may not bother others at all. For many people, it is frustrating to constantly struggle to be believed and heard.

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Meet the doctor: Trisha Pasricha is a physician at Massachusetts General Hospital, an instructor in medicine at Harvard Medical School and a medical journalist.