Read an Excerpt
GETTING ACQUAINTED WITH
FEARS, PHOBIAS, AND
OTHER ANXIETY DISORDERS
In this introductory chapter, you will become acquainted with various types of phobias and other anxiety disorders. You'll learn more about how extreme some reactions to phobias are and always have been.
Most people fear something but react in many different ways to those fears. Some of us feel just a little nervous in a fearful situation; others experience sudden, unpleasant "symptoms." For example, one individual can walk to the edge of a balcony and enjoy the view, but another will become drenched in sweat, shake, feel dizzy or faint, and pull back. These physiological reactions happen because what we perceive with these events affects what goes on in the body and vice versa. Many who have severe reactions to their fears tend to avoid the situations in which they experienced fear. Avoidance is a powerful coping skill or behavior because it results in immediate reduction or prevention of the aversive fear reaction. Avoidance also helps to make us unaware of the intensity of our fear reactions. Most people know they have certain fear reactions, but they do not understand the relationship between their fears, what triggers them, their thoughts, and their avoidance behaviors. Let's start to change that!
WHAT'S THE DIFFERENCE BETWEEN
A FEAR AND A PHOBIA?
Who is a "worry wart," and who is truly phobic? When does a fear become a phobia? How can you tell the difference? Natural fears are those that most people share, suchas fear of angry animals, dangerous snakes, or sudden loud noises. For most people, coming into contact with these triggers arouse fear reactions.
Fear is a natural reaction that most people in the same situation share, such as a feeling of sudden apprehension about being out on an exposed balcony. However, for the individual who retreats hastily and dizzily on hands and knees, the balcony situation is a phobia, and eventually that person may completely avoid going to places that have high, exposed balconies.
There are many "prepared" fears, that is, reactions that humans naturally resort to with fear because these reactions have helped humanity survive. The most common prepared fears are of being stared at (eyes), heights (edges), small animals, snakes, angry people, closed places (trapped), blood and injury, and death. Fears vary in intensity and, under the right conditions, can lead to the development of a phobia. A great proportion of phobias actually develop out of these natural fear reactions.
A phobia is an uncommon fear in which the reaction is out of proportion to the danger of the situation or the ongoing events. Others cannot reason away the person's fear of the given situation. Avoidance and escape are the first and most common modes of "coping" with these intense reactions. Unfortunately, these coping mechanisms often make the situation worse.
Phobias, fears, and other anxiety disorders are the most prevalent mental health disturbances in modern society. A large percentage of all adults have experienced at least one specific phobia at some time in their lives. Estimates are that from 5 to 11 percent of adults have fears that can be considered phobias. Of individuals who have specific phobias (fears of one thing), only about 6 percent seek treatment. Of agoraphobics (those who fear going out, particularly alone), fewer than 20 percent seek mental health treatment. Phobias are debilitating for many people. We hope this book will help direct some who do not seek treatment to embark on the self-help program and also to understand how professional assistance may help them.
What Are Some Types of Anxiety Disorders and Phobias?
Phobias are categorized by the American Psychiatric Association as anxiety disorders. There are three widely identified groups of phobias:
* specific phobias (formerly referred to as single or simple phobias)
* social phobias
* agoraphobia (with and without panic attacks)
Other types of anxiety disorders (which you will learn about in this book) include:
* generalized anxiety disorder (GAD)
* panic disorder (with or without agoraphobia)
* obsessivecompulsive disorder (OCD)
* posttraumatic stress disorder (PTSD)
What Are Some Specific Phobias?
The characteristic feature of a specific phobia is a persistent, uncommon fear of and compelling desire to avoid one specific object or situation. The category of specific phobias contains an endless list of fearsalmost any object or situation can be phobic for a given individualbut a majority of phobias are related to the "prepared" fears discussed earlier.
If you have a specific phobia, you may experience physiological symptoms that are typical of many anxiety disorders, and these are important to identify. However, because a single fear is so specific, you may be able to avoid contact with the phobic object or situation, especially when the likelihood of confrontation with the feared object or situation, such as snakes, is low. On the other hand, individuals who fear common situations, such as elevators or heights, may not be able to avoid these stimuli so easily.
Specific phobias that many people experience include certain modes of transportation, such as automobiles, and such activities as driving across bridges, flying in an airplane, public speaking, and being atop heights. Other common phobic objects or situations include harmless animals such as dogs and cats, thunderstorms, darkness, or enclosed places.
Blood and injury phobias are special types of specific phobias. Interestingly, unlike other single phobias, which cause increased pulse and other physiological signs of arousal, blood and injury phobias usually produce a sudden lowering of pulse and blood pressure that can bring on fainting spells. Because of this unique "vasal-vagal" reaction, we have to approach these phobias in a different manner.
What About Social Phobias and Social Anxieties?
Do you experience undue anxiety in social situations such as parties, during interviews, at restaurants, or when making complaints or interacting with the opposite sex? You may fear situations in which you believe you are being observed and evaluated by others, such as while speaking in public, writing checks, using public restrooms, or eating. Of course, many people experience some degree of discomfort in these situations: however, when an individual begins to feel extremely anxious, becomes self-conscious, and avoids or escapes these situations they become clinically identified as phobias.
Social phobia may be associated with fears of negative criticism, humiliation, or embarrassment, such as making a fool of oneself, sweating, fainting, blushing, calling attention to oneself, or being rejected. Individuals who have these phobias usually avoid the specific situations they fear. Some individuals will participate in their feared activity only when they cannot be seen, for example, swimming in the dark. Often, social phobias are also accompanied by high levels of generalized anxiety.
The triggers in social phobias are usually the presence of others and self-consciousness. Images of embarrassment and humiliation are often present, and sometimes fears of not being able to "perform" correctly or adequately occur.
What Happens with Agoraphobia?
Agoraphobia may be the most serious of the phobias because it can be the most debilitating. Agoraphobics are afraid to leave a "safe place" such as home or a safe person such as a spouse or a close relative. Such separations cause intense anxiety and sometimes panic attacks. A small percentage of agoraphobics become housebound for periods of time. This disorder obviously interferes with working outside the home and with social interactions, travel, and normal activities and enjoyments.
Agoraphobics show a wide range of avoidance behaviors, including fear of entering public places, being in open spaces, traveling, and riding on public transportation; places where they may feel trapped and not able to return to their safe place at will. Agoraphobics often experience physiological symptoms, such as palpitations, lightness in the head, weakness, chest pain, and difficulty in breathing. Agoraphobics express fears of losing control, going insane, embarrassing themselves and others, fainting, and dying. Agoraphobia often begins with panic attacks, but these soon diminish in frequency; the fear of having a panic attack, however, persists, and body sensations are often triggers for intense anxiety and avoidance.
Panic, Panic Attacks, and Panic Disorder
A panic attack is not like the ordinary anxiety and nervousness that most people feel before a job interview or giving a speech. Panic and panic attacks are characterized by one or more of many discomforts, including an abrupt surge of terror and a feeling of impending doom that quickly peaks. Other symptoms of a panic attack can include rubbery legs, light headedness, dizziness, difficulty breathing, palpitating and "racing" heart, and choking and tingling or numb sensations. Panic may be brought about by particular stimuli or sometimes even by thinking about it. It may also appear to occur unpredictably and spontaneously without any cues, but often cues are thoughts, memories, or unnoticed body sensations. People who have experienced one panic attack usually fear that another one will occur.
A person can have panic attacks without having agoraphobia. Agoraphobia seems to be a special condition associated with panic attacks and is significantly more common in women.
Other Anxiety Disorders
Now here's an overview of other types of anxiety disorders that you will see in this book:
* generalized anxiety disorder (GAD) * obsessive-compulsive disorder (OCD) * Posttraumatic stress disorder (PTSD)
GENERALIZED ANXIETY DISORDER (GAD)
The National Institute of Mental Health defines generalized anxiety disorder (GAD) as always anticipating disaster; often worrying excessively about health, money, family, or work; and a more-or-less chronic state of anticipating dread or anxiety. Worry is the most common component. The worrier may experience physical symptoms, such as trembling, muscle tension, and nausea. Worry seems to be chronic and there is evidence that GAD begins in early life and more or less occurs through the life span of development.
Many individuals with GAD startle more easily than other people. They tend to feel tired, have trouble concentrating, and sometimes experience depression. They tend to catastrophize, which means anticipating that the worst scenarios will occur. The effects of GAD usually don't interfere with one's home, work, or social life. Unlike people who have phobias, people with GAD usually don't avoid certain situations because of their disorder. However, in severe cases, GAD can become very debilitating and make it difficult to carry out even the most ordinary of daily activities without the constant distraction of intrusive anxiety.
OBSESSIVE-COMPULSIVE DISORDER (OCD)
Most descriptions of OCD include some phobias, and many phobias include some obsessive-compulsive characteristics. Rituals performed to try to reduce anxiety about dreaded consequences are called compulsions. Sufferers of OCD experience no pleasure in carrying out the rituals they are drawn to, only temporary relief from the discomfort caused by the obsession. They are usually aware that the obsession is irrational, but its occurrence establishes a state where terminating or ignoring it is difficult (because it is overvalued).
Some people are obsessed with dirt or germs and wash their hands repeatedly. Some check things over and over again. Some touch things or count things. Many people can identify with having some of the symptoms of OCD, such as checking several times that they have turned off the coffeepot before leaving the house in the morning; others may check their pockets to be sure the car keys are there. However, OCD is diagnosed only when these activities consume a lot of time, are very distressing, and interfere in a major way with daily life.
About 1 in 50 people are afflicted with OCD. Adults with this condition recognize that what they are doing is senseless, but they feel they cannot control their obsessions and compulsions. Some people, particularly children who have OCD, may not recognize that their behavior is out of the ordinary.
You may remember that in the 1997 movie As Good As It Gets Jack Nicholson portrays a man who suffers from and later successfully faces and overcomes some of his obsessions and compulsions. He uses a new bar of soap each time he washes his hands. He must also eat at the same table in the same restaurant and be served by the same waitress, and he brings his own wrapped, plastic tableware. He avoids stepping on lines in the sidewalk. Although these behaviors provide comic relief in movies, OCD sufferers are at the mercy of their obsessions and find these distressing and tiring.
POSTTRAUMATIC STRESS DISORDER (PTSD)
Ordinary events can serve as reminders of a trauma or an incident that occurred and may trigger flashbacks or intrusive images. PTSD can occur in people who have been raped, witnessed a crime, survived a school shooting, been in a car accident, or fought on a battlefield. People who have PTSD have recurrent frightening thoughts and memories of their ordeal and may feel emotionally numb and vulnerable, especially with people they were once close to. PTSD was once referred to as shell shock or battle fatigue; it was thought to happen only to war veterans. Now it is known that PTSD can result from any number of traumatic occurrences. Trauma itself has immediate and long-range effects in people, but PTSD is a reaction that often shows up years later and carries with it numbing sensations, loss of stimulus discrimination, and impulse and anxiety problems.
Some people who have PTSD repeatedly relive the trauma in the form of nightmares and disturbing recollections during the day. They may also experience sleep problems and depression or may be easily startled. They may feel irritable and more aggressive than before. Seeing things that remind them of the incident may be distressing and may lead them to avoid certain places or situations that bring back those memories. Symptoms vary and, as mentioned, often begin much after the traumatic event. Diagnosis is difficult and requires a review of the person's life history as well as symptom patterns.
There is also a condition called Partial PTSD that consists of more limited symptoms of less severity. This will not be covered in this book. It is difficult to treat PTSD with self-help; professional help is recommended.
BEFORE YOU GO ON ... SOME INTERESTING
HISTORICAL FACTS ABOUT PHOBIAS
The term phobia derives from the Greek word phobos, which means fear, panic, terror, and flight. The word phobos comes from the name of the ancient Greek deity Phobos, who provoked fear and panic in enemies. The word panic is derived from the name for the god, known as Pan, whom the Greeks worshiped as their god of flocks, herds, pastures, and fields. The Greek word for "all" is also pan. People were dependent on Pan to make the flocks fertile; Pan himself was a lustful creature and known for an ability to reproduce. Pan's shape was that of a goat, which could traverse fields and dart through herds of cattle. Pan loved to scare people: he would dart out of the woods and frighten passersby, often in dark forests at night. The fright he created was known as panic.
Hippocrates (460 B.C.377 B.C.) may have been one of the first who described phobias when he wrote about an individual who feared heights and precipices. If you have acrophobia (fear of heights), you may identify with this individual: "He would not go near a precipice, or over a bridge or beside even the shallowest ditch, and yet he could walk in the ditch itself."
William Shakespeare (1564-1616), in The Merchant of Venice, wrote of cat phobia, which is still a common phobia: "Some that are mad if they behold a cat."
In 1798, Benjamin Rush, American physician and author, published an article in which he gave his definition of phobia: "... a fear of an imaginary evil, or an undue fear of a real one." He then listed 18 species of fear named according to the object of excessive fear or aversion, such as dirt or rats.
IN UNDERSTANDING PHOBIAS
In 1895, Henry Maudsley (1771-1831), British psychiatrist and author, included all phobias under the heading of melancholia and advised against the trend of giving a special name to each variety of phobic situation because many phobias often were noticed together or successively in the same individual. Researchers and therapists today recognize that one individual may have one or more phobias.
Sigmund Freud's writing and theorizing at the end of the 19th century further contributed to the stimulation of interest in the causes and treatment of anxieties and phobias. In 1895, Freud wrote Obsessions and Phobias: Their Physical Mechanism and Their Aetiology. In this paper, he distinguished the two by suggesting that with phobias the emotional state is always one of morbid anxiety, while in the obsessions other emotional states such as doubt or anger may occur.
Freud emphasized that the origin of phobias was anxiety that came from symbols of unconscious fantasies and conflicts. The anxiety was a "signal" that these unconscious energies might break through into consciousness. The symbolism always concerned an unacceptable aggressive or sexual impulse. Freud suggested that phobia relates to objects that have unconscious symbolic meanings and represent regressions to earlier infantile fears, usually centered around Oedipal conflicts. To him, the object always symbolized some sexual anxiety, and every phobia, therefore, included some element of sexual energy. This idea of an individual underlying cause in each phobia promoted the use of labels and the old view that each phobia had unique early causes.
MANY VIEWPOINTS ON UNDERSTANDING
ANXIETY DISORDERS AND PHOBIAS
Developments in the latter half of the 20th century led to increased knowledge about anxiety and phobic disorders and new directions for treating them. Most therapeutic settings now focus on helping people cope with their individual phobic reactions. Also, phobias are seen as a large class of similar reactions learned by the same set of principles. In many settings, therapists use an integrated perspective. That means that no one viewpoint explains all the phenomena that various individuals experience. Although some psychiatrists suggest that phobias are maintained by unconscious conflicts remaining unconscious, other psychotherapists focus on the avoided behavior and thoughts of the individual, such as catastrophic misinterpretation of danger. These "behavioral" or "cognitive behavioral" approaches have proven to be the most effective for treating phobias and anxiety. We will concentrate on the principles of behavioral psychology to help you or your loved ones understand and cope with symptoms.
Some suggest that phobias are derived from conditioned experiences and that the phobic object may once have been part of a traumatic situation. On this basis, any object has an equal potential to become a phobic stimulus through association with traumatic conditions. Others say that certain phobic responses may be learned through imitating the reactions of others, or vicarious learning. Still another theory is that phobic reactions are learned by the positive consequences that follow (for example, soothing attention from a parent of a school-phobic child). This type of learning is called operant conditioning. Generally all three viewpoints affect the development of anxiety reactions.
We are just now beginning to understand the physiological mechanisms associated with anxieties, and this understanding has helped improve behavioral treatment. Furthermore, our biochemical and biological understanding have also improved and have led to improved medications that offer short-term relief from the effects of anxiety reactions.
EVOLUTION OF TREATMENTS
Psychoanalysis was used for many years as a treatment for anxiety disorders. However, in many cases, understanding the source of the anxiety did not make the anxieties and unwanted behaviors go away, so the effectiveness of psychoanalysis was questioned. Then, in the late 1950s and early 1960s, behavior therapy developed. Behavioral therapists believe that a phobia is a learned response and therefore can be unlearned. Behavioral therapists use techniques that involve gradually exposing the individual to whatever is feared. Exposure may take place in real life or in the person's imagination. For example, a person with a fear of heights may imagine himself over time higher and higher on a hill without anxiety; gradualness of exposure is an important factor.
Early behavior researchers speculated that effective results could follow from looking at an individual's symptoms, working with them, and systematically desensitizing them by gradual exposure. These methods proved to be much more highly effective than psychoanalytic or "talking" therapies. Thus, through a wide variety of behavior therapy techniques, thousands of individuals have learned that they do not have to be a victim of anxieties and phobias.
PHYSICAL EXAMINATIONS AND
In addition to behavior therapy, current treatment may include periodic examinations of cardiovascular, pulmonary, endocrine, or neurological functions, as well as pharmacological aspects. Also, the development of relatively safe, appropriate drugs in adjunct to working with therapists or with self-help has enabled many to overcome phobias, anxieties, panic disorders, and obsessivecompulsive behaviors. Drugs are most helpful as aids to support the person in working on functioning while anxiety situations are dealt with. Drugs have short-term benefits that over the long term become problems in and of themselves.
GETTING HELP FOR ANXIETY DISORDERS
In addition to self-help, such as following some of the suggestions in this book, if you or someone you know has serious symptoms of anxiety disorders, the best place to start may be your family physician. Your physician can help you determine whether your symptoms are due to some medical condition, an anxiety disorder, or both. Often, the next step may be a referral to a mental health professional. Those who can help include psychiatrists, psychologists, and social workers. Look for a professional who has specialized training in behavioral therapy or cognitive-behavioral therapy and who is open to the use of medications, should they be needed. It is also important that he or she have training and experience in treating anxiety disorders. You are free to ask them these questions.
If you embark on a therapy program, be sure to find a health care professional with whom you feel comfortable. You will work as a team to develop a plan to treat your anxiety disorder that may involve a variety of therapies.
New treatments for anxieties are being sought. The National Institute of Mental Health, for example, supports a sizable and multifaceted research program on the causes, diagnosis, treatment and prevention of anxiety disorders. This is part of an effort to overcome major mental disorders.
Now Take Three Steps: Move Forward in Your Life
In the next chapter, you'll learn about the Three-Step Process for beginning to face your fears. Face your fears and learn to control them. You'll take these steps one at a time. You may want to refer to the chapter several times as you continue to read the next chapters, which give more details about social phobias, specific phobias, panic attacks and agroraphobia, obsessive-compulsive disorder, posttraumatic stress disorder, depression, reducing fear of flying and sexual fears, and improving your self-esteem and feelings of well-being.