Phobias

Phobias

Definition

A phobia is an intense but unrealistic fear that can interfere with the ability to socialize, work, or go about everyday life, brought on by an object, event or situation.

Description

Just about everyone is afraid of something—an upcoming job interview or being alone outside after dark. But about 18% of all Americans are tormented by irrational fears that interfere with their daily lives. They aren't crazy—they know full well their fears are unreasonable—but they can't control the fear. These people suffer from phobias.

Phobias belong to a large group of mental problems known as anxiety disorders that include obsessive-compulsive disorder (OCD), panic disorder , and post-traumatic stress disorder . Phobias themselves can be divided into three specific types:

• specific phobias
• social phobia
• agoraphobia

Specific phobias

As its name suggests, a specific phobia is the fear of a particular situation or object, including anything from airplane travel to dentists. Found in one out of every 10 Americans, specific phobias seem to run in families and are roughly twice as likely to appear in women. If the person doesn't often encounter the feared object, the phobia doesn't cause much harm. However, if the feared object or situation is common, it can seriously disrupt everyday life. Common examples of specific phobias, which can begin at any age, include fear of snakes, flying, dogs, escalators, elevators, high places, disease, or open spaces.

Social phobia

People with social phobia have deep fears of being watched or judged by others and being embarrassed in public. This may extend to a general fear of social situations—or be more specific, such as a fear of giving speeches or of performing (stage fright). More rarely, people with social phobia may have trouble using a public restroom, eating in a restaurant, or signing their name in front of others.

Social phobia is not the same as shyness. Shy people may feel uncomfortable with others, but they don't experience severe anxiety, they don't worry excessively about social situations beforehand, and they don't avoid events that make them feel self-conscious. On the other hand, people with social phobia may not be shy—they may feel perfectly comfortable with people except in specific situations. Social phobias may be only mildly irritating, or they may significantly interfere with daily life. It is not unusual for people with social phobia to turn down job offers or avoid relationships because of their fears.

Agoraphobia

Agoraphobia is the intense fear of feeling trapped and having a panic attack in a public place. It usually begins between ages 15 and 35, and affects three times as many women as men—about 3% of the population.

An episode of spontaneous panic is usually the initial trigger for the development of agoraphobia. After an initial panic attack, the person becomes afraid of experiencing a second one. Sufferers literally fear the fear, and worry incessantly about when and where the next attack may occur. As they begin to avoid the places or situations in which the panic attack occurred, their fear generalizes. Eventually the person completely avoids public places. In severe cases, people with agoraphobia can no longer leave their homes for fear of experiencing a panic attack.

Causes & symptoms

Experts don't really know why phobias develop, although research suggests they may arise from a complex interaction between heredity and environment. Some hypersensitive people have unique chemical reactions in the brain that cause them to respond much more strongly to stress . These people also may be especially sensitive to caffeine , which triggers certain brain chemical responses.

Advances in neuroimaging have also led researchers to identify certain parts of the brain and specific neural pathways that are associated with phobias. One part of the brain that is currently being studied is the amygdala, an almond-shaped body of nerve cells involved in normal fear conditioning. Another area of the brain that appears to be linked to phobias is the posterior cerebellum.

While experts believe the tendency to develop phobias runs in families and may be hereditary, a specific stressful event usually triggers the development of a specific phobia or agoraphobia. For example, someone predisposed to develop phobias who experiences severe turbulence during a flight might go on to develop a phobia about flying.

Social phobia typically appears in childhood or adolescence, sometimes following an upsetting or humiliating experience. Certain vulnerable children who have had unpleasant social experiences (such as being rejected) or who have poor social skills may develop social phobias. The condition also may be related to low self-esteem, unassertive personality, and feelings of inferiority.

A person with agoraphobia may have a panic attack at any time for no apparent reason. While the attack may last only a minute or so, the person remembers the feelings of panic so strongly that the possibility of another attack becomes terrifying. For this reason, people with agoraphobia avoid places where they might not be able to escape if a panic attack occurs.

While the specific trigger may differ, the symptoms of different phobias are remarkably similar (e.g., feelings of terror and impending doom, rapid heartbeat and breathing, sweaty palms, and other features of a panic attack). Patients may experience severe anxiety symptoms in anticipating a phobic trigger. For example, someone who is afraid to fly may begin having episodes of pounding heart and sweating palms at the mere thought of getting on a plane in two weeks.

Diagnosis

A mental health professional can diagnose phobias after a detailed interview and discussion of both mental and physical symptoms. Social phobia is often associated with other anxiety disorders, depression , or substance abuse.

Treatment

People who have a specific phobia that is easy to avoid (such as snakes) and that doesn't interfere with their lives may not need to seek treatment. In all types of phobias, symptoms may be eased by lifestyle changes, such as:

• eliminating caffeine
• cutting down on alcohol
• eating a good diet
• getting plenty of exercise
• reducing stress

Meditation and mindfulness training can be beneficial to patients with phobias and panic disorder. Hydrotherapy, massage therapy , and aromatherapy are useful to some anxious patients because they can promote general relaxation of the nervous system. Relaxation training, which is sometimes called anxiety management training, includes breathing exercises and similar techniques intended to help the patient prevent hyperventilation and relieve the muscle tension associated with the fight-or-flight reaction of anxiety. Yoga , aikido, t'ai chi , and dance therapy help patients work with the physical, as well as the emotional, tensions that either promote or are created by anxiety.

Herbs known as adaptogens may be prescribed to treat the anxiety related to phobias. These herbs are thought to promote adaptability to stress, and include Siberian ginseng (Eleutherococcus senticosus ), and ginseng (Panax ginseng ). Adrenal modulators such as licorice (Glycyrrhiza glabra ) and borage (Borago officinalis ), nervine herbs such as chamomile (Chamaemelum nobile ) and skullcap (Scutellaria lateriafolia ), and antioxidal herbs like milk thistle (Silybum marianum ) are also beneficial. Tonics of skullcap and oats (Avena sativa ) may also be recommended to ease anxiety.

Allopathic treatment

When phobias interfere with a person's daily life, a combination of psychotherapy and medication can be quite effective. Medication can block the feelings of panic, and when combined with cognitive-behavioral therapy, can be quite effective in reducing specific phobias and agoraphobia.

Cognitive-behavioral therapy adds a cognitive approach to more traditional behavioral therapy . It teaches patients how to change their thoughts, behavior, and attitudes, while providing techniques to lessen anxiety, such as deep breathing, muscle relaxation, and refocusing.

One cognitive-behavioral therapy is desensitization (also known as exposure therapy), in which people are gradually exposed to the frightening object or event until they become used to it and their physical symptoms decrease. For example, someone who is afraid of snakes might first be shown a photo of a snake. Once the person can look at a photo without anxiety, he might then be shown a video of a snake. Each step is repeated until the symptoms of fear (such as pounding heart and sweating palms) disappear. Eventually, the person might reach the point where he can actually touch a live snake. Three-fourths of patients are significantly improved with this type of treatment.

Another more dramatic cognitive-behavioral approach is called flooding, which exposes the person immediately to the feared object or situation. The person remains in the situation until the anxiety lessens.

Several drugs are used to treat specific phobias by controlling symptoms and helping to prevent panic attacks. These include anti-anxiety drugs (benzodiazepines) such as alprazolam (Xanax) or diazepam (Valium). Blood pressure medications called beta blockers, such as propranolol (Inderal) and atenolol (Tenormin), appear to work well in the treatment of circumscribed social phobia, when anxiety gets in the way of performance, such as public speaking. These drugs reduce overstimulation, thereby controlling the physical symptoms of anxiety.

In addition, some antidepressants may be effective when used together with cognitive-behavioral therapy. These include the monoamine oxidase inhibitors (MAO inhibitors) phenelzine (Nardil) and tranylcypromine (Parnate), as well as selective serotonin reuptake inhibitors (SSRIs) like fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft), and fluvoxamine (Luvox).

A medication that shows promise as a treatment for social phobia is valproic acid (Depakene or Depakote), which is usually prescribed to treat seizures or to prevent migraine headaches. Researchers conducting a twelve-week trial with 17 patients found that about half the patients experienced a significant improvement in their social anxiety symptoms while taking the medication. Further studies are underway.

Treating agoraphobia is more difficult than other phobias because there are often so many fears involved, such as open spaces, traffic, elevators, and escalators. Treatment includes cognitive-behavioral therapy with antidepressants or anti-anxiety drugs. Paxil and Zoloft are used to treat panic disorders with or without agoraphobia.

Expected results

Phobias are among the most treatable mental health problems; depending on the severity of the condition and the type of phobia, most properly treated patients can go on to lead normal lives. Research suggests that once a person overcomes the phobia, the problem may not return for many years—if at all.

Untreated phobias are another matter. Only about 20% of specific phobias will go away without treatment, and agoraphobia will get worse with time if untreated. Social phobias tend to be chronic, and without treatment, will not likely go away. Moreover, untreated phobias can lead to other problems, including depression, alcoholism , and feelings of shame and low self-esteem.

A group of researchers in Boston reported in 2003 that phobic anxiety appears to be a risk factor for Parkinson's disease (PD) in males, although it is not yet known whether phobias cause PD or simply share an underlying biological cause.

While most specific phobias appear in childhood and subsequently fade away, those that remain in adulthood often need to be treated. Unfortunately, most people never get the help they need; only about 25% of people with phobias ever seek help to deal with their condition.

Prevention

There is no known way to prevent the development of phobias. Medication and cognitive-behavioral therapy may help prevent the recurrence of symptoms once they have been diagnosed. Early detection and treatments may decrease severity.

Resources

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision. Washington, DC: American Psychiatric Association, 2000.

Bloomfield, Harold H. Healing Anxiety with Herbs. New York: Harper Collins, 1998.

Peurifoy, Reneau Z. Anxiety, Phobias and Panic: A Step by Step Program for Regaining Control of Your Life. New York: Warner Books, 1996.

"Phobic Disorders. " Section 15, Chapter 187 in The Merck Manual of Diagnosis and Therapy, edited by Mark H. Beers, MD, and Robert Berkow, MD. Whitehouse Station, NJ: Merck Research Laboratories, 2002.

Schneier, Franklin, and Lawrence Welkowitz. The Hidden Face of Shyness: Understanding and Overcoming Social Anxiety. New York: Avon Books, 1996.

Stern, Richard. Mastering Phobias: Cases, Causes and Cures. New York: Penguin USA, 1996.

PERIODICALS

Kinrys, G., M. H. Pollack, N. M. Simon, et al. "Valproic Acid for the Treatment of Social Anxiety Disorder." International Clinical Psychopharmacology 18 (May 2003): 169–172.

Modica, Peter. "Social phobia may run in the family." American Journal of Psychiatry 155 (1998): 90-97.

Ploghaus, A., L. Becerra, C. Borras, and D. Borsook. "Neural Circuitry Underlying Pain Modulation: Expectation, Hypnosis, Placebo." Trends in Cognitive Science 7 (May 2003): 197–200.

Rauch, S. L., L. M. Shin, and C. I. Wright. "Neuroimaging Studies of Amygdala Function in Anxiety Disorders." Annals of the New York Academy of Sciences 985 (April 2003): 389–410.

Weisskopf, M. G., H. Chen, M. A. Schwarzschild, et al. "Prospective Study of Phobic Anxiety and Risk of Parkinson's Disease." Movement Disorders 18 (June 2003): 646–651.

ORGANIZATIONS

Agoraphobics Building Independent Lives. 1418 Lorraine Ave., Richmond, VA 23227.

Agoraphobics In Motion. 605 W. 11 Mile Rd., Royal Oak, MI 48067.

American Psychiatric Association (APA). 1400 K Street, NW, Washington, DC 20005. (888) 357-7924. <http://www.psych.org>.

Anxiety Disorders Association of America. 11900 Parklawn Dr., Ste. 100, Rockville, MD 20852. (301) 231-9350.

National Anxiety Foundation. 3135 Custer Dr., Lexington, KY 40517. (606) 272-7166. http://www.lexington-online.com/naf.html.

National Institute of Mental Health (NIMH) Office of Communications. 6001 Executive Boulevard, Room 8184, MSC 9663, Bethesda, MD 20892-9663. (866) 615-NIMH or (301) 443-4513. <http://www.nimh.nih.gov>.

OTHER

Anxiety Network Homepage. http://www.anxietynetwork.com.

National Institute of Mental Health (NIMH). Anxiety Disorders. NIH Publication No. 02-3879. Bethesda, MD: NIMH, 2002.

Paula Ford-Martin

Rebecca J. Frey, PhD