Useful Information On Phobias And Panic
Useful Information On Phobias And Panic
(posted by Hopkins Technology)


U.S. Department of Health and Human Services Public Health Service Alcohol, Drug Abuse, and Mental Health Administration

The Varieties of Fear

Phobias take many forms. Some people are terrified of dogs, even tiny dogs with wagging tails. Some people stiffen with fright at the mere thought of talking in front of a group. Some can't fly. Some tremble and hide at the crack of thunder. Some can't ride an escalator. Some are struck by panic attacks for no apparent reason. And some never leave their homes.

Fears such as these are very common. Millions of Americans are afflicted with phobias or panic disorder. They suffer intensely. To escape their fear, they go to great lengths to avoid the object, place, or situation that provokes it. They change jobs merely to avoid an elevator ride, for example, or cut back their social life. Some wear down their families with their clinging dependency. Nearly all lose out on much of life.

Many people to from doctor to doctor seeking cures for the physical symptoms that accompany their phobias. Often, even the doctor fails to recognize that stomach pains, high blood pressure, rapid heart beat, and other symptoms may be related to intense fear. Unless questioned, patients may not think to mention their fears. Doctors may not ask. While the bills keep mounting, the medical condition fails to improve.

The many phobic people who think their fears are silly, childish, or trivial often try to conceal them. While hiding from their fears, they hide their phobias from others, further limiting their experience of life.

 
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It is better to tell someone. Much of the pain and disruption - perhaps most of it - can be remedied. New treatments for phobias are remarkably effective. But few people, including doctors, know about them.

If you or someone you know is excessively fearful - afraid out of all proportion to the cause - then you may gain some understanding of the problem from this pamphlet. It describes what experts know about phobias and panic. It may help you.

PHOBIAS AND PANIC - ANXIETY DISORDERS

Anxiety is the emotion you feel when a person, object, situation, or impulse seems dangerous to you. If you're crossing a street and suddenly notice a car speeding toward you, you feel afraid that you will be hit, and you dash out of the way. This fear and the behavior it provokes probably save your life. If you're fed up with your boss and want to hit him, the sick feeling in the pit of your stomach - the anxiety you feel when you anticipate the consequences of slugging your boss - keeps you from carrying through on your impulse. The anxiety and your control of your behavior probably save your job.

While "normal" anxiety is adaptive - that is, it helps you to survive and be productive - too much anxiety can be crippling. People who suffer from certain patterns of signs and symptoms related to anxiety are considered by mental health specialists to have anxiety disorders. Phobias and panic attacks are the most common of these disorders. (Other anxiety disorders - generalized anxiety disorder, obsessive-compulsive disorder, posttraumatic stress disorder, and atypical anxiety disorder - are each characterized by somewhat different symptoms. They will not be discussed here.)

Both phobias and panic disorder are marked not only by great anxiety in situations that are relatively safe, but also by an exaggerated avoidance of the source of distress. Depending on the type of phobia or panic, the person may shy away from floor-to-ceiling windows in a highrise, refuse an invitation to speak in front of a church group, or stay out of crowded shopping malls. People with these disorders don't actually have to encounter what they fear.

They become intensely anxious just by anticipating that they might soon be in the feared situation, brooding over it in their imagination.

The fears can start in childhood or adulthood. Some people have suddenly become terrified of things they've been doing for years. For example, a flight attendant began having panic attacks on her 500th flight.

Some people can sidestep the thing they fear without much difficulty. Some, especially adults, can hide their distress and conceal their phobias. Even those who usually adjust their lives to fit their phobias are sometimes able to confront what they fear, "toughing it out," suffering all the while. While children may outgrow their phobias, adults usually do not get rid of them unless they receive treatment.

Recognized even in ancient times, phobias and panic are known around the world, probably in every human culture. The most recent and thorough studies show that, in the United States, phobias are the most common of all mental disorders. Seven out of every hundred Americans have phobias. Eight out of every thousand have panic disorder. Compared to men, women more often suffer from most types of phobia and panic disorder.

The reason that phobias and panic are more common in women is now known. Investigators speculate that men may be more likely to drown their fears, since alcohol abuse is more common in men than women. This is just one of many possible explanations, however. Differences in biological makeup or social and psychological experiences may also be responsible. For example, in our society some girls are encouraged to be more fearful and less independent than males.

TYPES OF PHOBIAS AND PANIC

Mental health professionals now recognize three types of phobia - simple phobia, social phobia, and agoraphobia (with and without panic attacks) - and a separate diagnosis for people who repeatedly experience severe attacks of panic.

SIMPLE PHOBIAS

The most common of the various phobias is simple phobia, the unreasonable fear of some object or situation. Bees, germs, heights, odors, illness, and storms are examples of the things commonly feared in simple phobias.

If you have a simple phobia, it might have begun when you actually did face a risk that realistically provoked anxiety. Perhaps, for example, you found yourself in deep water before you learned to swim. Extreme fear was appropriate in such a situation. But if you continue to avoid even the shallow end of a pool, your anxiety is excessive and may be of phobic proportions.

Simple phobias, especially animal phobias, are common in children, but they occur at all ages. The best evidence to date suggests that between 5 and 12 percent of the population have phobic disorders in any 6-month period.

The recognition by most phobics that their fears are unreasonable doesn't make them feel any less anxious. Simple phobias do not often interfere with daily life or cause as much subjective distress as most other anxiety disorders.

SOCIAL PHOBIAS

The person with a social phobia is intensely afraid of being judged by others. Even at a gathering of many people, the social phobic expects to be singled out, scrutinized, and found wanting. Thus, the person with a social phobia feels compelled to avoid social situations with such apprehensions.

If you have a social phobia, you might be afraid to go to a party because you fear that other people will laugh at your clothing or think you are hopelessly stupid because you won't be able to think of anything to say. Like people with simple phobias, you work hard to avoid these anxiety-provoking situations.

People with social phobias are usually most anxious over feeling humiliated or embarrassed by showing fear in front of others. Ironically, they are often so crippled by the inhibitions resulting from such fears that they, in fact, may have difficulty thinking clearly, remembering facts, or expressing themselves in words. Even success in social situations fails to make them feel more confident. They are likely to think something like, "Next time I'll fall on my face."

Although studies of the incidence of social phobias are so far only preliminary, most experts believe social phobias are not as common as simple phobias. But because they result in considerable distress, people who suffer from them are more likely to seek treatment than are people with simple phobias. Social phobias tend to begin between the ages of 15 and 20 and, if left untreated, continue through much of the person's life. Often, social phobias suffer from symptoms of depression, and many also become dependent on alcohol.

PANIC DISORDER

Another group of anxious people are subject to devastating episodes of panic that are unexpected and seemingly without cause. Such unpredictable panic attacks are marked by an overwhelming sense of impending doom and a host of bodily symptoms. The person's heart races and breathing quickens, as he gasps for air. (In the interest of brevity and grace of style, the pronoun "he" will be used throughout this pamphlet when either sex could be the topic of discussion). Sweating, weakness, dizziness, and feelings of unreality are also common. The person having a panic attack fears he is going to die, go crazy, or at least lose control.

Panic disorder is diagnosed when patients experience repeated episodes of such panic. Although people with simple or social phobias may sometimes experience panic, they are clearly responding to an encounter - or an anticipated encounter - with the object or situation they fear. Such is not the case with panic disorder, when the fear strikes from nowhere, seemingly "out of the blue."

People with simple and social phobias can also predict that they will feel fear every time they come close to a cat, climb to the roof of a tall building, or encounter whatever else they fear. People with panic disorder, by contrast, never can predict when they will suddenly be struck by panic. Some situations may seem more "dangerous," especially those that make escape difficult, but an attack does not invariably occur in those situations.

Panic disorder, which runs in families, afflicts some 1.2 million Americans. For most, panic attacks begin sometime between the ages of 15 and 19.

AGORAPHOBIA

Many people who suffer from panic attacks go on to develop agoraphobia, a severely handicapping disorder that often prevents its victims from leaving their homes unless accompanied by a friend or relative - a "safe" person. The first panic attack may follow some stressful event, such as a serious illness or the death of a loved one. (The agoraphobic often doesn't make this connection, though.) Fearing more attacks, the person develops a more-or-less continual state of anxiety, anticipating the next attack, avoiding situations where he would be helpless if a panic attack occurred. It is this avoidance behavior that distinguishes agoraphobia from panic disorder. Two different types of anxiety appear to afflict the person with agoraphobia - panic and the "anticipatory anxiety" engendered by expectations of future panic attacks.

If you have agoraphobia, chances are it developed something like this: One ordinary day, while tending to some chore, taking a walk, driving to work - in other words, just going about your usual business - you were suddenly struck by a wave of awful terror. Your heart started pounding, you trembled, you perspired profusely, and you had difficulty catching your breath. You became convinced that something terrible was happening to you, maybe you were going crazy, maybe you were having a heart attack, maybe you were about to die. You desperately sought safety, reassurance from your family, treatment at a clinic or emergency room. Your doctor could find nothing wrong with you, so you went about your business, until a panic attack struck you again. As the attacks became more frequent, you spent more and more time thinking about them. You worried, watched for danger, and waited with fear for the next one to hit.

You began to avoid situations where you had experienced an attack, then others where you would find it particularly difficult to cope with one - to escape and get help. You started by making minor adjustments in your habits - going to a supermarket at midnight, for example, rather than on the way home from work when the store tends to be crowded.

Gradually, you got to the point where you couldn't venture outside your immediate neighborhood, couldn't leave the house without your spouse, or maybe couldn't leave at all. What started out as an inconvenience turned into a nightmare. Like a creature in a horror movie, fear expanded until it covered the entire screen of your life.

To the outside observer, a person with agoraphobia may look no different from one with a social phobia. Both may stay home from a party. But their reasons for doing so are different. While the social phobic is afraid of the scrutiny of other people, many investigators believe that the agoraphobic is afraid of his or her own internal cues. The agoraphobic is afraid of feeling the dreadful anxiety of a panic attack, afraid of losing control in a crowd. Minor physical sensations may be interpreted as the prelude to some catastrophic threat to life.

Agoraphobics may abuse alcohol in an effort to keep the anticipatory anxiety in check. Their pattern of abuse appears to be different from the binging characteristics of alcoholism, however. The agoraphobic usually takes small amounts of alcohol, avoiding loss of control. Other drugs may also be abused.

Agoraphobia typically begins during the late teens or twenties. The best surveys done to date show that between 2.7 percent and 5.8 percent of the U.S. adult population suffer from agoraphobia. Women are affected two to four times more often than men. The condition tends to run in families.

Recent surveys have found that many people are afraid to leave their homes. Most likely, they are not all suffering from agoraphobia. Some people may stay confined because of depression, fear of street crime, or other reasons. These surveys also show, however, that many agoraphobics may have never suffered a panic attack. This finding suggests that their agoraphobia may have developed in ways different from that outlined above.

Panic and agoraphobia have received a great deal of attention from clinical investigators in recent years. Some believe that panic attacks are a severe expression of general anxiety, while others think that they constitute a biologically distinct disorder, possibly related to depression, possibly indistinguishable from agoraphobia. This controversy will probably be resolved through more research in the coming years.

THE MASQUERADE: PHOBIAS AND OTHER CONDITIONS

Given the dramatic symptoms of phobic and panic disorder, it is surprising that they are sometimes difficult to recognize, even for medical professionals. Some patients, especially those with simple phobias, are able to conceal the severity of their handicap. Agoraphobia is often not detected because its physical symptoms become the center of concern for both patient and doctor. Health problems, such as peptic ulcer, high blood pressure, skin rashes, tics, tooth grinding, hemorrhoids, headaches, muscle aches, and heart disease, often occur together with anxiety disorders.

Phobias may cover up other problems. School phobia, a complex condition in which a youngster refuses to attend school, is one example; often the underlying problem is the child's anxiety over separating from his parents. (A mental health professional can easily distinguish between school phobia and other causes of missing school.)

Just as panic and phobias can masquerade as other illness, some physical diseases may be mistaken for anxiety disorders. For example, people can become anxious as the result of such medical conditions as head injury, withdrawal from alcohol and drugs, and even pneumonia. In these cases, the panicky feelings usually disappear when the condition clears up. Phobic behavior also occurs in conditions that are not diagnosed as phobias, such as the phobic-like avoidance of sexual contact in a person whose principal problem is sexual.

Reactive hypoglycemia - a rapid decline in blood sugar followed by compensatory changes in adrenalin and other hormones - can produce many symptoms of panic, such as sweating, heart palpitations, and tremor. Most likely, this medical condition mimics panic disorder.

More puzzling is the relationship between panic attacks and agoraphobia, on the one hand, and depression, on the other. About half of people subject to phobias and panic are demoralized or depressed more often than the average person. Many agoraphobic patients develop their symptoms shortly after suffering a loss (which can trigger depression), and some either have histories of depressive episodes themselves or have relatives who do.

Whether phobias cause depression or depression causes phobias is unknown. Panic and anxiety can wear down a person until he or she feels demoralized. Alternatively, phobia and panic might result from depression and its symptoms - difficulties with sleep, appetite, and concentration, fatigue, lack of pleasure, and feelings of worthlessness.

Yet another possibility is the simple coexistence of anxiety and depression, neither causing the other. Some underlying biological process - an inherited vulnerability, perhaps - may be common to both anxiety and depression.

CAUSES OF PHOBIA AND PANIC

Phobias and panic, like all anxiety disorders, disturb many areas of a person's functioning. Take the woman who has agoraphobia. Her BEHAVIOR changes when she has to quit her job because she believes she is unable to ride the bus. Her THINKING goes awry when she judges the risk she faces. The memory of past FEELINGS of panic on the bus, when she was sure she would die, produces alterations in her PHYSIOLOGY as her heart pounds, her head gets dizzy, and her hands sweat. Her behavior, thinking, emotions, and her body's physiological responses are all involved in her agoraphobia.

Evidence of these effects has guided research investigators who have tried to understand the causes of anxiety disorders. They have formed their theories by observing patients, listening carefully to what they say, and measuring their functioning in the laboratory. Scientists then go beyond these observations to test theories, either in the clinic or in scientific experiments. These experiments show that other aspects of anxiety and related disorders are not as clearly evident. Some of the most influential or promising theories and bodies of research are described below.

PSYCHODYNAMIC THEORIES

One possible cause of anxiety that is difficult for a nonspecialist to observe is psychological conflict arising from emotions and impulses that remain unconscious (outside of the person's awareness). Much of the theory proposed by Sigmund Freud early in this century assumes that such unconscious forces, mostly deriving from childhood, profoundly influence adult life, including abnormal anxious states. These influences, for the most part, are inferred from the memories and associations of patients who undergo intensive, prolonged therapy. Until the last two or three decades, Freud and the psychoanalytic investigators who revised his theories were the dominant force in explaining and treating anxiety-related conditions. Although now out of fashion in academic settings, the ideas of the psychoanalytic school have influenced thinking throughout society, especially in clinics where people are treated for mental health problems.

In the view of psychoanalysts, anxiety is a signal of danger - a danger that is not real and present, but rather, is carried over from the memories and imaginations of childhood. Often, these dangers involve fantasies of loss or love (or actual separation from loved ones) or other fantasies that express guilt or sexually related events. When these fantasies are activated in adulthood - perhaps because something happens that the patient associates with the fantasies - they give rise to anxiety. The anxiety may be conscious or unconscious. In either case, it makes the person act defensively - that is, attempting to get away from the threat or, more often, to stop the fantasy from ever occurring by regulating or inhibiting the wishes that give rise to fantasies of danger. Because this defensive behavior relieves the anxiety, it tends to be repeated: It is, in other words, learned.

Modern psychodynamic research (that which focuses on mental conflicts) has put a great deal of emphasis on the anxiety that accompanies real or feared separation from a caretaker during childhood. Individuals who, as children, became extremely anxious whenever they were separated from their parents seem to be especially likely to develop agoraphobia later in life. Some 42 percent of agoraphobic patients report a history of childhood separation anxiety. This statistic suggests that agoraphobia may build on a foundation already present in early life or represent the aftermath of unresolved childhood separation anxiety.

In contemporary psychodramic models, the person with agoraphobia avoids situations that symbolize or threaten separation from a loved one. This view explains why a death or other kind of loss may trigger agoraphobia. It also may explain why some agoraphobics can venture out when accompanied by a spouse, child, or friend.

LEARNING THEORIES

Psychoanalytic theory from Freud to the present day has given some role to learning as a necessity for the development of abnormal anxiety states. Another school of thought puts learning squarely at the center in its theory of anxiety. In the simplest learning model, an individual may learn fear through direct experience (e.g., being bitten by a snake) or indirectly by witnessing injury to someone else, by observing fear reactions of others, or by being warned of an object's dangers. More likely, however, the reaction is the result of an association between an unpleasant, fearful response and the chance presence of the object that later is viewed as threatening. As early as 1920, one experimental psychologist showed that a young boy could be trained to fear a harmless white rat if frightened by a loud noise every time the rat was nearby. Because the adult with a phobia seldom remembers such an event, the fear seems unreasonable.

Knowledge about learning also sheds light on the possible way in which agoraphobia develops. As with simple phobias, the person who first experiences panic attacks in the presence of a certain set of circumstances - alone in a crowd, for example - may learn to associate awful sensations of panic with all crowds. Repeating the experience, or anticipating it, may reproduce the feeling of threat. Avoiding crowds reduces the discomfort. Because the avoidance behavior is rewarded, the person is more likely to avoid crowds in the future. Avoidance also reduces the opportunity for the person to test whether crowds actually do cause panic. By foregoing this kind of potentially corrective experience, the person further strengthens the phobia.

BIOLOGICAL THEORIES

Observers studying anxiety, including Freud, have long predicted that the brain and the central nervous system would be found to be functioning abnormally in patients with serious anxiety disorders. Their predictions remained speculations, however, because they were limited by the methods and knowledge of their times. All that has changed. Because of recent technological advances, much of the research now being done on anxiety and related disorders focuses on the brain. Biological research workers also attempt to understand anxiety disorders by experimentally producing anxiety in human beings and other animals. Others look for physical symptoms that often accompany phobias or panic to see if they may play a role in causing the disorders.

THE BRAIN AND CENTRAL NERVOUS SYSTEM

In light of what scientists would like to know about the role of the brain in anxiety disorders, this work has just begun. Research on neurotransmitters, the chemicals that carry messages from one nerve cell to another, has not found serious malfunctions associated with anxiety. But indirect measures suggest some abnormalities, particularly in the neurotransmitters norepinephrine, GABA, serotonin, and possibly adenosine.

Scientists are, however, still far from being able to say whether faulty brain function reflects the Cause of anxiety disorders - some genetic fault coded into the person's hereditary apparatus, for example. Experts disagree about the meaning of some research findings. Much of the work, for example, has focused on the brain's processing of drugs that reduce anxiety. Such work suggests, but does not prove, how the brain functions during episodes of severe anxiety. Another problem so far has been that most research necessarily is confined to animals; whether the results apply to human beings is not certain. Pieces of the neuroscientific puzzle have been found, and they are beginning to fall into place.

EXPERIMENTAL "ANXIETY

Investigators have identified several substances over the past few years that can actually produce panic attacks in people who have already experienced them (but not in people who haven't). This line of evidence suggests that patients who are subject to panic attacks may be biologically different from other people. It also offers clues to just what those differences might be. The ability to induce panic attacks gives research investigators a powerful tool for understanding them.

The most thoroughly studied of these anxiety-producing chemicals is sodium lactate. The use of this substance to induce panic attacks is based on the observation that some people who suffer extreme episodes of anxiety produce an excessive amount of the chemical lactate after routine exercise. For these people, exercise can actually set off a panic attack. Researchers have found that sodium lactate triggers panic attacks in a full 80 percent of patients with panic disorder, but in less than 20 percent of normal people. Lactate infusions may provide a means of suggesting which patients are biologically prone to panic attacks and thus apt to respond to drug treatments. It is unlikely, however, that lactate infusions will ever be a sure test.

Although less intensively studied, caffeine is another substance that can produce panic attacks in susceptible persons. Caffeine, of course, is common in coffee, tea, cola, and other soft drinks, and many other foods such as chocolate. About half of panic disorder patients have panic experiences after consuming caffeine equivalent to four or five cups of coffee. (Normal people also experience panic, but only after they ingest much higher amounts of caffeine.) Caffeine is thought to produce its effects by blocking the action of a brain chemical known as adenosine, a naturally occurring sedative. Clinical investigators have found that many people with panic attacks avoid caffeine after noticing that it causes attacks.

A SAMPLING OF OTHER BIOLOGICAL STUDIES

Other types of biological research are also under way. One of the oldest experimental approaches tests physiological responses - for example, heart rate, blood pressure, sweating, or characteristics in the skin. Another type of research examines the role of hormones. But none of these studies has as yet been integrated with what is being learned from studies of the neurotransmitter systems in the brain.

Several studies have shown that patients suffering from agoraphobia and panic disorder have different physiological reactions to fear-producing stress than the average person has. Differences of this type may be present from birth and may explain why some individuals are more susceptible than are others to anxiety disorders.

Several years ago, a number of investigators reported that some agoraphobic patients have a mild heart condition known as mitral valve prolapse or MVP. Like agoraphobia itself, the condition tends to run in families. MVP can give rise to heart palpitations, which some experts believe might trigger panic attacks. It is also possible, however, that chronic anxiety and panic attacks may produce MVP or that both panic attacks and MVP may be symptoms of an underlying nervous system disorder. Finally, it still remains unclear whether there is any difference in the frequency of mitral valve prolapse in panic patients when compared to the general population.

Malfunctions in the thyroid gland have been reported in about one in ten patients who are prone to panic attacks. The relationship between these conditions, which can also cause heart palpitations, and panic is still in the early stages of investigation.

Because breathing difficulty is a hallmark of panic attacks, research scientists have recently become interested in hyperventilation, a condition marked by rapid breathing. The symptoms are similar to those experienced sometimes when blowing up a balloon: dizziness, inability to pay attention or concentrate, and tingling sensations around the mouth and fingers.

ANXIETY AS HERITAGE

The role of history - as recorded in our genes, passed on through our cultures, or learned in our families - is also under study. Barely under way are attempts to learn the relative contributions of nature and nurture to the development of phobias and panic disorder. Some investigators are studying families, because phobias and panic are more common in the relatives of patients than in the general population. Whether this tendency is inherited - passed on genetically - or learned by growing up or simply living close to other anxious people is not known, although some evidence suggests that the link is at least partly genetic.

Clues to what causes anxiety disorders also come from naturalistic observations of animals and human societies very unlike our own. Something like a phobia seems to occur in many animals. Some dogs who have never been touched by anything but a loving hand will cower and slink away at the sight of a broom. Their fear, as well as the common human fear of snakes, may hark back to some earlier stage in evolutionary development. In human societies, cultural differences seem to produce surprising variations in anxiety disorders - the age at which they begin, the course they follow, the symptoms, the distribution among different social groups, the source of anxiety, the experience of the emotion, and the consequences in the life of the sufferer.

Some fears are shared across cultures, suggesting that they enhanced the chances of surviving in the evolutionary history of the human race. Most phobias are directed toward a relatively small number of objects and situations, though there is no reason to believe that these items cause unpleasant experiences more frequently than many others. Phobic fear of truly dangerous electrical outlets, for example, is rare, while fear of seldom-encountered snakes and harmless insects is common. People in our culture are more likely to receive a shock from an outlet than a bite from a snake or one of these insects.

Scientists have sought to explain this paradox by speculating that humans may have an inborn predisposition to fear certain things. This so-called preparedness theory is consistent with the fact that most common phobias (darkness, animals, etc.) involve objects and situations that date from primitive times and were, in the distant past, serious sources of danger.

THE RESEARCH IN SUM

Despite all the research being done on the anxiety disorders - an activity that has accelerated in the last few years - none of the theories that are tested in the various types of studies is adequate to explain what causes phobias and panic. The explanation is probably not far off, however. As they are now propounded, theories about the causes of different types of anxiety disorders tend to cluster either around psychological and social factors or around biological factors. Simple phobias are usually explained in terms of early experience and learning, while agoraphobia and panic (and sometimes social phobia) are becoming increasingly understood as at least partially biological in origin. Most likely, all phobias and panic result from a mixture of influences, although that mixture probably changes with the type of phobia and individual differences among patients. Many theories reflect an implicit assumption that the more serious disorders, such as panic attacks and agoraphobia, are more likely to have a biological basis than the troubling, but less disabling, simple phobias.

TREATMENT

Even though the causes of phobia and panic are not well understood, treatments for these disorders are often very effective. Therapists use a variety of techniques, their choice usually linked to their beliefs about the cause of the disorder. But, upon examination, it turns out that many of these techniques share a common feature: They all seem to require that patients* confront the source of their discomfort. Some therapists ask their patients to confront a feared situation in imagination, while others require a real-life confrontation. Some therapists define the source of fear as the external object or situation the patient identifies as fearful, while others find a deeper source within the patient - in the unconscious, in thoughts, or in physical sensations. Still another difference is that one therapist might set up an explicit program for confronting feared objects and situations, while another might use drugs or psychotherapy to prepare the patient to confront fearful situations in everyday life.

*The term "patient," usually heard in medical settings, will be used here interchangeably with the term "client," more typically used by psychologists and social workers.

PSYCHOTHERAPY

For the first two-thirds of this century, phobias, like other emotional disorders, were treated almost exclusively by psychoanalysis or related forms of psychotherapy. In psychoanalysis, unconscious conflict is seen as the source of anxiety. The goal of therapy is to bring that conflict to light, analyze what it means to the patient, and substitute present-day realistic appraisals for fearful ones that are based on the limited understandings of childhood. Psychoanalytic techniques include free association (encouraging the patient to say whatever comes into his mind), analysis of dreams, and analysis of the relationship between the patient and the therapist. Other forms of psychotherapy are usually more directive in their techniques: Instead of waiting for the patient's memories and feelings to emerge and drawing inferences from these patterns of association, some therapists actively try to provoke or suggest sources of conflict and direct their patients through "homework" assignments.

Unfortunately, psychoanalysis and related forms of psychotherapy prove disappointing in the treatment of phobias. Patients usually find the therapy helpful in resolving conflict, decreasing general anxiety, and identifying and modifying feelings and thoughts associated with panic attacks and phobic avoidance. But the phobic symptoms themselves often remain. Freud himself acknowledged the limitations of pure psychoanalysis in treating phobias (and anticipated the development of behavioral techniques), saying: "One can hardly ever master a phobia if one waits 'til the patient lets the analysis influence him to give it up...One succeeds only when one can induce them through the influence of the analysis to go about alone and to struggle with their anxiety while they make the attempt."

Just such an approach has been found to be effective in helping phobic patients stop avoiding the thing they fear (see section on exposure therapy below). Many therapists find that such improvements are more lasting if patients undergo psychotherapy as well, either individually or in groups. By monitoring situations that seem to give rise to the panic attacks, for example, an agoraphobic can identify thoughts and feelings that are troublesome. The therapist can then help the patient to work out a course of action that might realistically change the source of distress and to give up the habitual style of avoiding it by retreat into phobic behavior. Therapists can also help the patient to become more assertive when involved in conflict with other people and train him in skills needed for other social situations. The support of a caring therapist may be crucial for long-term success of any treatment technique.

EARLY BEHAVIORAL TECHNIQUES

A landmark event in the development of treatment for phobias occurred with the publication of a book in 1958. In the book, Joseph Wolpe, a learning theorist, reported excellent results from treating adult phobic patients with a procedure called "systematic desensitization," which he had adapted from a technique developed in the 1920's for helping children overcome animal phobias. Systematic desensitization requires the client to learn formal, deep-muscle relaxation. It is up to the client also to rank situations related to the phobia that cause anxiety. An individual who fears snakes, for example, might place "holding a snake" at the top of the list of things that make him anxious and "viewing a caged snake from across the room" at the bottom of the list.

The client is then asked to imagine, in as much detail as possible, the least fear-provoking scene from his list. At the same time he is asked to relax as previously taught. By remaining comfortable while imagining the feared situation, the client may weaken the association between the situation and feelings of anxiety. Once the client has become comfortable imagining the least threatening situation, he moves up the list and masters each in turn.

Proponents of this method have claimed that facing a feared situation in imagination is as effective as confronting it in reality. But most therapists have found that there is a gap between fantasy and reality. In other words, once the client has completed desensitization treatment and undertakes to face the real object or situation, he is likely to have to move part of the way back down his list. For example, while holding an imaginary snake, he may at first be able to touch, but not to hold, a real snake. By practicing further in the real situation, however, he may eventually be able to fully master his fear.

Systematic desensitization was the first form of behavior therapy used to treat phobias. The late 1960's witnessed development of another, named "implosion," which soon came to be widely used in a modified form termed "imaginal flooding."

Flooding, like desensitization, involves the client's experiencing fear-provoking situations in his imagination. In other ways, flooding and desensitization are quite different. In flooding, the therapist, rather than the client, controls the timing and content of the scenes to be imagined. He describes the scenes with great vividness, in a deliberate effort to make them as disturbing as possible. Also, the client is not instructed to relax; rather, the aim is for him to experience his fears and anxieties with maximum intensity, in the hope that by surviving "the worst," he can loosen the phobia's grip on him. The prolonged experience with these feared images is thought to help the client get used to them, so that they gradually lose their power to cause anxiety.

In the early days of implosive therapy and flooding, therapists included scenes referring to guessed-at unconscious conflicts believed to underlie the patient's phobias. But studies showed that not only were the horrifying scenes of implosion very disturbing to patients (sometimes causing nightmares), but also they did not make treatment any more effective than flooding alone. Thus, implosive techniques are no longer used.

A number of researchers have compared desensitization and flooding. They have found that the two forms of treatment are about equally effective: Both reduce phobic anxiety and behavior in people with simple phobias, but desensitization is not as effective as flooding for agoraphobia. Although not well studied, neither method appears to be very effective for social phobics.

EXPOSURE THERAPY

When behavior therapists observed that the exposure to the feared situation was the common ingredient in desensitization and flooding, they began to develop other techniques they hoped would be even more effective. While earlier methods were aimed at reducing anxiety so that clients could change their behavior (e.g. enter feared situations), the new techniques focused instead on altering behavior. Once behavior changed, the reasoning went, anxiety would diminish.

The underlying assumption is that phobic anxiety is maintained - it continues and may get more intense - when the person repeatedly avoids the object or situation that elicits the anxiety. Avoidance prevents him from "unlearning" the association between an object or situation and anxiety. Exposure to such situations, by contrast, gradually habituates the person to it - that is, he learns that no real danger is present. Gradually, the anxiety is extinguished. Some therapists believe that the more rapidly such exposure takes place, the more rapidly the phobia will be eliminated.

In treatment, the therapist explains this rationale to the client, outlines the procedure that will be followed, and helps him anticipate what his reactions are likely to be. The therapist assures the client that he will always be available to help the client cope with the sense of danger, and will be ready to stop the procedure at any time the client seems unable to tolerate the danger.

The client is then exposed to the object or situation he fears. Techniques differ on how gradually the person is made to encounter fearful objects and how long the exposure continues. In general, clients are asked to stay in the situation until their anxiety begins to diminish. With each session, they tolerate closer and longer confrontations with the threatening object or circumstance.

Such in vivo (in life) exposure has replaced methods that rely upon imagined danger. It is considered the treatment of choice for simple phobias. Most investigators also believe that it is the best available treatment for agoraphobia when accompanied by drug treatment (see below). Some therapists use exposure in imagination as a means of helping their clients confront feared situations in real life. There is some evidence that the effects of treatment may be more long-lasting when imagination-based exposure is used along with in vivo exposure, although not everyone needs both. Programs using in vivo exposure techniques have become the mainstay in the treatment of simple phobias and agoraphobia. Exposure does not seem to be as effective in treating social phobias, unless it is accompanied by training in specific social skills.

COGNITIVE THERAPIES

Several recently developed techniques that try to change the phobic's thought patterns may be used along with exposure. Most of these techniques have grown out of behavioral therapists' attempts to account for and change the persistent habits of thought that seem to bind people to their fears. One form of cognitive-behavioral treatment - "self-statement training" - teaches clients to become aware of such negative thought statements as, "I'll faint if I touch that," or "I can't do it," and to replace them with positive coping statements like, "Of course, I can do it." Once the client has become familiar with this approach, he can use it to help himself progress through a behavioral treatment program.

Taking a completely different tack, therapists using "paradoxical intention" encourage clients to try to feel as anxious and panicky as possible. Clients are urged to exaggerate their symptoms, often with a note of humor injected. For example, a woman who is afraid she may faint or fall down might be instructed to "faint" on purpose and to warn those around her: "Stay out of my way. When I fall, I fall hard. I bet I'm the best fainter you've ever seen." Frequently, taking charge of symptoms in this way diminishes their force. In fact, a client who is "trying" to faint, sweat, or tremble may find himself unable to do so.

DRUG THERAPY

Over the years, many drugs have been tried by phobic patients. Barbituates provided little benefit. The newer class of drugs used to treat generalized anxiety, the benzodiazepines (such as Valium or Librium), do lessen the anticipatory anxiety that accompanies phobias, but do not generally block panic attacks. The exception is alprazolam, a modified benzodiazepine, which appears to be effective in moderate to high doses, although dependency is often an unavoidable side effect when the drug is taken for long periods of time.

Beginning in the early 1960s, however, it was discovered that certain antidepressants could prevent the unpredictable panic attacks characteristic of agoraphobia. The assumption is that once panic attacks no longer threaten the patient, the anxiety that accompanies anticipation of future panic attacks and the avoidance of future panic attacks and the avoidance of behavior will also diminish. The two types of drugs that have been most extensively tested and shown to be effective are the MAO inhibitors (for example, phenelzine) and tricyclic antidepressants (for example, imipramine). Although usually used to relieve depression, these drugs also produce antianxiety actions that are independent of their antidepressant effects. Anticipatory anxiety sometimes diminishes once panic attacks have stopped. Some patients respond at low dosages, but most appear to require amounts equal to that needed to reduce depression.

MAO inhibitors and tricyclic antidepressants do produce some unwanted side effects. Most of these side effects, such as drowsiness, gradually subside after the drug is taken for several weeks. MAO inhibitors require special caution, however. Patients taking these drugs must restrict their intake of certain foods, such as aged cheese, red wine, and other medications. Reactions between these substances and the MAO inhibitors can produce high blood pressure, severe headaches, and other side effects that in rare cases can be life-threatening. Despite these possible complications, the MAO inhibitors, when used judiciously, can produce remarkable improvements in patients subject to panic attacks.

Drug therapy for panic attacks is generally given for periods of 6 months to 1 year. Many patients can then manage well without drugs, although relapses requiring resumption of medication are common. The relative duration of success of various therapies is still a matter of controversy.

As noted, most antianxiety drugs are not thought to be effective in stopping panic attacks, although recent research suggests that in very high amounts they may be. The common tranquilizers, such as Valium and Librium, are sometimes also used to treat the generalized anxiety that accompanies phobias.

As noted earlier, a relatively new drug, alprazolam (Xanax), a type of benzodiazepine, has been found to block panic attacks quite dramatically within days after patients start taking it. This rapid response, along with many other positive features, may make alprazolam a useful drug for treating panic, although this use has not yet been approved by the U.S. Food and Drug Administration. Alprazolam has the disadvantage, however, of producing physical dependence and drowsiness in some patients. Seizures have also been reported when the drug is abruptly discontinued.

Another class of drugs, beta adrenergic blockers, has been found useful in treating some phobias, especially specific types of social phobias, such as public speaking phobia. These drugs, usually used to treat high blood pressure, may be used in patients who do not respond to other forms of treatment. There is some suggestion that they may be especially appropriate for patients who have such physical symptoms as trembling and heart palpitations. MAO inhibitors have also been demonstrated to be effective in the treatment of social phobias.

NUTRITION

Solutions to the problem of phobias have also been sought in the realm of nutrition. Certainly, severely malnourished individuals are less able than others to cope with stress. And, patients who are subject to panic attacks have been found to be unusually sensitive to caffeine and may wish to gradually eliminate it from their diets. Otherwise, there is no reliable evidence that any special diet is likely to benefit most phobic patients.

PHOBIA TREATMENT PROGRAMS

Phobia treatment programs now exist in many parts of the United States. These programs use a variety of behavioral therapy techniques to help clients confront and overcome their fears. In addition, through these programs drugs may be recommended and prescribed for individuals likely to benefit from them.

In a typical program, phobic individuals work together in groups with a trained group leader. In some programs, family members and friends are also invited to attend the weekly meetings. Group sessions are used to teach attitudes and skills that are helpful in overcoming phobias. The client also has weekly practice sessions, either alone or in a group, with a therapist who is a mental health professional or a recovered phobic. During these sessions, the client uses his new coping skills in situations he would previously have avoided. With the therapist at his side, he gradually takes progressively more difficult steps toward his final goal. Setbacks are expected and viewed as opportunities for further practice and gain. Agoraphobic clients who are housebound sometimes begin their treatment in their own homes.

Although organized phobia treatment programs offer many advantages, they do not exist in all areas. Many individual therapists are experienced at working with phobic patients, and some will accompany their patients in fear-producing situations.

Referrals to treatment programs and therapists can be obtained by calling or writing to the local, regional, or State chapters of the American Psychological Association, the American Psychiatric Association, the National Association of Social Workers, the American Nurses Association, the National Mental Health Association, the American Association for Counseling and Development, and the Phobia Society of America. In addition, several books and tape cassettes offer self-treatment programs. Since the effectiveness of these programs has not been evaluated, referral to them in this pamphlet does not imply an endorsement by the National Institute of Mental Health.

A word of caution: Not every form of treatment is appropriate for every patient or client. Nor does every therapist or phobia program offer all forms of treatment - psychotherapy, behavior therapy, and medications. Often, a combination of these treatments is necessary. If you feel that you are not being helped by one clinic, program, or therapist, you may wish to seek help elsewhere.

OUTCOMES AND OUTLOOK

The outlook for people with phobias has improved greatly in the last two decades. People with simple phobias can often be relieved of their fears in a matter of weeks. People subject to panic attacks can usually find relief with antidepressant medication. Through the use of these drugs and exposure treatment, people with agoraphobia can be helped to venture out and face the threatening situations they have been avoiding. People with social phobias can be taught social skills and helped somewhat with exposure therapy and medication. All can learn to understand their fears, and possibly solidify their progress, with the help of other therapies - group or individual psychotherapy or family therapy.

If you or someone you know has a phobia, don't bypass the chance for help. Because physical diseases sometimes mimic phobias, it is a good idea to consult a physician to make certain that symptoms don't mask a serious physical illness. Then find someone who is skilled in treating phobias. The odds are three to one that the treatment will succeed.

PHOBIAS

Technophobia - Fear of technology Sciophobia - Fear of shadows Decidophobia - Fear of making decisions Nyctophobia - Fear of night Electrophobia - Fear of electricity Topophobia - Fear of performing (Stage Fright) Tropophobia - Fear of moving or making changes Triskaidekaphobia - Fear of the number 13 Gephyrophobia - Fear of crossing bridges Ophidiophobia - Fear of snakes Gatophobia - Fear of cats Hydrophobia - Fear of water Batrachophobia - Fear of reptiles Pyrophobia - Fear of fire Astrapophobia - Fear of lightning Spermophobia - Fear of germs Pnigerophobia - Fear of smothering Cynophobia - Fear of dogs Aerophobia - Fear of flying Ochlophobia - Fear of crowds Blennophobia - Fear of slime Katagelophobia - Fear of ridicule Spheksophobia - Fear of wasps Thalassophobia - Fear of the ocean Kakorraphiaphobia - Fear of failure Gynophobia - Fear of women Agoraphobia - Fear of open spaces Claustrophobia - Fear of enclosed spaces Eremophobia - Fear of being alone Acrophobia - Fear of heights Musophobia - Fear of mice Apiphobia - Fear of bees Gamophobia - Fear of marriage Scholionophobia - Fear of school Odynephobia - Fear of pain Keraunophobia - Fear of thunder Amathophobia - Fear of dust

FOR FURTHER INFORMATION

Beck, A.T.; Emery, G.; and Greenberg, R.L. ANXIETY DISORDERS AND PHOBIAS - A COGNITIVE PERSPECTIVE, New York: Basic Books, 1985.

DuPont, R.L., ed. PHOBIA: A COMPREHENSIVE SUMMARY OF MODERN TREATMENTS, New York: Brunner/Mazel, 1982.

Ferber L. Phobias and their vicissitudes. JOURNAL OF THE AMERICAN PSYCHOANALYTIC ASSOCIATION 7:182, 1959.

Klein, D.F., and Rabkin, J.G., eds. ANXIETY: NEW RESEARCH AND CHANGING CONCEPTS. New York: Raven Press, 1981.

Marks, I.M. CURE AND CARE OF NEUROSES. New York: Wiley, 1981.

Mavissakalian, M., and Barlow, D.H., eds. PHOBIA: PSYCHOLOGICAL AND PHARMACOLOGICAL TREATMENT. New York: The Guilford Press, 1981.

Sheehan, D.V. THE ANXIETY DISEASE. New York: Charles Scribner's Sons, 1983.

Tuma, A.H., and Maser, J., eds. ANXIETY AND THE ANXIETY DISORDERS. Hillsdale, N.J.: Erlbaum, 1985.

Uhde, T.W., and Nemiah, J.C. Panic and generalized anxiety disorders. IN COMPREHENSIVE TEXTBOOK OF PSYCHIATRY, 5th ed. eds. H.I. Kaplan and B.J. Sadock, Baltimore: Williams and Wilkins 1988.

Van Praag, H.M., ed. RESEARCH IN NEUROSIS. New York: SP Medical and Scientific Books, 1978.

Weiss, E., ed. AGORAPHOBIA IN THE LIGHT OF EGO PSYCHOLOGY. New York: Grune and Stratton, 1964.

Zitrin, C.M.; Klein, D.F.; Woerner, M.G.; and Ross, D.C. Treatment of Phobias. I. Comparison of imipramine hydrochloride and placebo. ARCHIVES OF GENERAL PSYCHIATRY, 40:125, 1983.

This booklet was written by Bette Runck, science writer in the Science Communication Branch. Office of Scientific Information, National Institute of Mental Health (NIMH). An earlier version was done on contract for NIMH by Washington, D.C. science writer Elaine Blume. Drafts were reviewed, sometimes repeatedly, by many experts on phobia. The assistance of the following is gratefully acknowledged: Jack D. Maser, Ph.D., Barry Wolfe, Ph.D., Jack Blaine, M.D., Robert Prien, Ph.D., Barbara Scupi, M.S., Thomas W. Uhde, M.D., Robert M. Post, M.D., Jack D. Burke Jr., M.D., and Jeffrey H. Boyd, M.D., all NIMH staff members; Donald F. Klein, M.D., and Michael R. Liebowitz, M.D., New York State Psychiatric Institute, New York City; Robert Michels, M.D., AND Katherine Shear, M.D., the New York Hospital-Cornell University Medical Center, New York City; Peter A. Di Nardo, Ph.D., State University of New York, Oneonta, N.Y.; Michael J. Kozak, Ph.D., Temple University School of Medicine, Philadelphia; and Bruce N. Cuthbert, Ph.D., Temple University School of Medicine, Philadelphia; and Bruce N. Cuthbert, Ph.D., University of Florida, Gainesville. Editorial assistance was provided by NIMH staff members Anne Cooley, Marilyn Sargent, Myrle Kahn, and Sherry Prestwich.

Department of Health & Human Services Public Health Service Alcohol, Drug Abuse, and Mental Health Administration Rockville, MD 20857

DHHS Publication No. (ADM) 88-1472 Printed 1986 Reprinted 1988

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