Phobias
WHAT IS A PHOBIA?
Elevated heart rate , elevated blood pressure, palpitations, sweating,
dizziness and so forth, everyone at least once in life experiences these
symptoms of fear; but when all this leads the subject to a distress, to
a deep discomfort, then we are referring to a form of phobia.
The word phobia is Greek, “phobos” ,it means panic, terror,
escape and it is also derived from the name of the Deus Phobos, who inspired
terror to the enemies, so warriors had his image on their weapons.
A phobia is considered an intense, unreasonable fear of a thing or a situation
that is far out of proportion to the actual ranger or harm that is possible.
It produces a conscious avoidance of the feared subject and the affected
person usually recognizes that the reaction is excessive.
A phobia is characterized by some elements:
• It is disproportionate to the stimulus: people involved feels
a deep discomfort, while others would react with less anxiety. For example
most people who fear heights would not avoid visiting a friend who lives
on the top floor of a tall building, a person with a phobia, would.
• It can’t be controlled: people involved have an anxious
reaction even if they only think of being in the situation they fear.
The phobic is not able to avoid the heart racing, the increasing breathing,
the elevated blood pressure, skin sweating and so on.
• Phobia forces the person to avoid the feared situation: it can
interfere with one’s everyday life or daily routine(school, work,
social relationships, exc.) because the need to avoid the object of the
phobia limits what a person feels comfortable doing. For example if you
fear high places, this prevents you from crossing necessary bridges to
get to some places, even to work.
HOW DOES A PHOBIA APPEAR?
Some people may be more likely to develop phobias than others. Genetic
factors play an important role: certain biological traits passed down
in families, they may affect the brain’s chemical regulation of
mood and can affect how sensitive someone is or how strongly they react
to fear cues. Another way to develop a phobia is the direct contact with
the object or the situation; this first encounter can produce a severe
anxiety so that the person becomes afraid of anything that might bring
him into contact with the object.
On the other hand a phobia can develop without a direct contact with the
phobic stimulus and without the involvement of the person, in this case
it is sufficient to be present to a traumatic accident involving other
persons, for example to assist to a car accident or to a dog attack(modeling).
Researches suggest that almost half of all people with a phobia have never
had a painful experience with the object they fear. Perhaps
we hear that someone has been injured by a snake, for example, and we
become afraid too. Another possible explanation is that people generally
develop phobias for objects they cannot predict or control. Danger is
more stressful when it takes us by surprise. Lightning is unpredictable
and uncontrollable. In contrast, you don't have to worry that electric
outlets will take you by surprise, so it's not likely that you'll have
an "electric outlet phobia."
CLASSIFICATION OF PHOBIAS
Phobic disorders can be divided into 3 types: specific phobias, social
phobia, and agoraphobia. The American Psychiatric Association's Diagnostic
and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) defines
specific phobia as a strong, persisting fear of an object or situation,
whereas social phobia is a strong, persisting fear of an interpersonal
situation in which embarrassment can occur. Agoraphobia is defined as
the fear of being alone in public places (e.g., a supermarket), particularly
places from which a rapid exit would be difficult in the course of a panic
attack. At least 75% of patients with agoraphobia experience panic disorder
as well. Specific phobia is more common than social phobia. Examples of
specific phobia include animal type, natural environment type (e.g., height,
water, storm), blood injection/injury type, situational type (e.g., planes,
elevators, enclosed spaces), and other types.
• Social phobia can be initiated by traumatic social experience
(e.g., embarrassment) or by social skills deficits that produce recurring
negative experiences. Current thought is that social phobia appears to
be an interaction between biological and genetic factors and environmental
events.
• Specific phobia can be acquired by conditioning, modelling, traumatic
experience, or even may have a genetic component (e.g., blood-injury phobia).
• Agoraphobia may be the result of repeated, unexpected panic attacks.
• Specific phobia has a female-to-male ratio of 2:1.
• Social phobia is more common in women, but more men seek treatment
due to career issues.
• Agoraphobia has a female-to-male ratio of 2-3:1.
Most anxiety disorders appear earlier in life. Animal phobias are most
common at the elementary school level. Other phobias appear later on.
Agoraphobia and social phobia tend to reach a peak prevalence in later
adolescence or early adulthood. Death is uncommon. Suicide can occur in
cases of severe agoraphobia, especially in those associated with panic
disorder. Significant morbidity is possible in terms of work and relationships,
especially in social phobia and agoraphobia
• Specific phobia: Age of onset depends on the phobia. In general,
specific phobia appears earlier than social phobia or agoraphobia. Examples
include the following: Animal phobia appears at a mean age of 7 years.
Blood phobia appears at a mean age of 9 years. Dental phobia appears at
a mean age of 12 years. Claustrophobia appears at a mean age of 20 years.
• Social phobia: Most social phobias begin before age 20 years.
• Agoraphobia: Agoraphobia usually begins in late adolescence to
early adulthood.
Overwhelming exposure in early childhood (e.g., a frightening experience
with an aggressive dog) may predispose the child to the development of
phobic symptoms. Intervention (psychotherapy or medication) in the early
stages of symptom development may be beneficial in preventing worsening
of symptoms. Left untreated, social phobia or agoraphobia can result in
tremendous morbidity. The patient becomes restricted to the most familiar
surroundings (e.g., house) or most trusted people (e.g., family member,
spouse). Therefore, the ability to work and relate to other people is
significantly impaired. Significant risk of substance abuse exists with
this degree of isolation.
There may be other reasons why some phobias are more common than others. One is that we have many safe experiences with cars and tools to outweigh any bad experiences. We have few safe experiences with snakes or spiders or with falling from high places. Cross-cultural psychologists point out that phobias are influenced by cultural factors. Agoraphobia, for example, is much more common in the United States and Europe than in other areas of the world. A social phobia common in Japan but almost nonexistent in the West is taijin kyofusho: in contrast to what happens in the social phobias (when the patient is afraid of being humiliated or loathed by other persons), taijin kyofusho is the fear of offending other persons by an excess of modesty or showing respect. The focus of cognition for a sufferer of this phobia is on the harm to others, not on embarrassment to the self as in social phobias in the West. Taijin kyofusho is described by Japanese psychiatrists as a pathological exaggeration of the modesty and sensitive regard for others that, at lower levels, is considered proper in Japan. The term taijin kyofusho literally means the disorder (sho) of fear (kyofu) of interpersonal relations (taijin),it is classified into four subtypes: sekimen-kyofu (the phobia of blushing), shubo-kyofu (the phobia of a deformed body), jikoshisen-kyofu (the phobia of eye-to-eye contact), and jikoshu-kyofu (the phobia of one’s own foul body odour) . Of these four subtypes, sekimen-kyofu can reasonably be included in the category of social phobia, since the fear of blushing is a common symptom. Fortunately effective relief can be gained through either behaviour therapy or medication.
THE SCHOOL PHOBIA
"I'm school-phobic"
Gemma, 14, tells her story
I've only been to school a few times this year. I'm phobic; terrified
of school - but I don't want to be. All I want is an education and to
have a laugh with my friends, but I can't. I just have to think about
school and I start shaking and crying - it's like I can't breathe. The
doctor says they're panic attacks. But I'm not a skive. I haven't always
hated school. "A term's homework in a week" It started last
September when I broke my rib. I was off school for nearly a month, and
still it wasn't better. I was really bored and getting more and more worried
about how far behind in my schoolwork I was. My mum called the school
to ask for some extra homework or home tuition for me, but they refused.
"We're not legally obliged to provide any," they said. But my
mum kept asking - after all, I'd missed a month's schoolwork. Then school
sent me a whole term's work to do in one week. "How am I going to
get it all done, mum?" I sobbed. She shrugged, "I don't know,
love." You know when you've got so much work that you don't know
where to start? This was like that, only 10 times worse. After six weeks
my rib had finally healed. But then I came down with flu, and the coughing
made my rib hurt even more. I knew I had to go back to school, but it
still hurt so much. Then, slowly, the fear of going to school because
of the pain turned into plain fear. Whenever I thought about it I'd have
another panic attack. I felt I'd missed out on most of my work. And I
felt my friends had left me behind. They'd just stopped calling me, and
when I called them they said they were busy. I suppose I can understand
it - I mean, I hadn't been around for over six weeks - but friends are
supposed to stick by you, aren't they? "Your mum will go to prison
if you don't go to school" Things started going more smoothly just
before the Christmas holidays. I'd started doing half-days to try and
get me used to going to school again - I even did three or four full days.
But then the Christmas holidays ruined it. I'd had two weeks off to dwell
on things, and I felt the school didn't understand me and my friends had
grown even more distant. Things were getting worse. Actually my tutor,
Mr Patrick, was really helpful. He fought for work to be sent home for
me and he understood right from the start how I felt, but it wasn't enough.
It was too late. I tried to do half days again, but the panic attacks
got worse. Eventually my doctor gave me a note saying I wasn't fit for
school. Still the school didn't help - it was like they didn't believe
that I was phobic. They sent me to an Education Welfare Officer, who told
me mum could go to prison if I didn't go to school. It wasn't mum's fault.
My family have been brilliant. My mum tried everything to get me to go
to school, but I just couldn't. Mum phoned and wrote letters to my head
teacher, but he ignored us. It was only when I had a panic attack in class
and had to be sent home that the school really began to take me seriously.
"A school for phobics" They told me about the phobic unit in
Swindon, which is a place where school-phobic kids can go to get an education
as well as therapy and counselling. I had a few meetings with them and
I've just been accepted there. They have a waiting list, but while I'm
waiting to get in they're going to give me home tuition. A couple of my
friends have also started calling me again after seeing my story in the
newspapers. I'm really pleased, and hopefully when I'm better I can go
back to school. A different school, that is. My current school really
could have tried helping me a bit more, because I had nothing. No help
or anything. I mean, all I want is an education.
About the school phobia The commonest ages of presentation are at five
and 11 (because of school transitions), and 14 -15 (because of accumulating
social and academic pressures).
• The child is reluctant to leave home and attend school. There
are often physical complaints, such as abdominal pain, headache, sore
throat, often with no signs of physical illness. The symptoms are typically
worse on weekday mornings and absent at weekends and holidays. Some children
complain of anxiety symptoms that include a racing heart, shaking; sweating,
difficulty breathing, butterflies in the tummy or nausea, pins and needles.
All symptoms are likely to be interpreted as signs of physical illness;
the clue is that they subside during school holidays or on Friday evenings,
or are present only in the morning. Attempts by the parents to insist
on attendance result in heightened distress, or temper outbursts.
• The child may express fears about the school environment (usually
bullying, social ostracism or difficulty with school work), or they may
be fearful about leaving the home because of worries such as family illness,
death or disability, or maternal depression with threats of self-harm.
Often, the child cannot voice these fears, and then they can only be guessed
at.
• There is often a history of separation difficulties on first starting
school.
• Background family factors include ineffectual organization and
discipline, often with an absent or uninvolved father, emotional over-involvement
with the child, with excessive anxiety about physical symptoms and difficulties
seeking or using help from teachers when school problems first emerge.
• There may be an underlying depressive disorder or generalized
anxiety. School refusal can be an expression of a particular fear or phobia
or a manifestation of generalized anxiety. Pointers to this can include
social withdrawal or avoidance. In depressive disorder, symptoms such
as loss of interest and enjoyment may pre-date the school attendance problem.
Some children with an anxiety disorder show no symptoms so long as they
are off school.
• The outcome is best in younger children and those who have been
out of school for a short time.
• A change of school is usually unhelpful because the problems tend
to recur in the new setting.
• Parents need to work together and agree a firm and consistent
approach to their child’s difficulties.
• It is crucially important for there to be good communication with
the school.
Another kind of phobia
"My house had a voodoo curse on it"
Indigo was 15 when frightening things started happening to her...
It started when I was 15. I’d wake up in the middle of the night
and have an awareness of something being in my room, even though I couldn’t
see anything. Sometimes I’d wake up and feel this weight on top
of me, but I couldn’t scream or move; it would be like my limbs
were stuck.
"I felt something stroke my skin"
It was terrifying, so I started sleeping with the light on. Then one night
I suddenly felt something sitting on the side of my bed. It stroked my
skin, but when I jumped up I was alone and there was nothing there, just
the sound of the dogs barking madly outside. And I thought, “They
always say animals can sense the presence of evil spirits”.
"I tried to scream but no sound came"
But the time that scared me the most was when I woke up one night feeling
a weight on me and I couldn’t breathe. My mind was awake and fighting
a battle with my body to make it move and take me to my parents’
bedroom. I tried to scream but no sound came, so I forced myself to roll
out of bed. I had this compulsion to leave the room and go to the kitchen
and fetch a knife for protection, which I did. I sat in the living room
for a few hours clutching the knife, afraid to go back to sleep.
"Something was behind my curtain"
When it first happened I never told anyone because I thought they were
just nightmares. But when I had the experience with the knife, followed
a few weeks later by something jumping out from behind a bedroom curtain
towards me, my dad started to wonder if there was more to my nightmares
that a child’s imagination.
"Had evil been sent as a curse?"
I come from a culture where people often accept the presence of good and
evil, ghosts and spirits, exorcisms and trances. Growing up I'd heard
stories about people being possessed by spirits, knew about the practice
of black magic like voodoo and witchcraft, or heard of houses where ‘evil
had been sent’ as a curse.
"He dug up voodoo charms"
Eventually my mum decided to call in a spiritualist. I was sceptical,
but the spiritualist said he could sense an evil presence. "Someone
has been practising evil in this house," he said. He marked a few
places where he felt that voodoo charms had been placed. I couldn’t
believe my eyes when he dug up things around the yard and spooky little
vials filled with fluid buried in the pot plants inside the house.
"Someone wanted to harm us"
He even found a giant boar’s tooth sewn into the foot of my parents'
mattress. The spiritualist said that someone meant us harm and it's possible
they wished the children of the house to be troubled and feel unsettled.
The man didn’t do an exorcism, but he did ‘bless’ the
house. He said things may be better after his visit. And I guess they
were, but that could have been psychological!
I still had the odd nightmare afterwards but a few years later I went
away to uni and it seemed like outside of my parents’ house, the
nightmares went away. So perhaps someone really had put a voodoo curse
on our house…
TREATMENTS FOR PHOBIAS
Simple or specific phobias have been quite effectively treated with behaviour
therapy. The behaviourists involved in classical conditioning techniques
believe that the response of phobic fear is a reflex acquired to non-dangerous
stimulus. The normal fear to a dangerous stimulus, such as a poisonous
snake, has unfortunately been generalized over to non-poisonous ones as
well. If the person were to be exposed to the non-dangerous stimulus time
after time without any harm being experienced, the phobic response would
gradually extinguish itself. Also, this assumes that the person does not
also experience the dangerous stimulus during that same extended period
of time. In other words, one would have to come across only non-poisonous
snakes for a prolonged period of time for such extinction to occur. This
is not likely to occur naturally, so behaviour therapy sets up phobic
treatment involving exposure to the phobic stimulus in a safe and controlled
setting. The exposure treatment, so called because the patient is exposed
to the phobic stimulus as part of the therapeutic process. One simple
form of exposure treatment is that of flooding, where the person is immersed
in the fear reflex until the fear itself fades away. Some phobic reactions
are so strong that flooding must be done through one's imagining the phobic
stimulus, rather than engaging the phobic stimulus itself.
Some patients cannot handle flooding in any form, so an alternative classical
conditioning technique is used called counter-conditioning. In this form,
one is trained to substitute a relaxation response for the fear response
in the presence of the phobic stimulus. Relaxation is incompatible with
feeling fearful or having anxiety, so it is said that the relaxation response
counters the fear response. This counter-conditioning is most often used
in a systematic way to very gradually introduce the feared stimulus in
a step-by-step fashion known as systematic desensitization, first used
by Joseph Wolpe (1958). This desensitization involves three steps: (1)
training the patient to physically relax, (2) establishing an anxiety
hierarchy of the stimuli involved, and (3) counter-conditioning relaxation
as a response to each feared stimulus beginning first with the least anxiety-provoking
stimulus and moving then to the next least anxiety-provoking stimulus
until all of the items listed in the anxiety hierarchy have been dealt
with successfully.
Also, systematic desensitization can be paired with modelling, an application
suggested by social learning theorists. In modelling, the patient observes
others (the "models") in the presence of the phobic stimulus
who are responding with relaxation rather than fear. In this way, the
patient is encouraged to imitate the model(s) and thereby relieve their
phobia. Combining live modelling with personal imitation is sometimes
called participant modelling. Family and friends can encourage the patient
to confront fears, help him when necessary and also can learn when to
stay out of the way and allow the patient to venture forth on his own.