Phobic Disorders

Phobic Disorders

Phobias involve persistent, unrealistic, intense anxiety in response to specific external situations, such as looking down from heights or coming near a small dog.

People who have a phobia avoid situations that trigger their anxiety, or they endure them with great distress. However, they recognize that their anxiety is excessive and therefore are aware that they have a problem.

Agoraphobia

Although agoraphobia literally means fear of the marketplace or open spaces, the term more specifically describes the fear of being trapped without a graceful and easy way to leave if anxiety should strike. Typical situations that are difficult for people with agoraphobia include standing in line at a bank or supermarket, sitting in the middle of a long row in a theater or classroom, and riding on a bus or airplane. Some people develop agoraphobia after experiencing a panic attack in one of these situations. Other people simply feel uncomfortable in these settings and may never, or only later, develop panic attacks. Agoraphobia often interferes with daily living, sometimes so drastically that it leaves the person housebound.

Agoraphobia is diagnosed in 3.8 percent of women and 1.8 percent of men during any 6-month period. The disorder most often begins in the early 20s; a first appearance after age 40 is unusual.

Treatment

The best treatment for agoraphobia is exposure therapy, a type of behavior therapy. With the help of a therapist, the person seeks out, confronts, and remains in contact with what he fears until his anxiety is slowly relieved by familiarity with the situation (a process called habituation). Exposure therapy helps more than 90 percent of the people who practice it faithfully. If agoraphobia isn't treated, it usually waxes and wanes in severity and may even disappear without formal treatment, possibly because the person has conducted some personal form of behavior therapy.

People with agoraphobia who are deeply de-pressed may need to take an antidepressant. Substances that depress the central nervous system, such as alcohol or large doses of antianxiety drugs, may interfere with behavior therapy and are tapered off gradually before therapy is begun.

As with panic disorder, the anxiety in some people who have agoraphobia may have its roots in underlying psychologic conflicts. In such cases, psychotherapy (in which the person develops a better understanding of the underlying conflicts) may be helpful.

Specific Phobias

Specific phobias are the most common of the anxiety disorders. About 7 percent of women and 4.3 percent of men have a specific phobia during any 6-month period.

Some specific phobias, such as the fear of large animals, the dark, or strangers, begin early in life. Many phobias stop as the person gets older. Other phobias, such as fear of rodents, insects, storms, water, heights, flying, or enclosed places, typically develop later in life. At least 5 percent of people are to some degree phobic about blood, injections, or injury, and these people can actually faint, which does not happen with other phobias and anxiety disorders. In contrast, many people with anxiety disorders hyperventilate, which can cause feelings of faintness, but they virtually never faint.

Treatment

A person can often cope with a specific phobia by avoiding the feared object or situation. For example, a city dweller who is afraid of snakes may have no trouble avoiding them. However, the city dweller who fears small, closed places such as elevators will have a problem working on an upper floor in a skyscraper.

Exposure therapy, a type of behavior therapy in which the person is gradually exposed to the feared object or situation, is the best treatment for a specific phobia. A therapist can help ensure that the therapy is carried out properly, although it can be done without a therapist. Even people with a phobia of blood or needles respond well to exposure therapy. For example, a person who faints while blood is drawn can have a needle brought close to a vein and then removed when the heart rate begins to slow down. Repeating this process allows the heart rate to return to normal. Eventually, the person can have blood drawn without fainting.

Drugs aren't very useful in helping people over-come specific phobias. However, benzodiaze-pines (antianxiety drugs) may give a person short-term control over a phobia, such as the fear of flying.

Psychotherapy, with a view toward gaining in-sight and understanding of internal conflicts, A may be helpful in identifying and treating the conflicts that may underlie a specific phobia.

Social Phobia

A person's ability to relate comfortably with others affects many aspects of life, including early family relationships, education, work, leisure, dating, and mating. Although some anxiety in social situations is normal, people with social phobia have so much anxiety that they either avoid social situations or endure them with great distress. Recent research shows that about 13 per cent of people have a social phobia sometime in their lives.

Situations that commonly trigger anxiety among people with social phobia include public speaking; performing publicly, such as acting in a play or playing a musical instrument; eating in front of others: signing a document before witnesses; and using a public bathroom. People with social phobia are concerned that their performance or actions will seem inappropriate. Often they worry that their anxiety will be obvious-that they'll sweat, blush, vomit, or tremble or that their voice will quiver; they'll lose their train of thought; or they won't be able to find the words to express themselves.

A more general type of social phobia is characterized by anxiety in almost all social situations. People with a general social phobia are usually concerned that if their performance falls short of expectations, they will feel humiliated and embarrassed.

Some people are shy by nature and show timidness early in life that later develops into social phobia. Others first experience anxiety in social situations at puberty. Social phobia often persists if left untreated, causing many people to avoid activities in which they would otherwise like to participate.

Treatment

Exposure therapy, a type of behavior therapy, works well for social phobia, but arranging for exposure to last long enough to permit habituation and comfort may not be easy. For example, a person who is afraid of speaking in front of his boss may not be able to arrange a series of speaking sessions in front of that boss. Substitute situations may help, such as joining Toastmasters (an organization for those who have anxiety about speaking in front of an audience) or reading a book to nursing home residents. Substitute sessions may or may not reduce anxiety during conversations with the boss.

Antidepressants, such as sertraline and phenelzine, and antianxiety drugs, such as clonazepam, can often help people with social phobia. Many people use alcohol as a social lubricant; in some cases, however, alcohol abuse and dependence can result. Psychotherapy, which involves talking with a therapist to better understand underlying conflicts, m may be particularly helpful for people who are capable of examining their own behavior and making changes in the way they think about and react to situations.

Obsessive-Compulsive Disorder

Obsessive-compulsive disorder is characterized by the presence of recurrent, unwanted, intrusive ideas, images, or impulses that seem silly, weird, nasty, or horrible (obsessions) and an urge or compulsion to do something that will relieve the discomfort caused by an obsession.

The pervading obsessional theme is harm, risk, or danger. Common obsessions include concerns about contamination, doubt, loss, and aggressive-ness. Typically, people with obsessive-compulsive disorder feel compelled to perform rituals-repetitive, purposeful, intentional acts. Rituals used to control an obsession include washing or cleaning to be rid of contamination, checking to allay doubt, hoarding to prevent loss, and avoiding the people who might become objects of aggression. Most rituals, such as excessive hand washing or repeated checkingto make sure a door has been locked, can be observed. Other rituals are mental, such as repetitive counting or making statements intended to diminish danger. Obsessive-compulsive disorder is different from obsessive-compulsive personality disorder.

People can become obsessional about any-thing, and their rituals aren't always logically connected to the discomfort that these rituals relieve. For example, a person who has been worried about contamination may have felt his discomfort decrease once when he happened to put his hand in his pocket. Since then, any time obsessions about contamination arise, he repeatedly puts his hand in his pocket.

Most people with obsessive-compulsive disorder are aware that their obsessions don't reflect actual risks. They realize that their physical and mental behavior is excessive to the point of being bizarre. Obsessive-compulsive disorder thus differs from psychotic disorders, in which people lose contact with reality.

Obsessive-compulsive disorder affects about 2.3 percent of adults and occurs about equally in men and women. Because people with this disorder are afraid they'll be embarrassed or stigmatized, they often perform their rituals secretly, even though the rituals may occupy several hours each day. About one third of the people with obsessive-compulsive disorder are depressed at the time the disorder is diagnosed. Altogether, two thirds become depressed at some point.

Treatment

Exposure therapy, a type of behavior therapy, often helps people with obsessive-compulsive disorder. In this type of therapy, the person is exposed to the situations or people that trigger obsessions, rituals, or discomfort. The person's discomfort or anxiety will gradually diminish if he prevents himself from performing the ritual during repeated exposure to the provocative stimulus. this way, the person learns that the ritual isn't needed to decrease discomfort. The improvement usually persists for years, probably because those who have mastered this self-help approach continue to practice it as a way of life without much effort after formal treatment has ended.

Drugs can also help many people with obsessive-compulsive disorder. Three drugs (clomipramine, fluoxetine, and fluvoxamine) have been specifically approved for this use, and two others (paroxetine and sertraline) have also been demonstrated to be effective. Certain other antide-pressant drugs are also used, but much less often.

Psychotherapy, with a view toward gaining in-sight and understanding of underlying conflicts, 0 has generally not been effective for people with obsessive-compulsive disorder. Ordinarily, a combination of drugs and behavior therapy is the best treatment. n

Adapted from an article by J.W. Jefferson MD and Richard P. Kluft MD

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