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- Herausgeber: Geddes and Grosset
- Kategorie: Ratgeber
- Sprache: Englisch
- Veröffentlichungsjahr: 2015
Explains phobias and gives advice on ways to heal, handle and cope
Das E-Book Understanding Phobias wird angeboten von Geddes and Grosset und wurde mit folgenden Begriffen kategorisiert:
Self-help, Phobias, health and fitness
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CHAPTER 1
Phobias
Introduction and general definition
A phobia is an anxiety disorder characterised by an overwhelming fear or dread of certain objects, animals, events or situations. A phobia can cause severe disruption and restriction of normal life activities and, at its worst, intense misery and suffering for the phobic person. The word is derived from the Greek phobos meaning extreme fear and flight. The ancient Greek god, Phobos, was believed to be able to reduce the enemies of the Greeks to a state of abject terror, making victory in battle more likely.
It is precisely this sort of incapacitating fear which grips the phobic person when confronted by the phobia stimulus and sometimes, even the anticipation or thought of the situation is enough to provoke the response. The fear is so strong that it produces a range of physical symptoms which typically may include sweating, trembling, feelings of faintness and dizziness, nausea, palpitations, hyperventilation and panic attack. There are, however, some apparent differences between the various categories of phobia, particularly with regard to their development, and these are discussed in more detail in Chapter 22.
A phobic person recognises that his or her fear is irrational and completely out of proportion to any possible threat posed by the stimulus and this, in itself, can be the cause of feelings of intense embarrassment. A person may go to great lengths to conceal the existence of his or her phobia and it is probable that, in many cases, the disorder remains unrecognised. This is especially likely when it is appreciated that there remains a lingering attitude, even in the modern Britain of today, that any form of mental disorder is a subject of shame.
The present situation
Recent surveys have revealed that phobias, especially specific ones, are the most commonly diagnosed mental disorder in Western psychiatric medicine. Studies indicate that between ten and thirteen per cent of the population may be affected at any one time with non-diagnosis making the figure even higher. Children and adults of both sexes are affected and an untreated child may or may not carry the phobia into adult life. Some people have a single phobia while others are phobic in response to several or many stimuli. Age and gender are sometimes relevant with certain phobias being more common to a particular age or sex.
Phobia occurs at the extreme end of a sliding scale which passes down through unreasonable, but less crippling fear, to aversion and strong dislike. If these responses are taken into consideration, most people would probably admit that they have experienced phobic symptoms to a certain extent, even if only on a single occasion. In fact, surveys have shown that sixty per cent of people have been affected by a phobia at some stage in life and that nearly all respondents are acquainted with at least one person who displays phobic symptoms.
Phobia in the past
Phobias appear to be present in all races and cultures although there may be some differences in the prevalence of particular types. They have been mentioned in early historical writings, particularly those of the Greeks and Romans. Allusions are made to phobias in later European writings but by the Middle Ages, they were often regarded as manifestations of demonic activity. Although some phobias have always occurred, for example animal phobias and height phobias, others, particularly those relating to specific diseases or illnesses such as plague, syphilis and rabies, were once more common. These diseases were major killers in the past and, not surprisingly, people were afraid of them.
In the eighteenth and nineteenth centuries, disorders of the mind were once more returned to the realms of medicine and science and attempts were made to study and explain the nature and development of phobias and to treat them. Several misconceptions were born at this time but continuing in-depth study of phobias throughout the twentieth century, particularly during recent years, has shed new light on these fascinating and prevalent disorders and resulted in successful treatment for many phobic sufferers.
Recent developments
The years of research and study by many experts in the field of phobias has led to several new developments. It is generally accepted that:
there are diagnostic criteria for three clinical categories of phobia.
the various categories of phobia and individual phobias, themselves, have different causes and reasons (aetiology or aetiological mechanisms) for their development.
cognitive factors have a part in the development and continuance of phobias. This means that phobias are not entirely unconscious but are, in some cases, and to differing extents, reinforced by a person’s perceptions and beliefs about the environment and the phobic stimulus. Recognition of the interplay of different mechanisms and cognitive factors in the development of phobias has challenged earlier, more simplistic theories about their origins.
increased study and understanding of phobias has led to the development of more helpful specific treatment programmes which can be tailored to individual needs and have proved to be highly successful.
Classification and diagnosis of phobias
(Please note that for the sake of simplicity the phobic person will be assumed to be male in the pages that follow.) Modern psychiatry recognises three major groups of phobia.
1. Agoraphobia
2. Social phobia
3. Specific (single) phobia which includes five subgroups.
The title ‘specific’ replaces the earlier label of ‘simple phobia’ which was discarded because it implied that the condition was not serious or distressing.
In the following pages, the first two categories are described in detail along with aspects of their treatment, followed by a general evaluation of the large third group of specific phobias. The subgroups, along with selected examples of specific phobias, are described in more detail on pages 107–166. Chapter 23, the treatments chapter, attempts to define and describe psychotherapeutic approaches and drug treatments with reference to phobias. Alternative therapies, which may be helpful, are described in Chapter 25.
CHAPTER 2
Agoraphobia
Symptoms and defining criteria
Agoraphobia means, literally, fear (phobus) of the marketplace (agora). More practically, a sufferer is afraid of being in open, public or crowded places, especially if there is no easy or readily accessible escape route. Many agoraphobics are additionally afraid of becoming mentally and/or physically incapacitated by fear or panic in these circumstances, particularly that they will lose control and be left helpless in front of strangers.
The exact nature of the feared situation varies from one sufferer to another with some agoraphobics being more afraid of open places where there are few people while others can cope better if it is dark or if they are accompanied by a trusted companion. The condition also varies in that, while many agoraphobics experience panic attacks or panic-like symptoms, others do not.
However, in all but the mildest cases, agoraphobia interferes significantly with normal life as the person typically avoids encountering the feared situation. Hence shopping, travelling on public transport, going to the cinema or a football match or indeed to any public venue, including visiting the doctor’s surgery, a child’s school or the bank, can all become impossible for an agoraphobic. In the most severe cases, avoidance is such that the sufferer becomes totally housebound.
Agoraphobia is a relatively common disorder affecting about four per cent of females and two per cent of males in any half-yearly period. The most likely age at which it makes its first appearance is during the early twenties. Agoraphobia rarely presents itself for the first time after the age of forty.
Many experts recognise the existence of two forms of the disorder: agoraphobia without a history of panic attacks and agoraphobia with panic attacks (or panic disorder). The second form is termed ‘panic disorder with agoraphobia’ in American psychiatric medicine.
The symptoms and criteria that might be likely to lead to a diagnosis of agoraphobia can be summarised as follows:
acute anxiety about the thought or reality of being in a (public) place or situation from which there is no easy means of escape. In these circumstances the person may experience feelings of unease that can vary in intensity.
these places or situations are either avoided or only endured with great difficulty or with the help of a trusted companion.
both of the above cannot be accounted for by some other mental disorder, physical illness or the effects of drugs or alcohol.
The symptoms and criteria which might lead a clinician to suspect agoraphobia with panic attacks are the same as the above but with the addition of the following
the experience of one or more panic attacks in the agoraphobic situation and the persistent fear that these might recur.
anxiety about the possible consequences of the panic attacks such as displaying visible physical symptoms or loss of physical and mental control over one’s body.
changed behaviour as a result of the panic attacks.
Surveys have shown that agoraphobia without panic attacks is much more prevalent than was previously realised and more common than agoraphobia with panic attacks. Some researchers believe that the true picture has been hidden because agoraphobics with panic symptoms are much more likely to seek help and be referred to clinicians. Other ‘ordinary’ agoraphobics may well remain undiagnosed within the community.
However, since panic attacks or full panic disorder are not infrequently associated with agoraphobia, it becomes helpful to define them at this point.
Panic attacks and disorders
Panic (or anxiety) attack
A panic attack involves the sudden appearance of four or more of the following mental and physical symptoms which are the manifestations of extreme anxiety. These are:
1. Rapid rate of heartbeat or palpitations.
2. Breathlessness or a feeling of being smothered.
3. Tightness or pain in the chest.
4. Tremor, trembling, shaking.
5. Feeling hot or cold or alternating between the two.
6. Shivering or sweating; pallor.
7. Choking feeling in the throat.
8. Dizziness, feelings of faintness or light-headedness.
9. Nausea or gastro-intestinal symptoms.
10. Tingling in the extremities of the limbs or feelings of numbness.
11. Fear that loss of physical control (for example of bladder and bowels) is imminent.
12. Fear that mental collapse and loss of control or ‘madness’ are imminent.
13. Feelings of detachment and unreality and fear that one may be dying.
The symptoms rapidly reach a peak of intensity within ten minutes of first appearing and then disappear as quickly as they arose. Although a panic attack can be extremely distressing, it is not physically harmful although the sufferer frequently believes that it is. Panic attacks are extremely common with about a third of people experiencing one in any given year.
Panic (or anxiety) disorder
Panic disorder is characterised by the occurrence of panic attacks which, at least in the first instance, arise unexpectedly and are not attached to a particular situation or stimulus. Anticipatory anxiety about the occurrence of further spontaneous attacks is a major part of the disorder. In many, but not all, cases the person avoids the place or situation where a panic attack occurred and this aspect has a strong correlation with agoraphobia.
The person also commonly believes that the panic attack is symptomatic of a serious physical disorder, such as a brain tumour or heart condition, and may report to a doctor or hospital on this basis. A diagnosis of panic disorder is unlikely to be made in these circumstances although it may emerge at a later date. The disorder itself is uncommon, affecting fewer than one in a hundred people in any given six-month period.
Development of agoraphobia
The mechanisms responsible for the development of agoraphobia are extremely complex and remain the subject of a great deal of debate. Numerous theories and models aimed at explaining the nature of the disorder have been put forward by many researchers since the late nineteenth century. Some of these theories are not widely accepted while others have helped to shed light on this complex condition. An understanding of the underlying mechanisms is not only of interest in itself but is of particular importance in devising effective treatment programmes for individual agoraphobics. The following eight factors appear to be relevant in agoraphobia.
1. Cognitive factors, that is beliefs, play a major role in agoraphobia. The fear involved is closely associated with the (mistaken) belief that the person either cannot escape from the situation or can only do so by behaving in a way that would attract attention. This behaviour is perceived to be, at best, embarrassing and, at worst, involving complete mental and physical collapse with awful personal consequences. The fear, and hence the pattern of agoraphobic avoidance, develops either as a result of actual experiences or because of a strong belief that awful events will occur.
2. Panic symptoms are one of the most common factors associated with agoraphobia and a person may develop the condition following a panic attack. However, other conditions may also lead to the development of a form of agoraphobia, such as epilepsy and the fear of having fits in a public place, osteoporosis and the fear of falling and breaking bones if away from home, incontinence and irritable bowel syndrome and the fear or being ‘caught short’ without access to a toilet while away from home. The difference lies in the fact that extreme fear is not usually a factor in these circumstances. Also, panic symptoms may occur for the first time after the development of agoraphobia or not at all. Hence, agoraphobia may be more usefully considered as motivated avoidance with panic being one of a range of significant factors involved.
3. There is evidence that at least in some cases, agoraphobics are less assertive and self-sufficient than other people.
4. Agoraphobics may, in some cases, have a history of school phobia in childhood or come from a family background in which relatives have experienced school phobia or agoraphobia.
5. There may be a greater tendency towards depression in some people with agoraphobia.
6. Agoraphobics with panic attacks have a greater fear of dizziness and a greater belief that they will faint or otherwise lose control, compared to those suffering from panic disorder who do not markedly avoid feared situations. These agoraphobics have a low belief in their ability to cope with panic and a high and strong belief in its catastrophic consequences.
7. Many agoraphobics develop coping or safety-seeking strategies to help them to deal with the disorder. Examples include leaning against a wall or hanging on to a super-market trolley and believing that by doing this, fainting and/or physical collapse is avoided.
8. The fear and panic symptoms (when present), avoidance, coping behaviours and beliefs (cognitive factors), all interact with each other in agoraphobia.
Treatments for agoraphobia
Behaviour therapy
Classic psychotherapeutic treatments for agoraphobia have employed a form of behaviour therapy called exposure therapy. With support, the agoraphobic person is gradually and increasingly exposed or encouraged to confront the feared situation until habituation takes place.
The idea is that the person’s anxiety will decrease as exposure to the situation is shown not to have the fearful consequences that he expects, allowing behavioural change to take place. This type of therapy may also involve flooding in which the person is intensively exposed to the feared situation. Methods to control panic attacks, such as using breathing or relaxation techniques, may be employed as part of the treatment (see Chapter 25).
Cognitive therapy
Cognitive therapists start from a slightly different standpoint. They take the view that the extreme anxiety in agoraphobia is a direct result of a sufferer’s distorted perception of threat and danger in the feared situation, especially that ‘giving way’ will take place and will be disastrous. The person typically overestimates the threat and underestimates his ability to cope. An interaction then occurs between the beliefs, anxiety or panic symptoms and safety behaviours such as avoidance or ‘coping strategies’ which help to maintain the agoraphobia.
Hence a cognitive therapist seeks to identify and change the distorted beliefs and safety or coping strategies by discussion and behavioural experiments. For example, an agoraphobic who believes that fainting in a public place will have dreadful consequences might be asked to observe a simulated fainting by a helper. Feelings of dizziness and faintness are a common symptom of phobia but actual fainting is almost entirely confined to blood–injury–injection phobia (see Chapter 12). When the person sees that the feared catastrophic consequences do not take place, his distorted beliefs are well on the way to being challenged and abolished.
Cognitive therapy also seeks to challenge the safety-seeking or coping strategies commonly employed by agoraphobics. For example, the person who believes that his legs will give way under him if he does not lean against a wall or hang on to a supermarket trolley is helped to discover that collapse in these circumstances is extremely difficult to achieve. Following a detailed and thorough discussion, the patient and therapist enter the agoraphobic situation with the sole purpose of conducting a ‘leg-collapse experiment’. The patient is not allowed to use his ‘safety prop’ and as soon as he experiences feelings of leg weakness, is asked to try and make his legs give way. When collapse does not occur, further discussion may ensue to see if there is anything else that the patient can do to make his legs fold under him. These may then be tried, with the same result, so that by the end of the experiments, the patient has begun to realise that his legs cannot fold under him and that he has, all along, been misinterpreting physical bodily sensations. Experiments such as these are held to be of great benefit by some therapists.
Differences between behaviour therapy and cognitive therapy
The differences between the two approaches can perhaps be best understood by considering an illustration. Behavioural therapy may be able to help an agoraphobic to get used to the feared situation by repeated exposure.
However, it is also possible to envisage that the agoraphobic could be employing an undisclosed safety or coping strategy on which he is secretly relying. He might, in fact, have his belief in the effectiveness of this reinforced by exposure alone, that is believing that he can confront the agoraphobic situation better because his safety strategy is working so well. Also, if panic control measures have been strongly taught as a part of behavioural therapy, the patient may subsequently be able to enter the agoraphobic situation only because he now believes that he can avoid catastrophe by employing them. It is then likely that he will not have come to realise that panic symptoms are harmless as this belief is not challenged by control alone. His agoraphobia has been controlled rather than changed and panic control has become a safety or coping strategy in its own right.
In cognitive therapy, panic control would perhaps be viewed as one of several useful measures aimed at changing an agoraphobic’s belief in the harmfulness of panic symptoms. In practice, cognitive therapy experiments, such as those described above, have to incorporate exposure, which is a key element of behavioural therapy.
There is, in fact, a considerable degree of overlap between the two approaches. The behavioural approach to agoraphobia, based on exposure therapy, has been proved to be effective in most cases and has also been shown to bring about cognitive changes. Many experts believe that the effectiveness of purely cognitive treatments has not been established or is inferior to that of behavioural therapy. The same view also tends to be taken with regard to combined therapies which have been tried. However, both behavioural and cognitive approaches have been proved valuable in the treatment of panic disorder.
The fact that a high percentage of agoraphobics are helped by behavioural exposure therapy is especially encouraging when one considers that it is generally only the most severely affected patients who seek treatment. As mentioned above, it is thought that many agoraphobics (no doubt including those who see themselves as being less seriously affected) remain ‘hidden’ within the community and never seek professional help. Hence part of the function of a book such as this should be to stress the importance and effectiveness of treatment compared with suffering the distress of agoraphobia.
Drug therapy
Such drugs as antidepressants or benzodiazepines are occasionally prescribed to help alleviate panic symptoms and/or severe depression, if present. These are prescribed only with great caution, generally for short-term relief and, in the case of benzodiazepines, may have to be discontinued before a programme of behaviour therapy can be started. This is because benzodiazepines may interfere with treatment and also cause dependency and withdrawal symptoms. Antidepressants are preferable in that they do not usually cause dependency but they can, on the other hand, produced unwanted side effects which can make them unacceptable to patients. Behavioural exposure therapy, possibly combined with panic control measures, is regarded by most experts as being the treatment of choice.
CHAPTER 3
Social Phobia
Symptoms and defining criteria
Social phobias form a group of common anxiety disorders that affect both men and women more or less equally. The most common age for social phobia to appear is between fifteen and twenty years. It can be defined as a clinically severe and irrational anxiety provoked by exposure to a range of social and/or ‘performance’ situations (for example when the person has a role or function to carry out in front of others). The anxiety frequently leads to avoidance of social situations. This can then result in loneliness, isolation and misery, especially since the person is frequently aware of his loss and desires normal social contact.
A key feature of social phobia is the person’s fear that he will experience embarrassment and feel humiliated if his behaviour does not meet his own preconceived standard. The social phobic typically fears that he will behave either inadequately or excessively, or in a manner which will attract the adverse criticism and judgement of others. Commonly, he fears that his anxiety will manifest itself in a visible way such as by blushing, trembling, particularly of the hands, having a quavering voice or stammering, not being able to make eye contact, becoming ‘tongue-tied’, experiencing nausea, vomiting and the urgent need to urinate.
In European psychiatry, the following criteria are used to make a diagnosis of social phobia:
