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A phobia can be defined as a fear and/or avoidance of an object, activity, or situation that the individual knows is out of proportion to the actual danger that that object, activity, or situation poses. Phobias are one of the most widespread mental disorders, with estimates ranging from 10% to 30% of the population reporting a fear severe enough to disturb some aspect of their functioning.
According to the Diagnostic and Statistical Manual phobic disorders fall into three types, based on the nature of the object or situation that produces the fear:
1) Simple phobias involve a fear of particular objects or situations, such as heights, the dark, moths, or small spaces.
2) Social phobias involve a fear of being watched or evaluated by others and a belief that the individual will, in some way, appear foolish. This results in avoidance of such situations as eating in front of others or going to parties or meetings.
3) Agoraphobia involves a fear of being unable to escape quickly or reach help in the event of sudden incapacitation, commonly a panic attack. Specifically, therefore, agoraphobia involves a fear of a wide variety of situations that the individual believes will either increase the likelihood of incapacitation or reduce the chance of reaching help should incapacitation occur. These situations include going to malls, using public transport, and generally being alone.
Agoraphobia is usually thought to be the most crippling phobic disorder, and simple phobia the least. People suffering with phobias can also have problems with chronic anxiety and depression. Simple phobias often begin in childhood; social phobias in the late teens; and agoraphobia in the mid-20’s. Phobias appear to be more common in females than in males, although social phobia seems to be fairly evenly divided.
The cause of the various phobia disorders is still under considerable dispute. Traditionally, psychologists have believed that phobias are the result of experiencing a traumatic event in the presence of a specific situation or object (conditioning); being bitten by a dog, for example. However, recent research suggests that this is likely to be the case in only a certain portion of phobic cases, especially cases of simple phobia and some social phobias, such as fear of eating, drinking, or writing in front of others.
Other ways in which many simple phobias and some social phobias are probably acquired include the passing of false or exaggerated information (e.g., being told dogs are dangerous) or seeing or hearing of someone else being injured or distressed in a particular situation (e.g., seeing someone being bitten by a dog).
Some social phobias appear to be worsenings of lifelong behaviors and personality factors. In other words, some people who are afraid of going to parties or formal meetings may report that they have always been “basically shy,” but only since they took on new responsibilities has this become severe enough to be considered a problem. The immediate cause of agoraphobic fear and avoidance involves an unexpected panic attack. This first panic attack is reported to occur “out of the blue.” The agoraphobic then begins to fear the occurrence of another such attack and avoids those situations that they believe may cause or worsen a future attack.
The reasons why an individual may begin to associate certain situations with panic attacks are not yet known. In addition, the cause of the initial panic attack is only just beginning to be investigated. Some factors that might be responsible for causing the first panic attack include life stressors, earlier experience with loss of control, a tendency to breathe too fast, or fluctuations in brain chemicals.
The basic treatment of choice for the phobic disorders involves what is called graduated exposure to the phobic stimulus. This means that the person is gradually and gently brought into contact with the avoided object or situations until he or she “gets used to ” it. Repeated investigations have demonstrated the value of exposure-based techniques for all types of phobias. For maximum improvement in most cases of social phobia, it also appears to be necessary to teach people to re-evaluate some of their thoughts and beliefs; to learn, for example, that “everyone is not watching me” or that “if I say the wrong thing, people will not think I am stupid.” Some form of social skills training may also be of value, because it may produce new skills and/or increase confidence.
While exposure to the feared object or situations is of immense value for the avoidance component of agoraphobia, maximum improvement is unlikely to occur without some attempt being made to deal with the unexpected panic attacks.
Treatment for panic attacks has traditionally involved the use of medications such as imipramine (Tofranil) or alprazolam (Xanax). More recently, psychological techniques are proving to be just as effective.
The specific components of psychological treatments for panic attacks, which are necessary for treatment effectiveness, have not yet been conclusively determined, but some possibilities may include
- teaching people to slow their breathing;
- teaching people that their symptoms are harmless; and
- doing gradual exposure to the actual physical symptoms of a panic attack.