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As per the DSM-IV, a phobia is defined as a significant
amount of anxiety due to a specific stimulus or situation that subsequently
leads to avoidance of that stimulus or situation. Phobias are clearly
related to anxiety disorders. They both present with a syndrome
of anxiety-like symptoms that when exacerbated can cascade into
a full-blown anxiety attack, but the difference is that phobias
are stimulated by a perceived fear of a particular stimulus or situation.
There are literally hundreds of phobias. Some of the more common
include claustrophobia or fear of enclosed places, agoraphobia or
fear of being in public places, and social phobias. For a complete
list of phobias, we recommend www.phobialist.com.
There is some speculation regarding the etiology of phobias. Some
purists believe there is an organic basis for phobias, and this
is somewhat evidenced by an approximately 80% increase in phobias
occurring in first generation siblings. However other individuals
will argue that point, stating that children have learned their
phobias from observing their parents or other adults in situations
where they exhibit extreme anxiety related to a specific event.
An example of this would be a child who observes a parent who is
extremely phobic of spiders or other insects becoming extremely
anxious, perhaps screaming, with a racing heart, diaphoresis (sweating)
and a rapid escape after coming into contact with an offending bug.
These episodes can become so severe that affected individuals will
not even walk into a basement where there may spiders, avoiding
the situation completely. A child observing this behavior will clearly
see the cause and effect relationship, and as they mature, might
go ahead and take on that phobia.
According to the DSM-IV, it is important to note that phobias cannot
be diagnosed in children under the age of 18 unless they have been
prominent and consistent for greater than 6 months. This is mostly
due to children having many fears around certain stimuli in their
environment, or certain situations. They do not become diagnostic
and significant until they last greater than 6 months, and secondly,
the phobias become so debilitating that they affect the individual’s
activities of daily living.
Phobia Treatment
Behavior modification and desensitization are two of the most appropriate
and effective treatment methods to target phobias. Medication has
been used as an adjunct and has been helpful to decrease the anxiety.
Interestingly enough, studies show that when you do give medication,
you can decrease the anxiety and the symptoms associated with that
such as racing heart rate and diaphoresis. However the individual
will still become frightened and will still present with stimulus-response
avoidance behavior.
As with most psychological disorders, a multi-treatment approach
is always beneficial. The combination of medication, as well as
behavior modification and desensitization has the highest cure rate,
as well as the quickest. Whether it is fear of flying, fear of heights
or fear of being in enclosed places, once individuals gain more
confidence and realize that their unrealistic fears are debilitating,
they will progress more rapidly and can eventually overcome them.
Therapy focusing on the specific reason why they are afraid has
not proven to be of much benefit. Many therapists will argue this
point; however, it is my opinion that examining why a person is
afraid of spiders, heights or enclosed places does not necessarily
in all cases expedite treatment. There are some situations where
that is important, specifically in phobias that may be related to
post-traumatic stress disorder or abuse. In those cases, it can
be extremely significant to delve into one’s past.
For the most part, treatment of phobias not only include the individual
being desensitized, but feeling that they do have a sense of control,
and they will not be injured or hurt by the offending stimulus or
situation.
Recidivism rates are fairly high and not that uncommon. One usually
sees the recidivism rate in phobic individuals rise as stress levels
increase in their lives and they feel they are no longer in control
of the specific stimulus. An argument can be made for phobias playing
an important role in an individual’s life, in that an individual
may receive support and greater attention from family members when
events occur. Of course this is not true in all cases. However this
author has seen this occur, where the phobia has been effectively
treated, and 6 months to 2 years later, there is some life trauma
in the person’s life, and the specific phobia does recur.
It is important to present this to the patient and provide them
an explanation as to why the recurrence is happening. Usually the
treatment interventions at times like this are similar to those
in the past. However treatment does not take nearly as long to be
effective, and success is almost always forthcoming.
Social Phobias
According to the DSM-IV, social phobias present with “a marked
and persistent fear of social or a performance situation in which
embarrassment may occur, or the perception of embarrassment. This
fear invariably provokes an immediate anxiety response.” As
per the DSM-IV, children under the age of 18 can only be diagnosed
with a social phobia if it lasts greater than 6 months. When anxiety
and fear occurs, the sympathetic response takes over and individuals
find themselves having symptoms of dry mouth (cotton-mouth), palpitations,
diaphoresis, tremors, and blushing. The perception is that these
individuals will be looked upon by others and judged, that they
are incompetent or “stupid.” It is important to be aware
that adolescents may have perceptions of their bodies that are not
egodystonic. In other words, these individuals have gross perceptions
of being overweight, underweight or feel that they are ugly. The
social phobia has to reach a level that interferes with their normal
occupational or academic functioning. These individuals will rarely
ask questions or perform speeches in class, and will not ask questions
in the workplace for fear they will be looked upon with disdain.
They will avoid work and may even call in sick. At this level, treatment
needs to be implemented.
Associated features of social phobias usually include hypersensitivity
to criticism, and individuals are usually not very assertive. They
feel very inferior and have a grossly low self-esteem. Frequently
they give very poor eye contact. With adolescents, many times parents
do not give the support they need. They frequently push their child,
and do not understand why their child is not achieving academic
excellence. Social phobias can frequently be associated with depressive
disorders and suicidal ideation.
Social phobias usually develop in the mid-teens. In school, there
is usually a decline in grades that continues into young adulthood.
Social phobias do differ from agoraphobia, which is a fear of public
places in the sense that a socially phobic individual may have anticipatory
anxiety, where the agoraphobic usually has panic attacks in large,
crowded areas. The two disorders can coexist; however the agoraphobic
many times does not feel that they are being looked upon with criticism
or disdain.
Social phobia treatment is similar to the treatment of phobias
in general. However it is very important to focus on an individual’s
perception of himself, as well as what they perceive others may
see in them. Empowerment is of the utmost importance. Once individuals
have achieved an accomplishment of one successful speech in front
of a classroom, or the ability to confront a boss at work in an
appropriate manner with subsequent success, the social phobia slowly
abates. The combination of this cognitive awareness with medication
expedites treatment. Some psychodynamic issues are frequently important
to look at. Invariably adolescents and teenagers have one or both
parents who are very critical of them. It could be that the father
or mother figure in a person’s life has been either condescending
or critical of their performance. Frequently one sees narcissistic
injury to a child over time. There are some situations where family
therapy can be beneficial. However caution is advised in moving
too quickly with family therapy, for it could backfire, especially
if the parents are resistant to looking at their own issues.
In summation, the treatment of social phobias should include:
- Looking at the individual as a whole.
- Empowering the individual.
- Reviewing historic occurrences of narcissistic injury that
might have occurred to the individual while growing up.
- Medication; anti-anxiety agents are very helpful in decreasing
the initial symptoms.
- The possibility of depression must be assessed, and an adjunct
anti-depressant may be helpful.
There is a high success rate in the treatment of social phobias,
for when the individual does successfully accomplish a speech in
public, or approaches the exact stimulus causing the intense anxiety,
resolution quickly occurs.
Commitment Phobia
There are no actual diagnostic criteria for commitment phobia.
Commitment phobia implies that an individual becomes anxious the
longer a relationship continues, whether it is a positive relationship
or negative and filled with chaos. Does one actually have increased
anxiety and panic attacks as their relationship becomes more committed?
This is usually not the case. Commitment phobia is a layman’s
term applied to individuals who bounce from relationship to relationship,
or have difficulty in staying with one partner for a period of time.
These individuals for the most part do not like emotional or physical
closeness. Frequently you see these individuals after intimacy wanting
to quickly leave the situation. Self-esteem is frequently impaired.
Individuals do not think highly of themselves and do not feel they
are worthwhile to their partner. This is not to be confused with
asocial tendencies, mostly seen in men who take advantage of their
partners for sexual favors, and then “dump the individual.”
With relationship conflicts that involve fear of commitment, it
has been shown that the majority of these individuals have a history
of some degree of dysfunction in their families. Usually their parents
are separated, or they have witnessed a divorce and/or some type
of abuse.
The focus of treatment needs to be two-fold: 1) Focus on the individual
and their issues with self-esteem and what a committed relationship
means to them, and what is their long-term goals and focus; 2) Marital
and couple therapy frequently is beneficial if the individual has
an ability to be introspective, and appreciate the needs and wishes
of their partner. There needs to be recognition of give and take.
Please see the sections on Marriage in Peace and Healing for more
information on relationships.
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