What are Phobias?
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 recommendwww.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.
What is the treatment for Phobias?
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.
What are 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.
What is a 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.