Part 1
Many people report anxiety attacks which seem to be
related to alcohol, and wonder what effects quitting will have in the short and
long run. From my own experience, I had serious panic attacks which gradually,
steadily went away after I quit. So the following article, while not strictly
based on behavioral approaches, is intended to give some background information
about anxiety attacks, panic disorders, and phobias.
This article is nearly 20 years
old, and there has been a lot of research about neurotransmitters and the
effects of drugs and alcohol on them since then. So it is a good starting
point.
(posted by Hopkins Technology)
U.S. Department of Health and Human Services Public Health
Service Alcohol, Drug Abuse, and Mental Health Administration
Phobias take many forms. Some people are terrified of
dogs, even tiny dogs with wagging tails. Some people stiffen with fright at the
mere thought of talking in front of a group. Some canÕt fly. Some tremble and
hide at the crack of thunder. Some canÕt ride an escalator. Some are struck by
panic attacks for no apparent reason. And some never leave their homes.
Fears such as these are very common. Millions of Americans
are afflicted with phobias or panic disorder. They suffer intensely. To escape
their fear, they go to great lengths to avoid the object, place, or situation
that provokes it. They change jobs merely to avoid an elevator ride, for
example, or cut back their social life. Some wear down their families with
their clinging dependency. Nearly all lose out on much of life.
Many people go from doctor to doctor seeking cures for the
physical symptoms that accompany their phobias. Often, even the doctor fails to
recognize that stomach pains, high blood pressure, rapid heart beat, and other
symptoms may be related to intense fear. Unless questioned, patients may not
think to mention their fears. Doctors may not ask. While the bills keep
mounting, the medical condition fails to improve.
The many phobic people who think their fears are silly,
childish, or trivial often try to conceal them. While hiding from their fears,
they hide their phobias from others, further limiting their experience of life.
It is better to tell someone. Much of the pain and
disruption - perhaps most of it - can be remedied. New treatments for phobias
are remarkably effective. But few people, including doctors, know about them.
If you or someone you know is excessively fearful - afraid
out of all proportion to the cause - then you may gain some understanding of
the problem from this pamphlet. It describes what experts know about phobias
and panic. It may help you.
Anxiety is the emotion you feel when a person, object,
situation, or impulse seems dangerous to you. If youÕre crossing a street and
suddenly notice a car speeding toward you, you feel afraid that you will be
hit, and you dash out of the way. This fear and the behavior it provokes probably
save your life. If youÕre fed up with your boss and want to hit him, the sick
feeling in the pit of your stomach - the anxiety you feel when you anticipate
the consequences of slugging your boss - keeps you from carrying through on
your impulse. The anxiety and your control of your behavior probably save your
job.
While ÒnormalÓ anxiety is adaptive - that is, it helps you
to survive and be productive - too much anxiety can be crippling. People who
suffer from certain patterns of signs and symptoms related to anxiety are
considered by mental health specialists to have anxiety disorders. Phobias and
panic attacks are the most common of these disorders. (Other anxiety disorders
- generalized anxiety disorder, obsessive-compulsive disorder, posttraumatic stress
disorder, and atypical anxiety disorder - are each characterized by somewhat
different symptoms. They will not be discussed here.)
Both phobias and panic disorder are marked not only by
great anxiety in situations that are relatively safe, but also by an
exaggerated avoidance of the source of distress. Depending on the type of
phobia or panic, the person may shy away from floor-to-ceiling windows in a
highrise, refuse an invitation to speak in front of a church group, or stay out
of crowded shopping malls. People with these disorders donÕt actually have to
encounter what they fear.
They become intensely anxious just by anticipating that
they might soon be in the feared situation, brooding over it in their
imagination.
The fears can start in childhood or adulthood. Some people
have suddenly become terrified of things theyÕve been doing for years. For
example, a flight attendant began having panic attacks on her 500th
flight.
Some people can sidestep the thing they fear without much
difficulty. Some, especially adults, can hide their distress and conceal their
phobias. Even those who usually adjust their lives to fit their phobias are
sometimes able to confront what they fear, Òtoughing it out,Ó suffering all the
while. While children may outgrow their phobias, adults usually do not get rid
of them unless they receive treatment.
Recognized even in ancient times, phobias and panic are
known around the world, probably in every human culture. The most recent and
thorough studies show that, in the United States, phobias are the most common
of all mental disorders. Seven out of every hundred Americans have phobias.
Eight out of every thousand have panic disorder. Compared to men, women more
often suffer from most types of phobia and panic disorder.
The reason that phobias and panic are more common in women
is now known. Investigators speculate that men may be more likely to drown
their fears, since alcohol abuse is more common in men than women. This is just
one of many possible explanations, however. Differences in biological makeup or
social and psychological experiences may also be responsible. For example, in
our society some girls are encouraged to be more fearful and less independent
than males.
Mental health professionals now recognize three types of
phobia - simple phobia, social phobia, and agoraphobia (with and without panic
attacks) - and a separate diagnosis for people who repeatedly experience severe
attacks of panic.
The most common of the various phobias is simple phobia,
the unreasonable fear of some object or situation. Bees, germs, heights, odors,
illness, and storms are examples of the things commonly feared in simple
phobias.
If you have a simple phobia, it might have begun when you
actually did face a risk that realistically provoked anxiety. Perhaps, for
example, you found yourself in deep water before you learned to swim. Extreme
fear was appropriate in such a situation. But if you continue to avoid even the
shallow end of a pool, your anxiety is excessive and may be of phobic
proportions.
Simple phobias, especially animal phobias, are common in
children, but they occur at all ages. The best evidence to date suggests that
between 5 and 12 percent of the population have phobic disorders in any 6-month
period.
The recognition by most phobics that their fears are
unreasonable doesnÕt make them feel any less anxious. Simple phobias do not
often interfere with daily life or cause as much subjective distress as most
other anxiety disorders.
The person with a social phobia is intensely afraid of
being judged by others. Even at a gathering of many people, the social phobic
expects to be singled out, scrutinized, and found wanting. Thus, the person
with a social phobia feels compelled to avoid social situations with such
apprehensions.
If you have a social phobia, you might be afraid to go to
a party because you fear that other people will laugh at your clothing or think
you are hopelessly stupid because you wonÕt be able to think of anything to
say. Like people with simple phobias, you work hard to avoid these
anxiety-provoking situations.
People with social phobias are usually most anxious over
feeling humiliated or embarrassed by showing fear in front of others.
Ironically, they are often so crippled by the inhibitions resulting from such
fears that they, in fact, may have difficulty thinking clearly, remembering
facts, or expressing themselves in words. Even success in social situations
fails to make them feel more confident. They are likely to think something like,
ÒNext time IÕll fall on my face.Ó
Although studies of the incidence of social phobias are so
far only preliminary, most experts believe social phobias are not as common as
simple phobias. But because they result in considerable distress, people who
suffer from them are more likely to seek treatment than are people with simple
phobias. Social phobias tend to begin between the ages of 15 and 20 and, if
left untreated, continue through much of the personÕs life. Often, social
phobias suffer from symptoms of depression, and many also become dependent on
alcohol.
Another group of anxious people are subject to devastating
episodes of panic that are unexpected and seemingly without cause. Such
unpredictable panic attacks are marked by an overwhelming sense of impending
doom and a host of bodily symptoms. The personÕs heart races and breathing
quickens, as he gasps for air. (In the interest of brevity and grace of style,
the pronoun ÒheÓ will be used throughout this pamphlet when either sex could be
the topic of discussion). Sweating, weakness, dizziness, and feelings of
unreality are also common. The person having a panic attack fears he is going
to die, go crazy, or at least lose control.
Panic disorder is diagnosed when patients experience
repeated episodes of such panic. Although people with simple or social phobias
may sometimes experience panic, they are clearly responding to an encounter -
or an anticipated encounter - with the object or situation they fear. Such is
not the case with panic disorder, when the fear strikes from nowhere, seemingly
Òout of the blue.Ó
People with simple and social phobias can also predict
that they will feel fear every time they come close to a cat, climb to the roof
of a tall building, or encounter whatever else they fear. People with panic
disorder, by contrast, never can predict when they will suddenly be struck by
panic. Some situations may seem more Òdangerous,Ó especially those that make
escape difficult, but an attack does not invariably occur in those situations.
Panic disorder, which runs in families, afflicts some 1.2
million Americans. For most, panic attacks begin sometime between the ages of
15 and 19.
Many people who suffer from panic attacks go on to develop
agoraphobia, a severely handicapping disorder that often prevents its victims
from leaving their homes unless accompanied by a friend or relative - a ÒsafeÓ
person. The first panic attack may follow some stressful event, such as a
serious illness or the death of a loved one. (The agoraphobic often doesnÕt
make this connection, though.) Fearing more attacks, the person develops a
more-or-less continual state of anxiety, anticipating the next attack, avoiding
situations where he would be helpless if a panic attack occurred. It is this
avoidance behavior that distinguishes agoraphobia from panic disorder. Two
different types of anxiety appear to afflict the person with agoraphobia -
panic and the Òanticipatory anxietyÓ engendered by expectations of future panic
attacks.
If you have agoraphobia, chances are it developed
something like this: One ordinary day, while tending to some chore, taking a
walk, driving to work - in other words, just going about your usual business -
you were suddenly struck by a wave of awful terror. Your heart started
pounding, you trembled, you perspired profusely, and you had difficulty
catching your breath. You became convinced that something terrible was
happening to you, maybe you were going crazy, maybe you were having a heart
attack, maybe you were about to die. You desperately sought safety, reassurance
from your family, treatment at a clinic or emergency room. Your doctor could
find nothing wrong with you, so you went about your business, until a panic
attack struck you again. As the attacks became more frequent, you spent more
and more time thinking about them. You worried, watched for danger, and waited
with fear for the next one to hit.
You began to avoid situations where you had experienced an
attack, then others where you would find it particularly difficult to cope with
one - to escape and get help. You started by making minor adjustments in your
habits - going to a supermarket at midnight, for example, rather than on the
way home from work when the store tends to be crowded.
Gradually, you got to the point where you couldnÕt venture
outside your immediate neighborhood, couldnÕt leave the house without your
spouse, or maybe couldnÕt leave at all. What started out as an inconvenience
turned into a nightmare. Like a creature in a horror movie, fear expanded until
it covered the entire screen of your life.
To the outside observer, a person with agoraphobia may
look no different from one with a social phobia. Both may stay home from a
party. But their reasons for doing so are different. While the social phobic is
afraid of the scrutiny of other people, many investigators believe that the
agoraphobic is afraid of his or her own internal cues. The agoraphobic is
afraid of feeling the dreadful anxiety of a panic attack, afraid of losing
control in a crowd. Minor physical sensations may be interpreted as the prelude
to some catastrophic threat to life.
Agoraphobics may abuse alcohol in an effort to keep the
anticipatory anxiety in check. Their pattern of abuse appears to be different
from the binging characteristics of alcoholism, however. The agoraphobic
usually takes small amounts of alcohol, avoiding loss of control. Other drugs
may also be abused.
Agoraphobia typically begins during the late teens or
twenties. The best surveys done to date show that between 2.7 percent and 5.8
percent of the U.S. adult population suffer from agoraphobia. Women are
affected two to four times more often than men. The condition tends to run in
families.
Recent surveys have found that many people are afraid to
leave their homes. Most likely, they are not all suffering from agoraphobia.
Some people may stay confined because of depression, fear of street crime, or
other reasons. These surveys also show, however, that many agoraphobics may
have never suffered a panic attack. This finding suggests that their
agoraphobia may have developed in ways different from that outlined above.
Panic and agoraphobia have received a great deal of
attention from clinical investigators in recent years. Some believe that panic
attacks are a severe expression of general anxiety, while others think that
they constitute a biologically distinct disorder, possibly related to
depression, possibly indistinguishable from agoraphobia. This controversy will
probably be resolved through more research in the coming years.
Given the dramatic symptoms of phobic and panic disorder,
it is surprising that they are sometimes difficult to recognize, even for
medical professionals. Some patients, especially those with simple phobias, are
able to conceal the severity of their handicap. Agoraphobia is often not
detected because its physical symptoms become the center of concern for both
patient and doctor. Health problems, such as peptic ulcer, high blood pressure,
skin rashes, tics, tooth grinding, hemorrhoids, headaches, muscle aches, and
heart disease, often occur together with anxiety disorders.
Phobias may cover up other problems. School phobia, a
complex condition in which a youngster refuses to attend school, is one
example; often the underlying problem is the childÕs anxiety over separating
from his parents. (A mental health professional can easily distinguish between
school phobia and other causes of missing school.)
Just as panic and phobias can masquerade as other illness,
some physical diseases may be mistaken for anxiety disorders. For example,
people can become anxious as the result of such medical conditions as head
injury, withdrawal from alcohol and drugs, and even pneumonia. In these cases,
the panicky feelings usually disappear when the condition clears up. Phobic
behavior also occurs in conditions that are not diagnosed as phobias, such as
the phobic-like avoidance of sexual contact in a person whose principal problem
is sexual.
Reactive hypoglycemia - a rapid decline in blood sugar
followed by compensatory changes in adrenalin and other hormones - can produce
many symptoms of panic, such as sweating, heart palpitations, and tremor. Most
likely, this medical condition mimics panic disorder.
More puzzling is the relationship between panic attacks
and agoraphobia, on the one hand, and depression, on the other. About half of
people subject to phobias and panic are demoralized or depressed more often
than the average person. Many agoraphobic patients develop their symptoms
shortly after suffering a loss (which can trigger depression), and some either
have histories of depressive episodes themselves or have relatives who do.
Whether phobias cause depression or depression causes phobias
is unknown. Panic and anxiety can wear down a person until he or she feels
demoralized. Alternatively, phobia and panic might result from depression and
its symptoms - difficulties with sleep, appetite, and concentration, fatigue,
lack of pleasure, and feelings of worthlessness.
Yet another possibility is the simple coexistence of
anxiety and depression, neither causing the other. Some underlying biological
process - an inherited vulnerability, perhaps - may be common to both anxiety
and depression.
Phobias and panic, like all anxiety disorders, disturb
many areas of a personÕs functioning. Take the woman who has agoraphobia. Her
BEHAVIOR changes when she has to quit her job because she believes she is
unable to ride the bus. Her THINKING goes awry when she judges the risk she
faces. The memory of past FEELINGS of panic on the bus, when she was sure she
would die, produces alterations in her PHYSIOLOGY as her heart pounds, her head
gets dizzy, and her hands sweat. Her behavior, thinking, emotions, and her bodyÕs
physiological responses are all involved in her agoraphobia.
Evidence of these effects has guided research
investigators who have tried to understand the causes of anxiety disorders.
They have formed their theories by observing patients, listening carefully to
what they say, and measuring their functioning in the laboratory. Scientists
then go beyond these observations to test theories, either in the clinic or in
scientific experiments. These experiments show that other aspects of anxiety
and related disorders are not as clearly evident. Some of the most influential
or promising theories and bodies of research are described below.
One possible cause of anxiety that is difficult for a
nonspecialist to observe is psychological conflict arising from emotions and
impulses that remain unconscious (outside of the personÕs awareness). Much of
the theory proposed by Sigmund Freud early in this century assumes that such
unconscious forces, mostly deriving from childhood, profoundly influence adult
life, including abnormal anxious states. These influences, for the most part,
are inferred from the memories and associations of patients who undergo
intensive, prolonged therapy. Until the last two or three decades, Freud and
the psychoanalytic investigators who revised his theories were the dominant
force in explaining and treating anxiety-related conditions. Although now out
of fashion in academic settings, the ideas of the psychoanalytic school have
influenced thinking throughout society, especially in clinics where people are
treated for mental health problems.
In the view of psychoanalysts, anxiety is a signal of
danger - a danger that is not real and present, but rather, is carried over
from the memories and imaginations of childhood. Often, these dangers involve
fantasies of loss or love (or actual separation from loved ones) or other
fantasies that express guilt or sexually related events. When these fantasies
are activated in adulthood - perhaps because something happens that the patient
associates with the fantasies - they give rise to anxiety. The anxiety may be
conscious or unconscious. In either case, it makes the person act defensively -
that is, attempting to get away from the threat or, more often, to stop the
fantasy from ever occurring by regulating or inhibiting the wishes that give
rise to fantasies of danger. Because this defensive behavior relieves the
anxiety, it tends to be repeated: It is, in other words, learned.
Modern psychodynamic research (that which focuses on
mental conflicts) has put a great deal of emphasis on the anxiety that
accompanies real or feared separation from a caretaker during childhood.
Individuals who, as children, became extremely anxious whenever they were
separated from their parents seem to be especially likely to develop
agoraphobia later in life. Some 42 percent of agoraphobic patients report a
history of childhood separation anxiety. This statistic suggests that
agoraphobia may build on a foundation already present in early life or
represent the aftermath of unresolved childhood separation anxiety.
In contemporary psychodramic models, the person with
agoraphobia avoids situations that symbolize or threaten separation from a
loved one. This view explains why a death or other kind of loss may trigger
agoraphobia. It also may explain why some agoraphobics can venture out when
accompanied by a spouse, child, or friend.
Psychoanalytic theory from Freud to the present day has
given some role to learning as a necessity for the development of abnormal
anxiety states. Another school of thought puts learning squarely at the center
in its theory of anxiety. In the simplest learning model, an individual may
learn fear through direct experience (e.g., being bitten by a snake) or
indirectly by witnessing injury to someone else, by observing fear reactions of
others, or by being warned of an objectÕs dangers. More likely, however, the
reaction is the result of an association between an unpleasant, fearful response
and the chance presence of the object that later is viewed as threatening. As
early as 1920, one experimental psychologist showed that a young boy could be
trained to fear a harmless white rat if frightened by a loud noise every time
the rat was nearby. Because the adult with a phobia seldom remembers such an
event, the fear seems unreasonable.
Knowledge about learning also sheds light on the possible
way in which agoraphobia develops. As with simple phobias, the person who first
experiences panic attacks in the presence of a certain set of circumstances -
alone in a crowd, for example - may learn to associate awful sensations of
panic with all crowds. Repeating the experience, or anticipating it, may
reproduce the feeling of threat. Avoiding crowds reduces the discomfort.
Because the avoidance behavior is rewarded, the person is more likely to avoid
crowds in the future. Avoidance also reduces the opportunity for the person to
test whether crowds actually do cause panic. By foregoing this kind of potentially
corrective experience, the person further strengthens the phobia.
Observers studying anxiety, including Freud, have long
predicted that the brain and the central nervous system would be found to be
functioning abnormally in patients with serious anxiety disorders. Their
predictions remained speculations, however, because they were limited by the
methods and knowledge of their times. All that has changed. Because of recent
technological advances, much of the research now being done on anxiety and
related disorders focuses on the brain. Biological research workers also
attempt to understand anxiety disorders by experimentally producing anxiety in
human beings and other animals. Others look for physical symptoms that often
accompany phobias or panic to see if they may play a role in causing the disorders.
In light of what scientists would like to know about the
role of the brain in anxiety disorders, this work has just begun. Research on
neurotransmitters, the chemicals that carry messages from one nerve cell to
another, has not found serious malfunctions associated with anxiety. But
indirect measures suggest some abnormalities, particularly in the
neurotransmitters norepinephrine, GABA, serotonin, and possibly adenosine.
Scientists are, however, still far from being able to say
whether faulty brain function reflects the Cause of anxiety disorders - some
genetic fault coded into the personÕs hereditary apparatus, for example.
Experts disagree about the meaning of some research findings. Much of the work,
for example, has focused on the brainÕs processing of drugs that reduce
anxiety. Such work suggests, but does not prove, how the brain functions during
episodes of severe anxiety. Another problem so far has been that most research
necessarily is confined to animals; whether the results apply to human beings
is not certain. Pieces of the neuroscientific puzzle have been found, and they
are beginning to fall into place.
Investigators have identified several substances over the
past few years that can actually produce panic attacks in people who have
already experienced them (but not in people who havenÕt). This line of evidence
suggests that patients who are subject to panic attacks may be biologically
different from other people. It also offers clues to just what those
differences might be. The ability to induce panic attacks gives research
investigators a powerful tool for understanding them.
The most thoroughly studied of these anxiety-producing
chemicals is sodium lactate. The use of this substance to induce panic attacks
is based on the observation that some people who suffer extreme episodes of
anxiety produce an excessive amount of the chemical lactate after routine exercise.
For these people, exercise can actually set off a panic attack. Researchers
have found that sodium lactate triggers panic attacks in a full 80 percent of
patients with panic disorder, but in less than 20 percent of normal people.
Lactate infusions may provide a means of suggesting which patients are
biologically prone to panic attacks and thus apt to respond to drug treatments.
It is unlikely, however, that lactate infusions will ever be a sure test.
Although less intensively studied, caffeine is another
substance that can produce panic attacks in susceptible persons. Caffeine, of
course, is common in coffee, tea, cola, and other soft drinks, and many other
foods such as chocolate. About half of panic disorder patients have panic
experiences after consuming caffeine equivalent to four or five cups of coffee.
(Normal people also experience panic, but only after they ingest much higher
amounts of caffeine.) Caffeine is thought to produce its effects by blocking
the action of a brain chemical known as adenosine, a naturally occurring
sedative. Clinical investigators have found that many people with panic attacks
avoid caffeine after noticing that it causes attacks.
Other types of biological research are also under way. One
of the oldest experimental approaches tests physiological responses - for
example, heart rate, blood pressure, sweating, or characteristics in the skin.
Another type of research examines the role of hormones. But none of these
studies has as yet been integrated with what is being learned from studies of
the neurotransmitter systems in the brain.
Several studies have shown that patients suffering from
agoraphobia and panic disorder have different physiological reactions to
fear-producing stress than the average person has. Differences of this type may
be present from birth and may explain why some individuals are more susceptible
than are others to anxiety disorders.
Several years ago, a number of investigators reported that
some agoraphobic patients have a mild heart condition known as mitral valve
prolapse or MVP. Like agoraphobia itself, the condition tends to run in
families. MVP can give rise to heart palpitations, which some experts believe
might trigger panic attacks. It is also possible, however, that chronic anxiety
and panic attacks may produce MVP or that both panic attacks and MVP may be
symptoms of an underlying nervous system disorder. Finally, it still remains
unclear whether there is any difference in the frequency of mitral valve
prolapse in panic patients when compared to the general population.
Malfunctions in the thyroid gland have been reported in
about one in ten patients who are prone to panic attacks. The relationship
between these conditions, which can also cause heart palpitations, and panic is
still in the early stages of investigation.
Because breathing difficulty is a hallmark of panic
attacks, research scientists have recently become interested in
hyperventilation, a condition marked by rapid breathing. The symptoms are similar
to those experienced sometimes when blowing up a balloon: dizziness, inability
to pay attention or concentrate, and tingling sensations around the mouth and
fingers.
The role of history - as recorded in our genes, passed on
through our cultures, or learned in our families - is also under study. Barely
under way are attempts to learn the relative contributions of nature and
nurture to the development of phobias and panic disorder. Some investigators
are studying families, because phobias and panic are more common in the
relatives of patients than in the general population. Whether this tendency is
inherited - passed on genetically - or learned by growing up or simply living
close to other anxious people is not known, although some evidence suggests
that the link is at least partly genetic.
Clues to what causes anxiety disorders also come from
naturalistic observations of animals and human societies very unlike our own.
Something like a phobia seems to occur in many animals. Some dogs who have
never been touched by anything but a loving hand will cower and slink away at
the sight of a broom. Their fear, as well as the common human fear of snakes,
may hark back to some earlier stage in evolutionary development. In human
societies, cultural differences seem to produce surprising variations in
anxiety disorders - the age at which they begin, the course they follow, the
symptoms, the distribution among different social groups, the source of
anxiety, the experience of the emotion, and the consequences in the life of the
sufferer.
Some fears are shared across cultures, suggesting that
they enhanced the chances of surviving in the evolutionary history of the human
race. Most phobias are directed toward a relatively small number of objects and
situations, though there is no reason to believe that these items cause
unpleasant experiences more frequently than many others. Phobic fear of truly
dangerous electrical outlets, for example, is rare, while fear of
seldom-encountered snakes and harmless insects is common. People in our culture
are more likely to receive a shock from an outlet than a bite from a snake or
one of these insects.
Scientists have sought to explain this paradox by
speculating that humans may have an inborn predisposition to fear certain
things. This so-called preparedness theory is consistent with the fact that
most common phobias (darkness, animals, etc.) involve objects and situations
that date from primitive times and were, in the distant past, serious sources
of danger.
Despite all the research being done on the anxiety
disorders - an activity that has accelerated in the last few years - none of
the theories that are tested in the various types of studies is adequate to
explain what causes phobias and panic. The explanation is probably not far off,
however. As they are now propounded, theories about the causes of different
types of anxiety disorders tend to cluster either around psychological and
social factors or around biological factors. Simple phobias are usually
explained in terms of early experience and learning, while agoraphobia and
panic (and sometimes social phobia) are becoming increasingly understood as at
least partially biological in origin. Most likely, all phobias and panic result
from a mixture of influences, although that mixture probably changes with the
type of phobia and individual differences among patients. Many theories reflect
an implicit assumption that the more serious disorders, such as panic attacks
and agoraphobia, are more likely to have a biological basis than the troubling,
but less disabling, simple phobias.
Even though the causes of phobia and panic are not well
understood, treatments for these disorders are often very effective. Therapists
use a variety of techniques, their choice usually linked to their beliefs about
the cause of the disorder. But, upon examination, it turns out that many of
these techniques share a common feature: They all seem to require that
patients* confront the source of their discomfort. Some therapists ask their
patients to confront a feared situation in imagination, while others require a
real-life confrontation. Some therapists define the source of fear as the
external object or situation the patient identifies as fearful, while others find
a deeper source within the patient - in the unconscious, in thoughts, or in
physical sensations. Still another difference is that one therapist might set
up an explicit program for confronting feared objects and situations, while
another might use drugs or psychotherapy to prepare the patient to confront
fearful situations in everyday life.
*The term Òpatient,Ó usually heard in medical settings,
will be used here interchangeably with the term Òclient,Ó more typically used
by psychologists and social workers.
For the first two-thirds of this century, phobias, like
other emotional disorders, were treated almost exclusively by psychoanalysis or
related forms of psychotherapy. In psychoanalysis, unconscious conflict is seen
as the source of anxiety. The goal of therapy is to bring that conflict to
light, analyze what it means to the patient, and substitute present-day
realistic appraisals for fearful ones that are based on the limited
understandings of childhood. Psychoanalytic techniques include free association
(encouraging the patient to say whatever comes into his mind), analysis of
dreams, and analysis of the relationship between the patient and the therapist.
Other forms of psychotherapy are usually more directive in their techniques: Instead
of waiting for the patientÕs memories and feelings to emerge and drawing
inferences from these patterns of association, some therapists actively try to
provoke or suggest sources of conflict and direct their patients through ÒhomeworkÓ
assignments.
Unfortunately, psychoanalysis and related forms of
psychotherapy prove disappointing in the treatment of phobias. Patients usually
find the therapy helpful in resolving conflict, decreasing general anxiety, and
identifying and modifying feelings and thoughts associated with panic attacks
and phobic avoidance. But the phobic symptoms themselves often remain. Freud
himself acknowledged the limitations of pure psychoanalysis in treating phobias
(and anticipated the development of behavioral techniques), saying: ÒOne can
hardly ever master a phobia if one waits Ôtil the patient lets the analysis
influence him to give it up...One succeeds only when one can induce them
through the influence of the analysis to go about alone and to struggle with
their anxiety while they make the attempt.Ó
Just such an approach has been found to be effective in
helping phobic patients stop avoiding the thing they fear (see section on
exposure therapy below). Many therapists find that such improvements are more
lasting if patients undergo psychotherapy as well, either individually or in
groups. By monitoring situations that seem to give rise to the panic attacks,
for example, an agoraphobic can identify thoughts and feelings that are
troublesome. The therapist can then help the patient to work out a course of
action that might realistically change the source of distress and to give up
the habitual style of avoiding it by retreat into phobic behavior. Therapists
can also help the patient to become more assertive when involved in conflict
with other people and train him in skills needed for other social situations.
The support of a caring therapist may be crucial for long-term success of any
treatment technique.