Phobias

PHOBIAS AND FEARS

A phobia is the sensation of extreme fear which is greater than fear which would be reasonable in a particular situation, or which is completely unrelated to any real threat. The phobic person, when confronted with even the idea of whatever s/he fears, feels extreme anxiety which is emotionally manifested as extreme terror and physically manifested in symptoms typical of anxiety or panic attacks. [See “Panic Attacks” article at www.selfgrow.co.za.]

Phobic people will go to extreme lengths to avoid the phobic object/event/experience, often endangering their own well-being, or impairing their happiness and success in life: People have, for instance, jumped out of moving vehicles or from high buildings to avoid such things as cockroaches or grasshoppers. Many people turn down promotions at work because they are afraid of flying or using a lift [elevator]; others live a life of seclusion because they are afraid of leaving their homes; some walk long distances to avoid passing near a home with barking dogs or a black door. Even commercially phobias are catered for, in that, for instance, buildings are numbered without a 13th floor, or offices and hotels without a room #13, or airplanes without seat #13: money was being lost because so many people fear the number thirteen.

Some phobias lead to Obsessive-Compulsive behaviours. In order to “neutralise” the felt threat which they obsess or think constantly about, sufferers will engage in an action, such as washing hands, or counting, or touching something a set number of times compulsively, until such actions take over their lives and significantly impair their ability to live, work or socialise.

The main difference between a Phobia and a Fear is that a phobia is deemed irrational, often even by the person who is phobic: “I know a cockroach can’t hurt me but I just panic when I see even just a picture of one” is a typical comment. Phobic people often become immobilised and panicky in the face of the threat and will go to great lengths to avoid it, whereas people who have a rational fear of a threat will often face their fears in order to be safe or successful or happy. People will often overcome real terror of something they have true cause to fear, in order to save themselves or others from further negative consequences: A mother may rush into a burning home to try to save her children; people in the armed forces or rescue units [like fire fighters] regularly overcome their rational fears of a situation for the sake of others’ safety. People can use reason to overcome their rational fears, but by its very definition, the irrational fear in a phobia can usually not be addressed by reason. Some phobic people overcome their avoidance, for instance of flying or snakes, but will still experience the bodily arousal [panic state], racing thoughts, helplessness, powerlessness and terrible foreboding that the experience arouses, often needing medication to get through the phobic experience.

Unlike fears of actual danger, phobias are irrational and result in panic symptoms and extreme avoidance. If you live in a rural area and are scared of snakes and very vigilant when you walk in scrub areas, this would be a rational fear. If you live in a city and are so afraid of snakes that you can’t look at a toy snake in a shop window without feeling faint, you probably have a phobia.

Some people have a specific phobia, such as a fear of feathers, whereas other have combinations of many phobias, such as fear of confined spaces, and thus also of lifts and of flying. Sometimes people also have more than one mental disorder in addition to phobias, such as Obsessive-Compulsive Disorder and some form of Personality Disorder, as is seen in the movie As good as it gets.

The most common phobias are the fear of having to speak in public, which is often related to performance anxiety, and social phobia [or social anxiety].

Phobias vary from the rare [such as the fear of peanut butter sticking to the roof of your mouth] to the very common, such as the fear of public speaking, meeting strangers or being in social situations, dogs, small spaces, lifts, flying, spiders, snakes, heights, failure, driving, water [to swim in], the number 13, or open spaces.

Here are names given to some common phobias: #13 = trikadekaphobia; animals = zoophobia; clowns = coulrophobia; confined spaces = claustrophobia; open or crowded spaces = agoraphobia [common with Panic Disorder]; crawling insects & snakes = herpetophobia; doctors/medical treatment = iatrophobia; foreigners – xenophobia; loud noises = ligvrophobia; needles = aichmophobia; night/dark = nyctopohobia; marriage = gamophobia; speaking/public speaking = glossophobia; spiders = arachnophobia; stage fright = topophobia. For a very long list of many different kinds of phobias, see http://phobialist.com .

Phobias are categorised as Anxiety Disorders. They affect more than ten million adults in North America alone, and are twice as common in women as in men. Some phobias are related to specific cultures or religions, some are common to families or small communities, others to events or eras, whereas many are specific to an individual. Examples of group phobias are the fear of witches or witchcraft at various times in various countries, the Tokoloshe in some South African cultures [a small man who will steal children or eat your feet or rape women, etc, if you do not put your bedposts on piles of bricks so that he can’t reach you], demons, black or the dark, water, the numbers thirteen or four or “666”, and now also “9/11”, solar or lunar eclipses, owls/crows, etc.

Causes of Phobias

Have you ever experienced that terrible feeling when you are so afraid of something that is not dangerous enough to warrant extreme panic, that you’ll do anything to avoid it? Afraid you would faint if someone just mentioned or showed you a picture of that feared object or event? So scared you would grab hold of a stranger, or lose bladder control, or vomit if you encountered it, that you start staying away from any place or situation you may think of it, to your own detriment? So embarrassed at what you knew was an irrational fear but beyond your control, that you withdraw from social situations and even from close friends?

Phobias can start at any time in someone’s life, and also occur in group settings. Sometimes the phobia is caused by a scary experience, such as being bitten by a dog, but often the phobia occurs because of indirect influences: A child may learn phobic behaviours or beliefs from adults or older children. Adults may similarly learn phobic responses from others. Phobias may be due to associated learning, such as hearing a scary or loud noise while encountering, for instance, an insect, or being on a high place. Sometimes it’s symbolic. Sometimes it’s the result of unpleasant emotions aroused by a story in a book, or told by someone else, or a movie, or actual historical events.

Most phobias are thus related to actual or imagined traumatic events, which is why De-briefing [or Desensitization] is an essential element in effective modern treatment protocols. As in PTSD [Posttraumatic Stress Disorder] or Acute Stress Disorder, symptoms include avoidance, sensory flashbacks, hyperreactivity [i.e. the reaction is extreme for a relatively non-dangerous trigger], hypersensitivity [jumping and screaming when a leaf falls on you under a tree because you fear it’s a snake, etc], hypervigilance [constantly being on the look-out for the possible stimulus object or event], anticipatory anxiety [of encountering the stimulus], and severe, undue emotional distress.

Phobias and the Brain

As indicated before, phobias constitute an irrational and strong fear/terror response to a relatively safe trigger. It is considered rational to be afraid when encountering a dangerous snake in the wild, but not to faint or panic when you see a plastic one in a shop, a picture of a snake, or a real snake in a sealed container.

Our four basic emotions [from which other emotions are derived] are formed in a primitive part of the brain, common to reptiles and even lower forms of life on the evolutionary development scale, like molluscs. These emotions help to keep us safe, through flight, fight or freeze responses, from real physical threat, to find food in order to live, and to procreate in order for the species to survive. 50% of these basic emotions create fear-based responses: the Panic system and the Fear system. [The other two are the Aggression-Rage and Seeking-Lust systems.]

Panic and phobic reactions are caused by responses from the Reptilian Brain just above the brain stem [involved in survival reflexes]. The Reptilian Brain is in charge of our physical survival and thus dominates any responses or response patterns required for what it perceives to be a dangerous threat. Just like it’s useless to try to reason with a crocodile that’s got hold of your foot, the Reptilian Brain does not respond to reason/rational thinking or speech. So it does not help to tell ourselves we should not be afraid of e.g. a lift [elevator] or cockroach or flying: the Reptilian Brain does not compute this.

The word “perceives” in the above paragraph is important. Reptiles react to the belief that they are in danger when they try to destroy, for instance, a person who is trying to rescue them from a danger like flood, fire or injury. When we see a scary movie or hear bad news about a scary event in another country, our brain causes our body chemicals to create a state of physical arousal of anxiety, fear, terror or panic – which is why many people cover their eyes during a scary part of a movie, or some dogs panic during thunder storms or even when they smell a benign smoke like from a barbecue fire: the primitive brain responds to the images of doom created by sensory or imagined or remembered stimuli, and creates a flight/fight physiological response. [Some people have spontaneously overcome this by Flooding or other techniques, for instance by watching numerous horror movies, and thus no longer interpret the stimuli as dangerous – see Treatment below.]

So when we see a plastic pink-spotted toy snake, our brain may create an image of how it becomes a real snake, sinks its now enormous fangs into our flesh and kills us in some agonising manner. [People who suffer from a phobia off snakes would probably have had a severe physiological fear reaction just reading that sentence!]

Deep within the Reptilian Brain is a tiny almond-shaped brain structure called the Amygdala [Greek word for almond]. The amygdala remembers actual or imagined experiences that trigger a strong emotional response like fear. This is important for survival for actual danger experiences like falling off a cliff or eating poisonous berries. The amygdala’s function is to prevent us having a repetition of such a dangerous and potentially fatal event at any cost, and thus creates a preventative or preparatory flight/fight/freeze response every time we encounter the potential or actual event, or even imagine it. That is why it is necessary to treat phobias through a combination of desensitization/debriefing, exposure [actual or imagined] and relaxation/self-soothing techniques.

Treatment

Many people handle phobias by simply avoiding the stimulus object or event altogether but for some people the phobia/s begin to control their lives and significantly impair their personal, work and social life – as seen in the examples above. This is so sad when most phobias can be cured relatively easily.

A further problem – as with any behavioural habit – is that the longer we reinforce a brain or neuronal pathway, the more fixed it becomes. Such pathways can allow the easy development of more and more phobias or other anxiety disorders.

I urge you to seek effective professional help as soon as possible if you suffer from any phobia.

Effective [modern] treatments for phobias usually include an examination of the stimulus characteristics, its possible origins in traumatic experiences or imaginings, various levels of symptoms, a change in ways of thinking and behaviour around the idea of the stimulus [CBT, or Cognitive-Behavioral Therapy], some form of de-briefing and/or de-sensitization with Exposure to the stimulus, relaxation responses, ego-strengthening hypnosis, and the practice of alternative [healthy] response patterns. Some people also use prescription anxiolytic [calming] medication or beta-blockers in order to begin the process.

The oldest form of exposure treatment was called Flooding: The phobic person had to be very brave and agree to be exposed to the stimulus in large quantities or over a long period of time, “flooding” the brain with distressing chemicals over time, while the expected disaster did not happen so that the amygdale “cancelled” its survival response programming. You can imagine one has to be very motivated and brave for this sort of treatment. Imagine sitting in a room full of creepy-crawlies until you’re no longer afraid of them! Flooding was later paired with Modeling, where the patient watches another non-phobic person encounter the stimulus in a calm manner.

A South African, Wolpe, devised a protocol of Systematic Desensitization which was more gradual and thus could be used by anyone, although it could take a long time, especially when multiple phobias had to be treated consequentially. It is still a common treatment for phobias today. First a list would be drawn up representing on a scale [e.g. of 0 to 100] the strength of the fear elicited by the phobia in various guises, for instance from encountering a venomous, hissing snake up close while alone [at 100 Units of Distress] to perhaps flowers arranged in a snake shape [at 10 or 5]. The patient would then be taught relaxation techniques [e.g. self-hypnosis]. The lowest level distress stimulus would be presented and the patient would be helped to relax until there was little or no distress. Then the next level would be presented, with relaxation, continuing until the patient could experience or imagine the highest level of fear stimulus with tolerable or no distress. The final step for most phobias would usually be in vivo desensitization: The therapist may, for instance, repeatedly go up and down in a lift with the client until the distress was manageable, and then let the client ride alone until s/he was confident of being able to manage in future. Sometimes a single level of desensitization took one or many weeks, so the treatment could take long and be expensive, especially if in vivo treatment required travel time for the therapist or renting a plane, a snake handler, or scuba equipment, etc. was required.

These days we can use computer technology to create Simulated Phobic Stimuli [similar to those used in, or instance flight simulator games] in place of real life [in vivo] situations, which makes the process more cost effective. We can also use calming computer imagery, with music or brainwave altering sounds to help patients relax effectively and quickly. Even so, the use of rhythmical and deep breathing techniques is still one of the most useful adjuncts to any protocol, as this form of breathing can stop even severe panic symptoms in a few minutes. [See the article on “Panic Attacks” on this web site.]

I find that a protocol consisting of panic or anxiety management [through information about the brain and its responses, plus calming breathing techniques], plus EMDR [Eye Movement Desensitization & Reprocessing – see the article on this web site] with relaxation/hypnosis, CBT [Cognitive-Behavioral Therapy] and Systematic plus in vivo or simulation desensitization, is the most effective and most cost-effective for treatment of any form of anxiety, and especially for phobias.

Some specific common phobias:

These were issues raised at a South African television show “Keeping it Real” on SABC 2, broadcast on 4 January 2011 [on which I acted as consultant]:

One of the most common phobias is that of speaking/presenting in public. Laura has suffered badly from this fear all her life, but was able to give an excellent account of her journey overcoming her fear, with the help of a Toastmasters Club. Although she showed us how her hands were shaking, there were no other noticeable signs of nervousness or anxiety and she spoke excellently, appearing very confident. It is interesting that the Toastmasters program incorporates support, modelling, gradual exposure, systematic desensitization of a kind, and plenty of practical information to help create competency feelings.

Another common phobia is social phobia, on a continuum with social anxiety. Tygerberg Hospital in Cape Town is conducting a research program in this disorder in 2011. People who believe they suffer from this disorder can apply to them to be part of the treatment program.

I have had cooperation from private individuals who are prepared to work in alliance with the therapeutic process for various phobias, for instance [in Cape Town] a driving instructor called Elda has helped some of my patients who were terrified of driving, to get their licences or regain confidence after accidents, for the in vivo part of the treatment [feel free to contact me for her details]. Places like the Sports Science Institute can help with in vivo part of treatment for fear of water. Some dentists have allowed me go with phobic clients so that I could induce a relaxed state through hypnosis anchors, allowing the patients to begin repair to badly damaged teeth and gums after several decades of avoidance due to severe phobias of dentists or of needles.

People in South Africa can contact the Depression and Anxiety Support Group for information, support and therapists, or find a suitably qualified therapist on the Psychology Society web site www.psyssa.com.

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