Specific phobias are regarded as the forms of anxiety disorder that can be treated effectively with cognitive-behvaioural therapy (CBT). Significant improvements can be seen in the course of a single 2 to 3-hour session of CBT. In these sessions, the patient is exposed to the feared stimulus gradually, in a safe setting, until this stimulus no longer produces a fear reaction. CBT has even been found to be just as effective when administered by means of a “self-help” book.
In contrast, studies indicate that medications such as the antidepressants and anxiolytics that are effective for treating most other anxiety disorders have little effect on specific phobias.
People who manage to avoid the things or situations that are the subject of their phobias can sometimes lead relatively normal lives. But people who have to take excessive steps to avoid these things or situations
are regarded as functioning pathologically, and it is essential for them to seek help.
PHOBIAS
Unlike a panic
attack, where the stimulus that causes the emotional reaction
is diffuse or unconscious, a phobia is a fear that is irrational
but that is consciously triggered by a specific
stimulus or a particular situation.
When people are put in the presence
of the thing or situation that triggers their phobia, they experience
great anxiety and a pressing urge to be somewhere else. This
leads them to adopt avoidance behaviours that can become serious
handicaps in their social lives—for
example, when someone has both social phobia and agoraphobia, the
two phobias that most commonly arise from particular situations.
Social phobia is an excessive fear of being
forced to play a role in society. People with social phobia are
chronically afraid to speak in public, of course, but they may
also experience great distress if they simply have to go to a
party, or eat in a cafeteria, or write in the presence of other
people, or hold a conversation, or meet someone new.
In
fact, people with social phobia experience great fear at the
mere thought of having to interact with other people. Social
phobics are constantly afraid that they will do or say something
stupid. They are unhealthily concerned about what other people
may think of them. Their emotional, social, and professional
lives are littered with lost opportunities, and they often end
up leading solitary lives.
So we are not just talking here about simple shyness, or a slight
uneasiness that someone may feel in the presence of others and
that may actually help him or her mobilize the personal resources
to adapt to the situation. To anxiety-provoking situations, people
with social phobia actually cut themselves off from a whole range
of activities, thus perpetuating the vicious cycle of their phobia.
Agoraphobia is, in some sense, even more disabling
than social phobia, because with agoraphobia, the fear is triggered
by the mere fact of being in public. Agoraphobics thus avoid
going into stores, taking buses or subways, being in crowds,
and so on.
What agoraphobics say they fear most is being stuck someplace
where it would be hard to get away or to get help if they experienced
a panic
attack. Some people even develop their agoraphobia after experiencing
an embarrassing panic
attack in public.
Agoraphobia can even lead sufferers to close themselves up in
the safety of their home, and some will completely refuse to come
out of the house, sometimes for years on end.
In treating
panic disorders, as in treating most other forms of anxiety
disorders, psychosocial therapies can complement medication
very effectively. In these forms of therapy, patients are
encouraged to understand their panic attacks and identify
the things that trigger them. Relaxation therapies, for
example, can provide patients with valuable tools to help
them deal with the situations that make them anxious.
Anxiety
disorders arise when a person's internal alarm
system starts working overtime and gets
out of control. Because of the similarity of the physiological
responses that accompany them, all of the anxiety disorders
can be regarded as variations on the same theme—anxiety.
There are some major similarities among all these disorders,
but some major differences too.
PANIC DISORDERS
Panic
disorders resemble phobias and post-traumatic
stress disorder in the intensely rising anxiety that
they generate, but differ in that the source of this anxiety
is more often internal rather than associated with any
given external stimulus. Thus, whereas people with specific
phobias can develop behaviours specifically designed to
avoid the source of their anxiety, people with panic disorders
find it much harder to do so. In fact, some patients with
panic disorders develop behaviours to avoid such broad
categories of locations that they are said to have panic
disorder with agoraphobia.
One common
explanation of panic disorders is that they represent a form
of conditioning between a particular physiological process
(such as a rise in blood pressure) and a disagreeable situation
(for example, being the target of verbal or physical aggression).
Once this conditioning is established, whenever this physiological
process (such as the rise in blood pressure) recurs, even
if it is triggered by an entirely different situation (such
as a discussion with one's supervisor, or in front of a large
audience), it will, by association, cause the person to re-experience
the disagreeable feelings that will trigger the panic attack.
PTSD
is often accompanied by depression and,
in the most serious cases, a genuine risk of suicide.
Like people with any other mental illness, people with
PTSD will probably also tend to abuse alcohol
or other drugs. Psychiatrists see this abuse
as an attempt at self-medication that does not remedy anything
in the long term.
Behavioural and cognitive
therapies can alleviate the symptoms experienced by people
who have PTSD. These forms of therapy often involve a process
of desensitization, in which the patient is exposed to
memories of the traumatic event in the secure setting of
the psychotherapist's office. This process can help the
patient to feel less afraid and eventually to manage his
or her fears more effectively.
PTSD sometimes resolves itself over time, even without treatment.
Thus, in a sense, the purpose of the psychotherapy is to
accelerate this natural process of forgetting.
POST-TRAUMATIC
STRESS DISORDER (PTSD)
People
who experience events that involve loss of life or risk
of death or serious physical injury may develop post-traumatic
stress disorder (PTSD). The feelings of despair and horror
associated with PTSD are manifested in the following three
kinds of symptoms.
- Intrusion Symptoms
When PTSD sufferers manifest intrusion symptoms, they do
not simply experience memories of the traumatic event—they
cannot stop their memories from coming back to haunt them.
Some of these people experience veritable flashbacks so
invasive that it feels as if they are literally reliving
the event. Nightmares are another form of intrusion symptoms.
- Avoidance Symptoms
When PTSD sufferers show avoidance symptoms, they try to avoid conditions and
situations that might trigger memories of the traumatic event. They also tend
to avoid talking about this event, so that they do not have to confront it directly.
Another avoidance symptom is a dulling of the emotions, sometimes so extreme
that these individuals become emotionally deadened. They lose interest in activities
that they used to love, stay away from friends and family, and turn inwards on
themselves.
- Overstimulation Symptoms
People with PTSD may experience many symptoms of hypervigilance that make it
hard for them to concentrate and to finish the activities that they start. More
specifically, these people may: experience insomnia and nervousness, tend to
become frightened easily, have a constant sense of danger or imminent disaster,
be highly irritable, and even engage in violent behaviour.
It was long
thought that people could develop PTSD only if they were
involved in disasters such as being in a plane crash, witnessing
a homicide, or being trapped in a building that had collapsed
in an earthquake or a bombing attack. War is in fact the
main cause of PTSD, and in North America, the largest group
of PTSD sufferers consists of Vietnam War veterans. Indeed,
most of what we know about PTSD comes from studies of combat
veterans.
Over 90% of people
with OCD have both obsessions and compulsions. Almost 50%
also say they have multiple obsessions.
Cognitive-behavioural
therapy is the most effective treatment for most people
with OCD. This therapy consists in exposing patients to
situations that trigger their obsessions, then gradually
giving them some ways of preventing the anxiety and the
compulsive behaviours associated with them. For example,
if someone is obsessed with cleanliness, the therapist
might have him touch things that he perceives as “contaminated” until
his anxiety disappears. The next step would be to have
him not wash his hands after having handled a “contaminated” object.
Cognitive-behavioural therapy for OCD typically involves 12 to
20 of these sessions, and 75% of the patients
who complete the full course of treatment
experience substantial, lasting relief from
their obsessions and compulsions.
In the most severe cases of OCD, certain medications, such
as selective serotonin reuptake inhibitors (SSRIs) and tricyclic
antidepressants, can help prepare patients to benefit from
cognitive-behavioural therapy.
OBSESSIVE-COMPULSIVE DISORDER
(OCD)
People with obsessive-compulsive
disorder (OCD) are the slaves of their repetitive thoughts
and behaviours. These people recognize the absurdity and
senselessness of these worries and rituals, but giving
them up would take so much time and energy that it would
seriously compromise their ability to function at work,
at school, and at home.
Typically,
a distinction is made between obsessions, which are intrusive,
undesired thoughts, and compulsions, which are repetitive,
often stereotyped actions. But obsessions and compulsions
are closely related: the latter represent an attempt to calm
the former.
Obsessions, then, are recurrent thoughts
or mental images that impose themselves on an individual's
consciousness. They resurface constantly and uncontrollably,
so that the person's mind can never relax, and hence they
constitute a major cause of distress.
Compulsions are repetitive behaviours
in which people with OCD engage to try to drive away their
obsessions and reduce the anxiety that they cause.
Compulsions tend to become stylized into sequences of elementary
actions that the sufferer must perform at any cost in order
to avoid anxiety and distress. Compulsions often resemble
rituals in which the sequence and repetition of gestures
is minutely codified and in extreme cases may even involve
the patient's friends, family, and other people as well.
The following table lists the most common obsessive ideas and
the corresponding compulsive behaviours.
Obsession
Compulsion
Fear of being contaminated by dirt, dust, germs, bacteria
Washing hands or entire body or cleaning objects excessively
Fear of losing control and hurting oneself or harming
someone else
Engaging in slow, complex, time-consuming rituals revolving
around organization and control
Feeling of having forgotten to do something important
(turn off the faucet, lock the door, etc.)
Repeatedly checking whether you have done the thing in
question (for instance, checking the door 100 times to
see whether you have locked it)
Fear of having disgusting, violent, sexual, or sacrilegious
thoughts
Reciting numbers, names, or phrases to drive away the
undesired thoughts (for example, counting down from 10
then up to 10 a hundred times)
Need for symmetry, need to organize and save even the
most useless objects
Tidying the house and arranging things in a certain order,
saving things and being unable to throw any of them away
As with many other
anxiety disorders, the treatments available to people who
have generalized anxiety disorder (GAD) include various
forms of psychotherapy, medications, or a combination of
the two. It is up to each patient to talk with her doctor
to see what form of treatment works best for her.
The medications prescribed for GAD include tranquilizers,
such as the benzodiazepines,
and antidepressants in the Prozac family.
One the most effective forms of psychotherapy used to treat
GAD is cognitive re-evaluation, which helps patients to correct
thinking patterns that cause them to worry. Other potentially
beneficial therapeutic approaches include learning new ways
to solve daily problems, confronting and gradually gaining
control over one's worries, and various relaxation techniques.
In a recent Canadian study, 77% of GAD patients who had received
short-term psychotherapy remained GAD-free one year after
treatment.
GENERALIZED ANXIETY DISORDER (GAD)
Generalized anxiety
disorder (GAD) is manifested by worrying excessively
over extended periods, about various things that are
not necessarily interrelated. In other words, people
with GAD worry about events that have a strong chance
of never occurring.
Thus, if someone with GAD has a headache, consults
the doctor about it, and is told that nothing is wrong,
he or she may still worry that the cause was actually
a brain tumour, and the doctor simply missed it.
In addition to illness, the most typical subjects of concern
for people with GAD include being short of money, losing their
jobs, and not being able to take proper care of their families,
as well as more routine matters such as being late for an appointment.
But in this last case, a person with GAD might reason as follows: “If I'm
late for this appointment, I might lose my job, and then I don't know how I'm
going to make ends meet. I might be so broke that I'll have to sell my car.” Such
trains of thought can lead to ruminations that last anywhere from a few minutes
to several hours. By endlessly reviewing so many negative scenarios in this way,
people with GAD become hypervigilant and highly
vulnerable to environmental stressors. People with GAD are also far more
susceptible to health
problems involving weakening of the immune system.
In
fact, people with social phobia experience great fear at the
mere thought of having to interact with other people. Social
phobics are constantly afraid that they will do or say something
stupid. They are unhealthily concerned about what other people
may think of them. Their emotional, social, and professional
lives are littered with lost opportunities, and they often end
up leading solitary lives.
What agoraphobics say they fear most is being stuck someplace
where it would be hard to get away or to get help if they experienced
a 
