PHOBIAS AND FEARS

SOCIAL PHOBIA

What is social phobia or social anxiety?

Social phobia or social anxiety disorder is an anxiety disorder characterized by anxiety occurring during situations involving social interactions. The feared situations may be limited (for example, performance situations such as public speaking) or more general, impacting the life of the individual. Like other phobias, there is no discomfort outside the feared situations, hence a tendency to avoidance. The prospect of being in a feared situation can cause anticipatory anxiety: and the person suffering from social phobia or social anxiety worries in advance of a public speaking, if that is their phobic tendency.

What are the causes of social phobia or social anxiety?

As with other anxiety disorders, the causes of social phobia or social anxiety are multifactorial, involving an interaction of genetic, congenital, learning,  and social factors. Nevertheless the families of these individuals often exhibit limited social interactions: for example these parents themselves are unsociable.

What are the common symptoms of social phobia or social anxiety disorder?

People with social phobia (or social anxiety disorder) usually have the following symptoms:

Anticipatory anxiety of the feared situation with tendency to avoidance;

More or less intense discomfort when they find themselves in the feared situation with the possibility of physical symptoms (tremor, stuttering, sweating, blushing) in addition to the fear of being criticized by others or perceived as inadequate or bizarre;

When the person is afraid of blushing, it is called ereutophobia.

Social phobia or social anxiety disorder can be so debilitating as to impact the social and professional life of the person who is affected.  It is likely to lead to addictive behaviors such as alcohol or drugs misuse in order to facilitate social contacts.

What is the treatment of social phobia (or social anxiety disorder)?

While medications have proven their effectiveness (antidepressants and tranquilizers) and can be prescribed in very severe cases, the treatment is based on mainly psychotherapy.

Cognitive and behavioral psychotherapies are particularly recommended, individually and in groups, but other approaches can also have a role, for example systemic therapy and EMDR. The therapeutic work will focus on expanding the "comfort zone" of the individual, therefore helping them to gradually confront the distressing situations  by challenging the cognitions that underlie the discomfort.

If you have a friend or significant other with social phobia (or social anxiety disorder), it is of course important to be understanding, patient and avoid any sort of mockery. Undoubtedly one way to help would be to accompany them to gradually confront the feared situations: dinners, meetings, public events. The goal of exposure therapy is for the individual to one day be able to face the feared situation alone.


AGORAPHOBIA

What is agoraphobia?

Agoraphobia is an anxiety disorder characterized by anxiety occurring in a space that the individual considers to be dangerous or uncomfortable: in particular open spaces where a crowd gathers. In these situations the individual fears that they may have a panic attack, and they also suffer from anticipatory anxiety in the moments prior to heading to such places, and this can lead to avoidance.  Agoraphobia can occur in any location where the individual cannot escape easily: airport or train station, supermarket, crowded community clinic waiting room, but also just a meeting room.

What causes of agoraphobia?

As with other anxiety disorders, the causes are multifactorial and consist of an interaction of genetic, congenital, learned and social factors.

What are the common symptoms of agoraphobia?

People with agoraphobia generally have a history of panic attack associated with places where they become scared. Then occurs a phenomenon of overgeneralization whereby they feel scared in other places having the same characteristics. Thus a panic attack will occur in the subway, and the person become fearful of the subway, then any place resembling the subway such as trains, shuttle buses elevators and airplanes.

The phobia is accompanied by anticipatory anxiety and avoidance tendencies. So agoraphobia confined to crowded places will make you avoid stores, but also very busy streets, stations, malls, and so on…until it becomes vey debilitating. Usually the individual is ashamed of their disability and will find plausible reasons to avoid such environments.

The concept of being able to escape is central. So an employee can become agoraphobic of business meetings through the thought that they are unable to escape without showing their vulnerability. In this scenario, the individual usually escapes to a safe place in order to avoid the gaze of others.

What is the treatment of agoraphobia?

While medications have proven efficacious (antidepressants and tranquilizers) and can be prescribed in very severe cases of agoraphobia, treatment is based mainly on psychotherapy.

Cognitive and behavioral psychotherapies are particularly recommended in agoraphobia but other approaches may also have a role, for example systemic therapy and EMDR. The therapeutic work will focus on expanding the "comfort zone" of the agoraphobic, so helping them gradually confront the distressing situations all the while challenging the unhelpful thoughts that underlie the discomfort.

In my practice, the demands for this type of problems are quite common and diverse: from agoraphobia that is confined to heavily crowded places (streets, shopping centers, airports and train stations) to agoraphobia confined on closed spaces (subway, plane, bus, elevator), without forgetting the employee who is agoraphobic of business meetings. I have helped many people understand and cope better with these debilitating problems.

SPECIFIC PHOBIAS

Individuals with a specific phobia have anxiety related to a specific situation or object, such as fear of flying, needles, blood, or a particular animal (snakes, spiders) or insect. The specific object or situation is perceived as an overestimated threat of harm to the person, and this perception leads to avoidances and safety seeking behaviors in relation to situations or places where they may come into contact with the feared stimulus.

Emotional and physical changes during phobias are similar to panic, as are the range of avoidance, reassurance seeking and checking behaviors that occur. People can end up leading highly impaired and restricted lives.

Blood and injury phobias (including needles) are the only anxiety disorder in which the individual may faint. For a person to faint, a rapid reduction in blood pressure has to happen. When a person is anxious during a panic attack, generally blood pressure increases rapidly and there is no possibility of fainting. In contrast, in blood and injury phobias blood pressure actually drops, so it makes evolutionary sense for the individual to fall or lie down, so that the head and heart are on the same vertical level, thereby maximizing blood flow to the brain (the so-called vasovagal response).

Cognitive Behavioral Therapy (CBT) is the cornerstone of treatment, but other approaches may also have a role such as EMDR in order to address a traumatic history.

HYPOCHONDRIASIS

The individual with hypochondriasis (also known as health anxiety) has fear of having particular illness or disease, and misinterprets physical symptoms as a sign that confirms that illness. In a panic attack, the fear might be of collapsing right now, whereas in hypochondriasis, the fear is of significant and nasty illness that will cause harm or damage to the person some time in the future. It is important to confirm the diagnosis of health anxiety (hypochondriasis) with a proper physical history and appropriate investigations, as many physical disorders also cause anxiety-style presentations (such as heart disease, asthma, thyroid dysfunction and diabetes). Do not fall into the trap of making a premature and incorrect psychological diagnosis when the problem has a physical cause.

In health anxiety, anxiety is predominant. The anxious concerns lead to physiological arousal, and selective attention focused on the person's own body, which is then misinterpreted as evidence of the illness. The same occurs with common everyday bodily sensations and also symptoms of mild but self-limiting diseases such as colds and tummy bugs. For example, the individual may have health anxiety related to a brain tumor, and may misinterpret eye strain or headaches as a sign that they have a tumor.

Patients with hypochondriasis are likely to seek repeated consultations with health professionals, and some may even have had exploratory tests or treatment. Safety behaviors such as presenting and re-presenting to health professionals for further tests and reassurance only reduce anxiety for a short time before the person seeks even more tests and still more reassurance.

As with other anxiety disorders, the causes of hypochondriasis or health anxiety are multifactorial and involve an interaction of genetic, congenital, learning and social factors. In some cases the individual has had traumatic events in their life such as a relative or significant other who died abruptly from an illness.

The treatment of health anxiety is essentially based on psychotherapy first. Cognitive Behavioral Therapy (CBT) is particularly recommended, but other approaches can also have a role such as EMDR or systemic therapy. In some cases of health anxiety, the psychiatrist might be tempted to prescribe a psychotropic medication, such as an antidepressant or tranquilizer, but any intolerance or side effect can increase anxiety.