Mental Health Care

Specific phobias, like the fear of animals, commonly begin in childhood. Some children grow out of their fears when they become adults without any treatment. In others, it may linger into adulthood, and then continue for life. Phobias are quite common in the general population. In community samples, lifetime rates (once in life incidence) range from 10 to 11.3 per cent, with 75-90 per cent sufferers being women.

Agoraphobia typically strikes in late adolescence or early adulthood. It is also more commonly diagnosed in women than in men.

Social phobia can begin at any age, but it generally begins in the early to late teens. It may wax and wane in severity and runs a chronic course. In community studies, the lifetime prevalence figures of social phobia range between 3-13 per cent. Men and women are represented almost equally.

Phobias may run in families. First-degree biological relatives of a sufferer are more likely to develop the disorder.

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Specific phobias are characterized by a striking and persistent fear of a particular object or situation. The fear is so overwhelming that even the thought of a coming encounter with the fear-provoking stimulus fills the person with severe anxiety and apprehension. The fear may relate to an imagined or real harm that may befall him from the stimulus. For example, a person may have phobia of dogs because of the fear of being bitten; may be phobic of flying because he fears the aircraft may crash, or may avoid crossing a bridge because he fears that the bridge might collapse. Sometimes, the phobic stimulus may be absolutely trivial, such as the fear of cockroaches which do not pose any real danger.

At other times, fear preys on fear. People who are afraid of a particular object or situation might demonstrate the symptoms of phobia because they fear that they might lose control over themselves and panic when exposed to the object or situation. A person afraid of closed spaces thus might panic and start screaming on the thought of being confined in an elevator, and a person phobic of heights might fear the dizzy feeling so much that he begins to feel afraid even before he finds himself at a height.

The severity of response also varies with the circumstance. The closer the person draws to the phobic stimulus the more intense is the fear. If he can escape from the phobic object, he feels more reassured and is not so acutely anxious as he would be if there were no exits. Thus, a man afraid of dogs finds his fear growing if the dog draws nearer, and diminishing as the dog moves away. A person with the fear of closed spaces would feel most terrorized when the elevator is in transit than when it is about to open.

Specific phobias are further categorized into the following subtypes on the basis of the fear-provoking stimuli:

Animal type: Some people have their fear cued to animals and insects. This phobia usually begins in childhood.

Natural environment type: If objects in the natural environment, such as heights, water bodies or storms, are the cues for fear they are best placed in this subtype. Generally, such fears also begin in the childhood.

Blood-injection-injury type: If seeing blood, injection, injury or surgery prompts the fear, the phobia is part of this subtype. It runs in families and is often characterized by fainting at the sight of the stimulus.

Situational type: In this subtype, fear relates to a specific situation such as travelling in a bus, passing through tunnels or over bridges, riding elevators, flying, driving, or sitting in a closed space such as a theatre or cinema hall. This disorder begins either during childhood or in the mid-twenties.

Other types: If the fear is brought on by any other stimulus, such as loud noises, choking, vomiting or contracting an illness, it is placed into this subtype.

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Some people develop agoraphobia. They fear being alone or in public places from where escape might be difficult or help might not be available in case of sudden incapacitation. They become extremely anxious and experience overwhelming fear in different everyday settings, like if they were to shop in a crowded shopping plaza, move in a bus or train, cross a bridge or travel through a tunnel. The fear is so acute that they become housebound and reclusive. Some 95 per cent of the victims also suffer panic attacks

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Phobias are thought to be learned, not innate, emotional responses. It is generally held that phobias occur when fear produced by an original threatening situation is transferred to other similar situations, with the original fear often repressed or forgotten. A traumatic childhood experience such as being attacked by an animal, being trapped in a closet, or a near drowning, can produce a specific phobia for the animal, closed spaces, or water. It may also relate to an unpleasant childhood memory of seeing another person suffer. For example, a child who sees a person fall from a height might develop a phobia of heights. The impressionable young mind might also develop a fear modelled on the behaviour of a parent or role model. Likewise, repeated viewing of horror-filled images of a train accident or airplane crash on the television, and repeated warnings from a parent or elder about the dangers of an object can also spur a phobia. The individual may at first try to avoid the object or situation. This response might reduce anxiety in the short term, but it instils deep fear of the object in the inner consciousness and generates phobia.

Social phobias often emerge out of a childhood history of social inhibition or shyness. They may also relate to a stressful or humiliating experience. A poor public performance followed by loss of esteem can cause permanent cracks in the inner self

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Some people feel extremely anxious in social settings. They feel they might be under scrutiny and their actions might embarrass or humiliate them. Although the fear is all in the head, it becomes so intense and persistent that they begin to shiver at the thought of facing up to such a situation and do their best to avoid it. The fear may become so pervasive that it might interfere with their daily routine, occupation or social life. Social phobias can relate to several situations. The more common examples include the fear of public speaking or stage performance, fear of eating in a restaurant and fear of using a public restroom. The whole thing can turn into a vicious cycle. The anxiety associated with the disorder may actually mar performance and worsen the phobia.

People who suffer from social phobia are often hypersensitive to criticism, negative evaluation, or rejection by others. They find it difficult to be assertive and suffer from low self-esteem. They may not be able to achieve as much as they are capable of at work. The anxiety in speaking to a group or to authority figures and colleagues further lets them down.

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Phobias can be successfully treated. Pharmacological treatments offer quick relief, but their benefit is short lived. On the other hand, behaviour therapy can eliminate the phobia altogether, but the treatment is more intensive.

Medications

Several anxiety-quelling medicines come in handy in the treatment of phobias. They block the anxiety response aroused by the phobic object or situation. Benzodiazepines, like alprazolam; beta-blockers, like propranolol, and antidepressant medicines can help check the symptoms of phobia, and can be used before a public performance by those having social phobia. The benefit lasts till the medication is taken.

Behaviour therapy

Behaviour therapy is the most effective treatment for phobias. It holds the promise of a definite cure. A number of techniques are in vogue, and the most popular is the systematic desensitization. In this method, the phobic person is exposed to the anxiety-provoking object or situation in a gradual graded manner. The first step focuses on allaying the person’s anxiety. For this, he or she is given anxiety­relieving medication and lessons on how to relax in the face of anxiety­provoking stimulus. Once he or she is sufficiently equipped to handle the situation, they are confronted with the object or situation that is increasingly similar to the feared one. Gradually, the person learns to overcome fear. In this way, the strong associative links between the feared situation, the experience of anxiety, and subsequent avoidance of that situation are broken. The following case history illustrates the usefulness of the technique.

Therapists have also found other behavioural techniques useful in the treatment of phobias. Thus, in the flooding technique, the therapist encourages the person to actually face up to the feared situation. Gradually, they reach the point when they no longer dread the object or event. The implosion technique, similarly, tries to demolish the fear by training the individual to confront the feared object or situation in their imagination.

Visual imagery, deep breathing and other relaxation techniques are also useful in overcoming social phobia. Yoga, particularly pranayama (conscious breathing) and meditation can also help with their calming effect on the mind.

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Man’s rendezvous with fear must date back to the beginning of life itself. The moment Adam and Eve took their first steps on this planet, they must have bumped into fear. The ‘terrible’ elements of nature-including storms, lightning, dizzy heights, water bodies, fierce and powerful animals, and caves and hidden crevices-must have filled them with trepidation. This natural instinct of self-protective fear still dwells within us after thousands of years of evolution. If we were in a jungle, with no arms and ammunition for safety, and a tiger were to suddenly spring on us, most of us would be petrified. A severe earthquake, tornado, or storm would evoke the same emotion.

This natural fear, in the face of danger, is an in-built mechanism within all human beings. Sometimes, however, some people begin to fear a specific object, situation, or activity, without any logic or justification. This pathological fear, which is persistent, intense, and has no relationship to the real situation, is termed phobia.

People who have phobia realize that their fear is unreasonable. Yet, faced with a feared object or situation, they lose control over themselves, are stricken by terror and go through acute bodily changes. The heart begins to race and thump against the ribs. The skin turns cold and deathly pale and breaks out in cold sweat. The hair stands on end. The eyes and the mouth are open wide. The pupils dilate. The breathing becomes hard and laboured. The mouth turns dry. The lips tremble. The voice becomes indistinct or husky or fails. The bowels and the bladder may move. The muscles become tense. All in readiness to flee or fight.

Most people, who suffer from phobia, try to sidestep their illness. They learn to avoid the object or situation that causes the fear, even if it cripples their freedom. This avoidant behaviour may hamper their daily routine, compromise their social life and rob them of career prospects. For example, a sales manager who develops a phobia of flying might avoid travel, fail to meet his sale targets and be thrown out of his job. Yes, phobia can make life most difficult!

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