Phobia

Understanding Phobic Disorders

Graphics courtesy of HealioOpens in new window A phobia is a persistent, irrational fear attached to an object or situation that objectively does not pose a significant danger.

The person with a phobia experiences a compelling desire to avoid dreaded object or situation, even though he or she usually recognizes that the fear is unreasonable or excessive in proportion to the actual threat.

Marks (1987) has defined phobia on the following criteria:

• The fear is out of proportion to the demands of the situation.
• It cannot be explained or reasoned away.
• It is beyond voluntary control.
• The fear leads to an avoidance of the feared situation.

Phobias usually do not result from past, negative experiences. In fact, the person may never have had contact with the object of the phobia.

People with phobias understand that their fear is unusual and irrational and may even “joke” about how “silly” it is. Nevertheless, they feel powerless to stop it.

Also, people with phobias develop anticipatory anxietyOpens in new window even when thinking about possibly encountering the dreaded phobia object or situation. They engage in avoidance behavior that often severely limits their lives. Such avoidance behavior usually does not relieve the anticipatory anxiety for long.

Classification of Phobias

There are three broad categories of phobias which include agoraphobiasOpens in new window, specific phobiaOpens in new window, and social phobiasOpens in new window.

1.     Agoraphobia

AgoraphobiaOpens in new window without history of panic disorder is less common than the type that precipitates panic attacksOpens in new window.

Agoraphobia is characterized by a fear of being in places or situation from which escape might be difficult, or in which help might not be available in the event of suddenly developing a panic attack symptom(s) that could be incapacitating or extremely embarrassing. Examples include dizziness or falling depersonalization or derealization, loss of bladder and bowel control, vomiting or cardiac distress.

2.     Social Phobia

Social phobia is an excessive fear of situations in which a person might do something embarrassing or be evaluated negatively by others. The individual has extreme concerns about being exposed to possible scrutiny by others and fears social or performance situation in which embarrassment may occur.

In some instances, the fearOpens in new window may be very defined such as fear of speaking or eating in a public place, fear of using a public rest room or fear of writing in the presence of others.

In other cases, the social phobia may involve general social situations, such as saying things or answering questions in a manner that would provoke laughter on the part of others. Exposure to the phobic situations usually results in feeling of panic, anxiety, with sweating, tachycardia and dyspnoea.

3.     Specific Phobia

Specific phobia is characterized by marked, persistent and excessive or unreasonable fear when in the presence of or when anticipating an encounter with a specific object or situation.

Specific phobiasOpens in new window frequently occur concurrently with other anxiety disordersOpens in new window, but they are rarely the focus of clinical attention in these situations.

Phobias are very common mental disorders seen in general population. Approximately 5 to 10 percent of the population is affected by phobias. The lifetime prevalence of agoraphobiaOpens in new window ranges from 0.6 to 6 percent. Among men, half of them have panic disorders. Both men and women are affected.

The typical age of onset of phobia is usually in childhood and adolescence, specific phobias that persist into adulthood are lifelong 80% of the time.

Many people express “phobias” about snakes, spiders, rats or similar objects. These fears are very specific, easy to avoid and cause no anxiety or worry.

The diagnosis of a phobic disorder is madely only when the phobic behavior significantly interferes with the person’s life by creating mark distress or difficulty in interpersonal or occupational functioning.

Phobias are very common mental disorders seen in general population. Approximately 5 to 10 percent of the population is affected by phobias. The lifetime prevalence of agoraphobiaOpens in new window ranges from 0.6 to 6 percent.

Among men, half of them have panic disorders. Both men and women are affected. The typical age of onset of phobia is usually in childhood and adolescence, specific phobias that persist into adulthood are lifelong 80% of the time.

Many people express “phobias” about snakes, spiders, rats or similar objects. These fears are very specific, easy to avoid and cause no anxiety or worry. The diagnosis of a phobic disorder is madely only when the phobic behavior significantly interferes with the person’s life by creating mark distress or difficulty in interpersonal or occupational functioning.

Etiology (Causes) of Phobia

The cause of phobias is unknown. However, various theories exist that may offer insight into the etiology. The predisposing factors that influence the rise of phobias are as follows:

1.    Psychoanalytical Theory

Freud believed that phobias developed when a child feeling normal incestual feelings toward the opposite-sex parent (Oedipal/Electra complexOpens in new window), becomes frightened of the aggression he or she perceives from the same-sex parent towards the self (castration anxietyOpens in new window).

To protect themselves, these children repress the fear of hostility from the same sex parent and displace it onto something safer and more neutral, which becomes the phobic stimulus. The phobic stimulus becomes the symbol for the parent, but the child does not realize this.

Modern-day psychoanalysts believe in the same concept of phobic development, but they do not believe that castration anxiety is the sole source of phobias. They believe that other unconscious fears may also be expressed in a symbolic manner as phobias.

For example, a female child who was sexually abused by an adult male family friend while he was taking her for a ride in his boat grew up with an intense, irrational fear of all water vessels.

Psychoanalytical theory postulates that fear of the man was repressed and displaced on to boats. Boats became an unconscious symbol for the feared person, but one that the young girl viewed as safer because her fear of boats prevented her from having to confront the real fear.

2.     Learning Theory

Classic conditioningOpens in new window in the case of phobias may be explained as follows: A stressful stimulus produces an “unconditioned” response of fear. When the stressful stimulus is repeatedly paired with a harmless object, eventually the harmless object alone produces a “Conditioned” response fear. This becomes a phobia when the individual consciously avoids the harmless object to escape fear.

Some learning theories hold that fearsOpens in new window are conditioned responses and thus learned by imposing rewards for appropriate behaviors. In the instance of phobias, each time, the individual avoids the phobic object, he or she escapes fear. This is a powerful reward indeed.

Phobias may also be acquired by direct learning or imitation (modelling) (e.g., a mother who exhibits fear toward an objet will provide a model for the child, who may also develop a phobia of the same object).

3.    Cognitive Theory

Cognitive theorists espouse that anxieyOpens in new window is the product of family cognitions or anxiety-inducing self-statementsOpens in new window. Two types of faulty thinking have been implicated: Negative self-statementsOpens in new window and irrational beliefsOpens in new window. Cognitive theorists believe that some individuals engage in negative and irrational thinking that produces anxiety reactions. The individual begins to seek out avoidance behaviorsOpens in new window to prevent the anxiety reactions and phobias result.

Somewhat related to the cognitive theory is the involvement of locus of controlOpens in new window. It has been suggested that individuals with internal locus of control and those with external locus of control might respond differently to life change.

These researches proposed that locus of control orientation may be an important variable in the development of phobias.

Individuals with an external control orientation experiencing anxiety attacks in a stressful period are likely to mislabel the anxiety and attribute it to external sources (e.g. crowded areas) or to a disease (e.g. heart attack). They may perceive the experienced anxiety as being outside of their control.

4.     Biological Theories

(i) Temperament: More than 50 percent of children experience normal fears and anxieties before they are 18-year-old. Most infants are afraid of loud noises. Common fears of toddlers and preschoolers include strangers, animals, darkness and fears of being separated from parents or attachment figures.

During the school-age years, there is fear of death and anxiety about school achievement. Fears of social rejection and sexual anxieties are common among adolescents.

Innate fears represent a part of the overall characteristics or tendencies with which one is born that influence how he or she responds throughout life to specific situations.

Innate fearsOpens in new window usually do not reach phobic intensity but may have the capacity for such development if reinforced by events in later life.

For example, a 4-year-old girl is afraid of dogs. By age 5, however, she has overcome her fear and plays with her own dog and the neighbor’s dogs without fear. Then, when she is 19, she is bitten by a stray dog and develops a dog phobia.

(ii) Life Experiences: Certain early experiences may set the stage for phobic reactions later in life. Some researchers believe that phobias, particularly specific phobiasOpens in new window, are symbolic of original anxiety-producing objects or situations that have repressed. Examples include:

• A child who is punished by being locked in a closet develops a phobia for elevators or other closed spaces.
• A child who falls down a flight of stairs develops a phobia for high places.
• A young woman who, as a child, survived a plane crash in which both her parents were killed has a phobia of airplanes.

Psychotherapeutic Treatments

Psychotherapy cognitive behavior therapy and pharmacotherapy all have been used to treat phobic disorders. Insight-oriented psychotherapy is the superior to psychoanalytic psychotherapyOpens in new window.

Insight-oriented psychotherapyOpens in new window enables the patient to understand the origin of the phobia, the phenomena of secondary gain and the role of resistance, and enables the patient to seek healthy ways of dealing with anxiety provoking stimuli.

Cognitive behavioral therapyOpens in new window and various techniques of behavior therapy like desensitization, flooding and social skill training are used.

DesensitizationOpens in new window is carried out entirely in imagination and geared around the hierarchy of anxiety provoking situations whereas in flooding most therapeutic effects is concentrated at the top hierarchy.

The therapist teaches the patient various techniques to deal with the anxiety, including relaxation, breathing control and cognitive approaches to situation.

Social skill trainingOpens in new window includes such methods as modelling and role-playing. All the three types of behavior therapies are useful in the treatment. The key aspects of successful behavior therapy are:

1. The patietn’s commitment to treatment
2. Clearly identified problems and objectives, and
3. Available alternative strategies for copying with the patient’s feelings.

In the special situation of blood/injection/injury phobia, some therapists recommend patients to tense their bodies during the exposure to help avoid possibility of fainting from vaso-vagal reaction to phobic stimulation.

One behavioral therapy often used to treat phobias is Systematic DesensitisationOpens in new window in which the therapist progressively expose the client to the threatening object in a safe setting until the client’s anxiety decreases.

During each exposure, the complexity and intensity of exposure gradually increases but each time the client’s anxiety decreases. The reduced anxiety serves as a positive reinforcement until the anxiety is ultimately eliminated.

For example, for the client who fears flying, the therapist would encourage the client to hold a small model airplane while tailing about his or her experiences, later the client would talk about flying while holding a larger model airplane.

Later exposures might include walking past an airport, sitting in a parked airplane, and finally taking a short ride in the plane. Each session’ challenges is based on the success achieved in previous sessions.

Flooding is a form of rapid desensitization in which a behavioral therapist confronts the client with the phobic object (either a picture or the actual object) until it no longer produces anxiety.

Because the client’s worst fear has been realised and the client did not die, there is little reason to fear the situation anymore. The goal is to rid the client of the phobia in one or two sessions. This method is highly anxiety producing and should be conducted only by a trained psychotherapist under controlled circumstances and with the client’s consent.

Nursing Diagnosis

Nursing diagnoses are formulated from the data gathered during the assessment phase and with background knowledge regarding predisposing factors to the disorder. Some common nursing diagnoses for clients with phobias include:

• Fear related to causing embarrassment to self in front of others, to being in a place from which one is unable to escape or to a specific stimulus, evidenced by behavior directed toward avoidance of the feared object or situation.
• Social isolation related to fears of being in a place from which one is unable to escape, evidenced by staying alone, refusing to leave room or home.

Planning

The following criteria may be used for measurement of outcomes in the care of the client with phobic disorders. The same may be used to formulate the objectives of nursing care in which the client:

1. Functions adaptively in the presence of the phobic object or situation without experiencing panic anxiety.
2. Demonstrates techniques that can be used to maintain anxiety at a manageable level.
3. Voluntarily attends group activities and interacts with peers.
4. Discusses feelings that may have contributed to irrational fears.
5. Verbalises a future plan of action for responding in the presence of the phobic object or situation without developing panic anxiety.

Evaluation

Reassessment is conducted to determine if the nursing actions have been successful in achieving the objectives of care. Evaluation of the nursing actions for the client with a phobic disorder may be facilitated by gathering information using the following types of questions:

1. Can the client discuss the phobic object of situation without becoming anxious?
2. Can the client function in the presence of the phobic object or situation without experiencing panic anxiety.
3. Does the client voluntarily leave the room or home, to attend group activities?
4. Is the client able to verbalise the signs and symptoms of evaluating anxiety?
5. Is the client able to demonstrate techniques that he or she may use to prevent the anxiety from escalating to the panic level?
6. Can the client verbalise the thinking process that promoted the irrational fears?
7. Is the client capable of creating change in his or her life to confront, eliminate or avoid the phobic situation?