Phobic Disorders
Phobias involve persistent, unrealistic, intense anxiety and fear in response to specific external situations.
People who have a phobia avoid situations that trigger their anxiety and fear, or they endure them with great distress. However, they recognize that their anxiety is excessive and therefore are aware that they have a problem.
Agoraphobia
Agoraphobia is characterized by anxiety about or avoidance of being trapped in situations or places with no way to escape easily if anxiety or panic develops.
Agoraphobia is diagnosed in about 4% of women and 2% of men during any 12-month period. Most people with this disorder develop it in their early 20s; agoraphobia rarely develops after age 40.
Although agoraphobia literally means "fear of the marketplace," the term more specifically describes the fear of being trapped, often in a busy place filled with people, without a graceful and easy way to leave if anxiety becomes severe. Typical situations that are difficult for people with agoraphobia include standing in line at a bank or supermarket, sitting in the middle of a long row in a theater or classroom, and riding on a bus or airplane. Some people develop agoraphobia after experiencing a panic attack in one of these situations. Other people simply feel uncomfortable in these settings and may never, or only later, develop panic attacks. Agoraphobia often interferes with daily living, sometimes so drastically that it leaves the person housebound.
Treatment
If agoraphobia is not treated, it usually waxes and wanes in severity and may even disappear without formal treatment, possibly because the person has conducted some personal form of behavior therapy.
Exposure therapy, a type of behavior therapy in which the person is exposed repeatedly to the anxiety-provoking situation, is the best treatment for agoraphobia, helping more than 90% of people who practice this therapy faithfully.
People with agoraphobia who are deeply depressed may need to take an antidepressant. Substances that depress the central nervous system, such as alcohol or large doses of antianxiety drugs, may interfere with behavior therapy and are tapered off before therapy is begun.
Social Phobia
Social phobia (social anxiety disorder) is characterized by significant anxiety induced by exposure to certain social or performance situations, often resulting in avoidance.
Humans are social animals, and their ability to relate comfortably in social situations affects many important aspects of their lives, including family, education, work, leisure, dating, and mating.
Although some anxiety in social situations is normal, people with social phobia have so much anxiety that they either avoid social situations or endure them with distress. About 13% of people have social phobia sometime in their lives; the disorder affects about 9% of women and 7% of men during any 12-month period. Men are more likely than women to have the most severe form of social anxiety, avoidant personality disorder (see Section 7, Chapter 105). Some people are shy by nature and show timidness early in life that later develops into social phobia. Others first experience anxiety in social situations around the time of puberty.
Some social phobias are tied to specific performance situations, producing anxiety only when the person must perform a particular activity in public. The same activity performed alone produces no anxiety. Situations that commonly trigger anxiety among people with social phobia include public speaking; performing publicly, such as reading in church or playing a musical instrument; eating with others; signing a document before witnesses; and using a public bathroom. People with social phobia are concerned that their performance or actions will seem inappropriate. Often they worry that their anxiety will be obvious--that they will sweat, blush, vomit, or tremble or that their voice will quaver; that they will lose their train of thought; or that they will not be able to find the words to express themselves.
A more general type of social phobia is characterized by anxiety in many social situations. In both types of social phobia, the person's anxiety comes from the belief that if his performance falls short of expectations, he will feel humiliated and embarrassed.
Treatment
Social phobia often persists if left untreated, causing many people to avoid activities in which they would otherwise like to participate.
Exposure therapy, a type of behavior therapy in which the person is exposed repeatedly to the anxiety-provoking situation, is effective, but arranging for exposure to last long enough to permit getting used to the anxiety-provoking situation and growing comfortable in that situation may not be easy. For example, a person who is afraid of speaking in front of his boss may not be able to arrange a series of speaking sessions in front of that boss. Substitute situations may help, such as joining Toastmasters (an organization for those who have anxiety about speaking in front of an audience) or reading a book to nursing home residents.
Antidepressants, such as selective serotonin reuptake inhibitors (SSRIs) and monoamine oxidase inhibitors (MAOIs), and antianxiety drugs can often help people with social phobia. Many people use alcohol as a social lubricant; for some people, however, alcohol abuse and dependence can result. Beta-blockers are commonly used to reduce the increased heart rate, tremor, and sweating experienced by people who are distressed by performing in public.
Specific Phobias
A specific phobia is an irrational fear of specific objects or situations.
Specific phobias, as a group, are among the most common anxiety disorders but are often less troubling than other anxiety disorders. During any 12-month period, about 13% of women and 4% of men have a specific phobia.
Some specific phobias cause little inconvenience, while others severely interfere with functioning. For example, a city dweller who is afraid of snakes may have no trouble avoiding them. However, a city dweller who fears small, closed places such as elevators will have a problem working on an upper floor in a skyscraper.
Some specific phobias, such as fear of large animals, the dark, or strangers, begin early in life. Many phobias stop as the person gets older. Other phobias, such as fear of rodents, insects, storms, water, heights, flying, or enclosed places, typically develop later in life.
At least 5% of people are to some degree phobic about blood, injections, or injury. These people can actually faint due to a decrease in heart rate and blood pressure, which does not happen with other phobias and anxiety disorders. In contrast, many people with other phobias and anxiety disorders hyperventilate, which can cause them to feel as though they might faint, although they virtually never faint.
 See the table Some Common Phobias.
Treatment
A person can often cope with a specific phobia by avoiding the feared object or situation. When treatment is needed, exposure therapy is the treatment of choice. A therapist can help ensure that the therapy is carried out properly, although it can be done without a therapist. Even people with a phobia of blood or needles respond well to exposure therapy. For example, a person who faints while blood is drawn can have a needle brought close to a vein and then removed when the heart rate begins to slow down. Repeating this process allows the heart rate to return to normal. Eventually, the person should be able to have blood drawn without fainting.
Drug therapy is not very useful in helping people overcome specific phobias. However, benzodiazepines (antianxiety drugs) may give a person short-term control over a phobia, such as the fear of flying.
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