Chronic Anxiety Disorders: The Phobias

Anxiety was defined in the Acute Anxiety article and will not be dealt with in detail in this one. Remember, however, that it is a physical response mediated, primarily, by the sympathetic branch of the autonomic nervous system and a mental response that is best described as a need to escape, or flee, but without conscious realization of what it is you are escaping from and where you can flee. By definition, the feared stimulus is not identified; if it were, it would be fear and not anxiety.

Sometimes, the response is severe and acute and leads to what is called a panic disorder, previously discussed. Sometimes the anxiety, however, never reaches panic levels, but is present all or much of the time in lower amount. It is still uncomfortable, of course, but it can be and often is lived with. This is a description of what has been called "free floating anxiety." In its undefended form, it is called a generalized anxiety disorder. However, instead of simply feeling the chronic anxiety, many people adopt ways to reduce it. Some of these ways, called defense mechanisms, can be quite effective and not interfere in the normal lives of the people who use tham. Some can be so inefficient and disruptive that they seem to add to the problem overall, but are stubbornly maintained in a rigid fashion. When these mechanisms visibly impair normal functioning, they are diagnosed as anxiety disorders. So, if you have no effective defense mechanisms at all, and experience the anxiety in the 'free floating' form, if that is disruptive, it is called a "Generalized Anxiety Disorder." If you have defenses that may reduce the anxiety, but, themselves, interfere with normal functioning, then it is an anxiety disorder that is specific to the type of inefficient defense that is used.

Thus, two issues about the defense mechanisms must be clearly understood. One is that everybody has some, well -- almost everybody. Their complete absence occurs only two ways (aside from death); one of which is a fully deteriorated psychotic, which we will not discuss, and the other is in the theoretical perfect, absolute psychopathic personality disorder, which we also won't discuss. All the rest of us, clinically anxious or not, have defense mechanisms. Some of them work better than others; that's issue two. The poorly working defenses that are clung to despite their inefficiency are what define some of the anxiety disorders. Let's look at some of the more interesting categories.

Specific Phobia:

What is interesting about this category is that it appears to contradict the definition of anxiety because there is a specific object or situation of which the individual is afraid. In fact, the definition rests on the fact that there is a "...marked and persistent fear of clearly discernable, circumscribed objects or situations." (DSM IV. p. 405). So what makes this anxiety and not fear? How about the fact that the feared object or situation is not really what the person is afraid of. OK, the individual is, for all intents and purposes, afraid of the stimulus, in fact, terribly, excessively, unreasonably afraid. Therein lies the crux. The fear is excessive; it is unreasonable; it is, in short, irrational in both target and degree. And, in many cases, it isn't really the stimulus that is threatening to the individual; it's a symbol of it, or a substitute for it, and it allows the person to avoid what is really troublesome and not recognize what it actually is at the same time.

Sometimes, that is not the case. Sometimes the Specific Phobia is an overreaction to a genuinely traumatic encounter (usually in childhood) with that stimulus, an encounter, or repeated encounters that were so traumatic that the person became conditioned to avoid that stimulus at all costs. When that is the case, the phobia is easy to treat. It is an overreaction more that the kind of defense mechanism described above. However, when it is the displaced or symbolic fear, the phobia is much more difficult to treat. So what kinds of things can engender these responses?

In the good old days, when these were called "simple phobias," there was a list, usually with a Greek prefix, for every one that anybody ever saw. Zoophobia (fear of animals), arachnophobia (spiders), claustrophobia (being closed in), lysophobia (fear of 'falling apart', that is, going crazy), acrophobia (heights), aquaphobia (water), photophobia (light), phobophobia (phobias); OK, I made that up, but that's what everybody did, make up phobias and publish them. Dark, dogs, cats, bridges, pylons, blood, and on and on.

Now, in our enlightened age, we have retained only a few categories: animal, blood-injection-injury, natural environment, situational, and, of course, "other." Interestingly, these categories are not entirely arbitrary. There are interesting differences that correlate with the categories. For example, animal and natural types usually begin in childhood and may be traumatic or imitative. The blood-injection-injury type has a high familial loading, and the situational type has characteristics in onset similar to Panic Disorder with Agoraphobia. This last observation leads to an interesting question. Why isn't Agoraphobia without Panic Attacks considered a specific phobia? The answer to that is that it really isn't specific. It has very broad manifestations that lead the person to make major life changes in order to accommodate it. The actual phobic situation is a fear of having a panic attack in unprotected circumstances, but the behavioral manifestation isn't just becoming anxious when encountering a specific situation, for example going shopping alone, it is defined by the fact that it tends to prevent the individual from leaving the house at all (unless with a safe person) and causes a major abnormal lifestyle.

When the feared objects are symbolic of some more deep seated fears, what are some examples of those? First, a disclaimer: these generalizations certainly do not fit everyone with the symptoms described. There are many individual variations and unique reasons for the phobias, but there are some very interesting correlations. For example, fear of heights and bridges both are associated with suicidal impulses that are threatening to the individual, who tries to avoid realizing them. Often, clinically, you will hear the fantasy of how easy it would be to jump over the railing or off the bridge, not fall, passively, but actively contribute to the plunge; in other words, commit suicide. Blood-Injection-Injury has been linked to death or aggression, and then there are some that are not intuitively obvious (or even reasonable), such as the fear of spiders' correlating with very overbearing and threatening mothers. (So help me, more than one study and my own clinical observations have confirmed this.) Of course, you can rationalize the pathway of that after the fact, but it would have been hard to predict, I think. Some of the underlying anxiety producing fears are linked to sexual threats (stemming from your own urges) or aggressive threats (also stemming from your own impulses) corroborating much of what Sigmund Freud found clinically and intuitively, not of course, to the extent he postulated. Still, it's interesting.

OK, enough detail. In summary, the diagnostic criteria for Specific Phobia are 1) the very marked, excessive, and unreasonable fear of the stimulus, 2) the fact that encountering the stimulus virtually always triggers an immediate anxious response (possible including panic), 3) the disruptive nature of the symptom to the individuals normal functioning, 4) avoidance of the feared stimulus, and 5) recognition that the fear is unreasonable, This last criterion is not necessarily present if the patient is a child or an adolescent.

Social Phobia:

There is only one other category that is currently defined as a true phobia. That is, the Social Phobia, or, as it is sometimes called, Social Anxiety Disorder. This category presents theoretical and diagnostic challenges. On the one hand, some degree of the primary symptom is so common that it is hard to draw the lines between normal, shy, avoidant, and anxiety disorder. On the other end, its severity can border on Agoraphobia, with, or without, panic attacks, making that distinction difficult. As a quick note, there is a (nearly useless) laboratory finding that well diagnosed agoraphobics with panic attacks can be chemically stimulated into panic states more easily than people diagnosed with similar looking Social Phobia. This finding is neither pronounced enough nor consistent enough to really aid diagnosis, however.
OK, so what is Social Phobia? Well, not too surprisingly, it's a fear of social situations or performing even common behaviors in front of other people. Lots of people have a fear of speaking in front of crowds. Lots of people are afraid to display that piano piece in front of a school assembly that they have been practicing for eight months when they were alone. Are they Social Phobics? No, probably not, particularly if they are nearly never called on to do these things. But people who play in the Cleveland Symphony Orchestra and are terrified of the crowds at Severance Hall, who feel very anxious when they perform, and sometimes play badly or miss concerts because of this anxiety, definitely are. There are two differences between the people who feel the same anxiety, or think they would, in the first example and those who do feel it and attempt to encounter the terrifying stimuli, anyway, and incompletely succeed in dealing with them.

The first difference is that the second group, the musicians, actually experienced the anxiety. The anxiety has to be more than theoretical for an anxiety disorder to be diagnosed. It has to be felt. The second difference is that the first group experienced practically no disruption in their lives, which would be pretty much the same with or without the expressed fears. The feared circumstances simply had no place in their lives. They weren't actually avoiding them (perhaps); they were just never relevant. Was the difference merely circumstance and luck? Were the two groups of people psychologically equivalent, but one just luckier in avoiding their symptoms than the other? Very probably not. Who knows whether the first people would really have the symptoms if forced to confront the situations? As it is, they have no significant effect in the people's lives (assuming they didn't avoid brilliant violin and piano careers because of them) and, therefore, whatever symptoms they might have are not manifesting. They don't experience the anxiety, and their lives are not deleteriously affected by their fears. Consequently, they do not have social phobias. The musicians do and they need to have them cured or find another line of work.

The result of confronting the social situation to which the person is phobic is the manifestation of a significant number of the anxiety (sympathetic nervous system) symptoms described in the previous article. That is the sweating, heart palpitations and racing, increased blood pressure, trembling, gastrointestinal discomfort, dyspnea, and fainting along with the feeling of extreme discomfort and desire to escape. That last is an essential component, only a few of the physical symptoms are necessary for the diagnosis and to a lesser degree than in a panic attack, although they could reach that level. Also, unless it is a child, the individual is aware of the excess nature of the fear, knows it is out of proportion to a real danger.

Social Phobias are part of a continuum from normal to agoraphobic and panicked. And there are people all along the path. The diagnostic categories are not discrete groupings with little between them. People are distributed pretty much at every step along the way. Of course, there are substantially more down toward the normal end, but quite a few spread across the rest of the spectrum. Studies have found a lifetime prevalence (chance that you will be diagnosed as having a Social Phobia at some time in your life) to vary from 3% to 13%. Obviously, these groups were not applying the criteria identically because there was not that much difference between the populations, thus proving that this is a hard category to define. Nevertheless, even the lower ranges of these studies found a hell of a lot of people they were pretty sure were suffering from Social Phobias. So, if it's so common, why is it a disorder?

The answer to that lies in one of the necessary criteria for diagnosis. The fact that it is a significant disruption in the course of normal functioning, social, occupational, school, or simply happiness. Note that the Social Phobic still functions in all of the arenas, but in an impaired manner. Thus, a behavioral symptom that causes significant but not total impairment in functioning is what defines the level of pathology of this disorder.

Not too surprisingly, such people are often socially inept, beset by inferiority feelings, hypersensitive to criticism, and non-assertive. The disorder is truly chronic, usually starting young, and often lasting throughout life. However, many people do tend to improve in adulthood or with controlled circumstances that are not threatening, if they have been able to produce those. Sometimes, symptoms appear after a traumatic experience having to do with social circumstances, such as a speech that goes badly.

Some phobias can be treated behaviorally, and most can be benefited to some degree by medications. After completing the anxiety disorders, we shall touch on treatment considerations.