Agoraphobia and the panic disorder that provokes it is the most common and most severe phobia. Affected individuals are not so much afraid of particular circumstances as they are afraid of their own feelings. They think they may suffer an ever-increasing level of panic that will disable them, that is, cause them to lose control of themselves so that they do something embarrassing or dangerous. Consequently, they feel they have to escape from wherever they happen to be. They can feel trapped anywhere, but most typically in certain stereotyped circumstances: closed-in places, such as elevators; transportation, such as airplanes and trains; large crowded areas, such as arenas or shopping centers; traveling through places where turning back is difficult, such as tunnels or bridges; sitting passively and quietly, such as in church or a movie theater; or waiting in line. Since the feeling of being trapped comes mostly from social pressures—the difficulty of getting up from the table during lunch, leaving a party, even interrupting an ordinary conversation—they can feel trapped anywhere.
The specific phobias, including animal phobias, are easier to treat. They do not represent a fear of an internal feeling—which can go anywhere that the affected person goes—but rather the fear of a very particular thing. Avoiding that thing does not lead to avoidance in general, as it does with agoraphobia. The DSM IV lists these specific phobias:
- Animals—including insects.
- Natural environment—including storms, heights, or water.
- Blood-injection, injury—including medical procedures
They also mention situational types, which are really variants of agoraphobia. Indeed, the fear of heights, in my experience, often precedes and leads into an agoraphobia. (The affected person is afraid of jumping or falling—a kind of loss of self-control.)
Specific phobias, although easier to treat than agoraphobia, can be serious. I remember a woman who could not leave her house because she was afraid she might encounter a snake. She had never seen a snake where she lived, which was suburban Connecticut. She was not just afraid of poisonous snakes. She was afraid of all snakes. Another woman’s career as an operatic singer was ruined by her fear that someone might bring a dog backstage. Fear of pigeons is not uncommon, even though everyone knows they are not dangerous. Fear of spiders is common. Fear of bees is also common and made worse, unfortunately, by the fact that some people are especially vulnerable to anaphylactic shock, a potentially life-threatening condition, when stung by a bee. When a fear reflects a real danger, it can scarcely be called a phobia; but some of these individuals are so afraid of bees that they cannot be outdoors. Fear of thunder is another common phobia. The following examples demonstrate the usual steps in treatment. Each step is designed to raise the patient’s level of anxiety initially, after which it drops with repeated exposure:
- All animal and insect phobics should start with reading about the feared object. A book with pictures is better than just text. Those afraid of snakes and insects should become as expert as possible on those subjects. The lady mentioned above collected a number of books on snakes. At first, just holding the book made her anxious. Then she proceeded to reading about snakes, and, more difficult, looking at pictures of them.
- Her aide from the Phobia Clinic gave her a toy snake on a string. She learned to make it slither.
- She obtained snake skins from someplace and kept them about the house. Ultimately, she put them on a side table beside her bed and left them there when she was sleeping.
- She went with her aide to a pet store and watched a snake in an aquarium from a distance, and then closer and closer. (Watching snakes, which are usually asleep, is inherently boring.)
- She watched her aide handle a snake. She touched the snake.
- She went to a nature center where she learned how to handle snakes. She learned, to her surprise, that when you drop a snake on the ground, it always goes away from you.
Her husband was not able to help in treatment very much, because he became too distressed when she became distressed. In the end, he complained about “all the snake skins” that were still strewn about the house.
- The opera singer overcame her dog phobia enough to walk through her neighborhood but was unable to resume her career. She did what the woman afraid of snakes did; but since dogs are at least in theory potentially dangerous, she needed instruction from a dog trainer on what posture to take when threatened by a barking dog and how to handle that situation. In the end, her sense of being in control freed her from her phobia; still she had to start by approaching puppies.
- The fear of spiders is dealt with similarly. One in-between stage consists of keeping dead spiders in a jar, sort of like keeping snake skins. Ultimately, the phobic person should be able to push the insect around with a finger.
- Fear of bees is difficult for the reason given above. An intermittent stage is accompanying men who are trained as beekeepers.
- I remember dating a girl who was afraid of pigeons. She could see pigeons on top of buildings from blocks away. It took weeks for her to approach pigeons closely, even though it was obvious that they were afraid of her.
An important element in every animal and insect phobia is the idea that the creature will dart at the person, and possibly bite or sting. It is essential that the phobic feel at the end of treatment that he/she is in control of the animal, rather than the other way around. Very often, as in the case of pigeons, or beetles, the animal is inclined to fly away, rather than to attack.
The fear of thunder is dealt with by getting used to a recording of thunder at louder and louder sound levels. The fear of heights is best dealt with on a terrace in an apartment building. The affected person sits on a chair, closer and closer to the edge until he/she can look over at the ground, comfortably. Similar step-wise exposures diminish the fear of needles and the fear of drowning.
The treatment of these conditions is difficult only in that it takes a lot of time. The patient has to go at his/her own pace, but should practice, if possible, every day.
P.S. There are some people who are very easily startled by loud or sudden sounds. When severe, this can be miserable since the affected person is vulnerable to every clown who comes up and says “boo.” This is not the same condition as being afraid of thunder or the sound of firecrackers. Unfortunately, in my experience, exaggerated startle reactions seem to be lifelong.
(c) Fredric Neuman.
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