What is Anxiety?
Anxiety is the most common issue that people come to psychologists about, and forms the basis of a large number and variety of mental health disorders. Even so, there is a lot of uncertainty around the definition of the complex emotional and behavioural response that anxiety represents. Part of this is due to the challenge of explaining and defining subjective experiences- we all experience anxiety in our inner world, but how can we fully put it into words? (Taylor and Arnow, 1988).
Complicating the issue is the huge range of terms relating to fear and anxiety. We talk about concern, trepidation, anxiety, apprehension, terror, panic, alarm, agitation, and many other words, all with slightly different shades of meaning. While these different terms highlight how central and important anxiety is to our experience as humans (Marks, 1987), they also add to the difficulties around defining the core aspects of anxiety and phobias.
Fear is considered an adverse state rooted in the “fight or flight” response designed to escape or eliminate harm. Fear is not always extreme- it ranges from mild feelings of unease to uncontrollable panic and terror.
Normal and Abnormal Anxiety
Anxiety is a response to perceived harm. The full complexity of this process on a neurological level is not fully understood, but is known to involve brain areas including the visual thalamus, visual cortex and amygdala. The brain stimulates the release of adrenaline, activating the body’s “fight or flight” response- a series of changes which prepare the mind and body for action.
The fight or flight response occurs on three separate levels. First, the body prepares for physical action by increasing the heart rate and depth of breathing, to increase available levels of oxygen in the bloodstream. At the same time, resources are diverted away from the digestion system-which is not needed during times of danger- leading to feelings of nausea.
Second, on a cognitive level, the brain automatically shifts our attention towards the perceived threat. This can make it hard to concentrate on anything but the object of fear. Third, the fight or flight response motivates the individual to take action- to attempt to avoid or confront the source of their fear.
The fight or flight response is essential to our survival. Feeling no reaction to danger and having no motivation to avoid harm would seriously reduce our changes of dealing with danger. Anxiety, while unpleasant, therefore serves a critical function.
Unfortunately, the fight or flight response is not perfect- sometimes it can produce “false alarms” and activate when we are not actually in danger, or in a way that is out of proportion to the actual threat of a situation. Having your mind and body respond as though you are in a life or death situation when in fact you are not can be very unhelpful. Public speaking, for example, is a situation in which having your body react as though it is getting ready to run away by raising your heart rate, making you sweat, and focusing your attention on all sources of threat around you, becomes extremely disruptive.
Anxiety disorders do not always cause fears of the same things. Two people with social anxiety may fear completely different social situations, and for completely different reasons: one may fear talking to members of the opposite sex for fear of rejection, while another may fear public speaking due to worries about being seen as incompetent. Any treatment for anxiety must therefore target the specific fears, beliefs and symptoms of the individual experiencing them.
Development of Anxiety
Four main pathways have been identified by which anxiety disorders may form:
The most obvious means by which excessive fear can be acquired is through direct experience. It stands to reason that a very dangerous or negative situation involving a particular stimulus would lead to a strong fear of this stimulus, but through the process of classical conditioning it is also possible to acquire a fear of neutral, non-threatening stimuli if they are encountered at the same time as something genuinely dangerous. For example, a person who experiences a life-threatening car crash may develop a fear of driving. Previously the idea of driving was not associated with any fear, but after the crash it has become mentally linked with the idea of danger, and so produces fear on its own.
Not all extreme fears are the result of direct experience, and not all dangerous experiences lead to the formation of an anxiety disorder. So why are some people able to experience traumatic events without developing an anxiety disorder as a result?
One possible explanation is a process called latent inhibition. This is where a prior positive experience serves to “protect” you from developing a fear after a negative experience. For example, prior positive experiences with dogs may mean that a single negative experience with a dog is seen as an exception rather than the rule, and may not lead to the development of a fear of dogs (Poulton & Menzies, 2002).
Also known as vicarious conditioning, modelling refers to the process of learning by observing others. Simply watching others acting fearful in the presence of a certain stimulus is frequently enough to lead to the development of a fear yourself.
Information passed on by parents, friends, or the media can often lead to the development of strong fears even without any direct contact. Examples of this process could include overly anxious parents warning their children of the dangers of wild animals, TV adverts for antibacterial products warning about germ transmission, or sensationalist news reports about the risks of natural disasters.
The reason for this seems to be that humans are predisposed to fear stimuli and situations which posed a danger to us in our evolutionary past. Stimuli such as spiders, snakes or heights were certainly a danger to our early ancestors, and this danger appears to linger in our minds as a predisposition to fear them.
Why Do Anxiety Problems Remain Over Time?
Many people experience traumatic situations such as car crashes, experiences with frightening dogs, or humiliating situations in public. These situations may produce a temporary increase in anxiety or distress, but would not lead to the development of a clinical anxiety disorder. So why do some people who experience these dangerous situations recover while others develop phobias?
Many anxious individuals will overestimate the likelihood of something bad happening if they encounter their feared situation. Individuals with a dog phobia may overestimate the likelihood that a dog will attack them on sight, while individuals with a flying phobia may severely overestimate the odds of a plane crashing. Both these situations are technically possible, but very unlikely and unlikely to provoke much fear in people without these beliefs.
Even when feared situations occur, they are often not as bad as you may imagine. A bee sting is unpleasant, but hardly catastrophic. And yet anxious individuals will often believe that the negative consequences of their feared situations will be unbearably severe (Gellatly & Beck, 2016). This belief greatly contributes to anxious individuals’ desire to avoid their feared situations.
Intolerance of Uncertainty
Even if the odds of something bad happening in a fearful situation are extremely low, for some anxious people the mere possibility of something happening is enough to be a source of great worry. For some, any level of uncertainty is deemed unbearable. This intolerance of uncertainty can cause people avoid any and all situations in which there is even the slightest risk of coming into contact with their feared situation (Dugas, Buhr, & Ladouceur, 2004).
Low Coping Self-Belief
Another belief which can create increased distress out of anxiety is the belief that you will be unable to cope with any dangerous situation. Low estimates of your own coping ability can make an individual fearful of situations which others may find completely non-threatening (Bandura, 1988). Very anxious individuals typically underestimate their own ability to cope with stress and difficulty, increasing their desire to avoid any sources of fear and stress. This avoidance deprives them of the chance to see that they could in fact cope much more effectively than they imagine.
Very anxious individuals may fear the consequences of being in a stressful situation, but they may also fear the anxiety itself. A person who fears dogs may fear the possibility of being bitten, but if they were highly sensitive to anxiety (Cox et al, 1999), they may also fear the possibility of panicking or losing control in the presence of a dog, or fear making fools of themselves due to their anxiety. Individuals may fear that prolonged anxiety may have highly negative consequences, such as having a heart attack or losing their mind.
When feeling anxious, people often rely on certain actions or behaviours to feel safe. Safety behaviours vary greatly depending on the type of anxiety- examples could include repeated calls to a GP over fears about your health, clinging constantly to a handrail when in high places, keeping your eyes shut while riding an elevator, or only going near a feared animal in the presence of another person.
Safety behaviours are undertaken in order to reduce anxiety but often they serve to maintain it by leading individuals to think that they are dependent on them to avoid feeling anxious. Safety behaviours can therefore become very restrictive- a person who only ever stays holding onto the handrail when near high ledges may start to think that this behaviour is the only thing keeping him safe.
There are four main types of safety behaviour, which we’ll look at now.
Individuals will often try to simply avoid contact with their feared situation or stimuli. Depending on how the individual’s fears operate, these avoidance strategies can be predictable and all-encompassing, or highly context-specific. A social phobia may, for example, lead to a blanket avoidance of going to large social gatherings, or it may lead to a more specific form of avoidance, such as avoiding social gatherings over a certain number of people. Some people may need others to engage in their avoidance strategies in order to feel safe- for example a patient with OCD may ask their entire family to avoid contact with anything deemed dirty or contaminated.
Checking and Reassurance Seeking
When an anxious person is unsure if they are safe, they may engage in repeated actions to try and ascertain whether they are or not. Checking actions could include frequently checking yourself for symptoms of illness, or regularly checking for spiders behind the sofa. Repeatedly seeking reassurance by asking others to allay your fears is also common, for example frequent contact with doctors to ask about symptoms, or asking a partner to check behind the sofa.
Compulsive rituals are repetitive internal actions which people perform in an attempt to feel less anxious. Often they are triggered by a sense of pressure or a need to act, based on rules or worries in the person’s mind. Rituals can be overt, such as regular hand washing, or purely internal, such as forcing yourself to think happy images in response to fearful thoughts. Such rituals may be performed over and over, in the belief they are helping remove anxiety. Since rituals often do create a temporary reduction in anxiety, they are reinforced each time they are performed, creating a stronger desire to perform the ritual the next time the feared situation or trigger arises.
As well as performing specific mental or overt actions, safety behaviours can also include paying close attention to cues or signals of safety in the environment. Cues to safety can vary greatly- the presence of your spouse, having medication close to hand, or being at home are all possible examples.
Individuals don’t necessarily need to utilise these safety cues- often their mere presence is sufficient to reduce their anxiety. This can lead to a form of dependence on the presence of these signals and increased anxiety whenever they are not present. Since they are so passive, individuals may not even recognise that they are part of their anxiety problem.
What is a Phobia?
A specific phobia is defined as a persistent fear of a specific object or situation which causes significant impairment, interference or distress (APA, 1994). Phobias are the most common form of anxiety disorder, with about 12.5% of the population experiencing one at some point in their lives (Kessler, Berglund, & Demler, 2005).
While there are countless different specific situations or objects which a person may fear, specific phobias are normally divided into four main groups (Curtis, Magee, Eaton, Wittchen, & Kessler, 1998):
- Situational (fear of flying or being in an enclosed space)
- Natural environment (fear of heights, thunderstorms, the ocean)
- Animal (fear of dogs, wasps or snakes)
- Blood, infection and injury (fear of dental procedures, injections or seeing blood)
Phobias often have their onsets early in life (Craske et al, 1996). They are also becoming recognised as risk factors for the later development of other disorders, such as major depression (Kessler et al, 1996) and alcoholism (Kessler et al, 1997).
Phobias are very distressing to live with. Many people dealing with phobias report severe impairment in their ability to live a normal functioning life during the worst phases of the disorder (Wittchen, Nelosn, and Lachner 1998).
Despite the suffering specific phobias create, many who experience them are hesitant to come forward for treatment. Only 31%of those who meet the criteria for specific phobia seek out professional treatment (Regier, Narrow, & Rae, 1993). There are many possible reasons for this.
First, individuals with phobias may believe their condition to be untreatable, or be unaware of the treatment options available to them.
Second, since the treatment for phobias often involves facing the feared situation, those who are aware of the treatment may still be apprehensive about taking part. Research shows that around 25% of people with phobias are unwilling to be exposed to the feared situation as part of treatment (Marks, 1992; Marks & O’Sullivan, 1988).
Some examples of the adjustments people make to avoid their feared situations include the following:
- A patient who puts off surgery because of a fear of having an injection as part of the treatment
- A patient with a spider phobia seeing a spider in their garage and refusing to enter the garage for months afterwards
- A construction worker having to avoid certain jobs due to a fear of heights
- An individual unable to leave her home on cloudy days due to her intense fear of being out in a thunderstorm
- An individual whose driving phobia stopped her being able to commute to work
- A businessman with a flying phobia who turned down a promotion because the new job would require frequent flying
Despite the low percentage of people suffering from phobias who seek treatment, phobias are in fact one of the most treatable anxiety conditions.
Phobia in Different Age Groups
Young children often experience extreme or disproportionate fears, however these are normally transitory and disappear quickly. For a diagnosis of a phobia to be made, a psychologist would need to assess whether the level of fear is appropriate to the child’s developmental level, or whether it is causing impairment and distress in excess of what would normally be expected.
Phobias are less common in older adults, but still one of the most commonly experienced anxiety disorders in later life. Phobias of enclosed spaces, flying, darkness and injections are equally common in older adults as in younger adults, while fears around storms, heights and falling are more common in older adults. Treatment using exposure remains effective, but additional factors need to be considered.
First, in older adults as with other populations, specific phobias often co-occur with other mental and medical conditions, in particular coronary heart disease and chronic obstructive pulmonary disease. Older adults are likely to attribute the symptoms of their phobias to these medical conditions rather than being aware of the phobias as separate conditions.
Second, older adults often show anxiety in different ways to younger adults. Older adults often report less severe anxiety symptoms, but also show symptoms of both anxiety and depression in relation to phobias, when compared to younger adults. These additional symptoms could lead to a different diagnosis.
Does Treating Specific Phobia Require a Clinician?Treating phobia is often time consuming and difficult for clinicians. It is therefore important to understand whether treatment actually requires a therapist or whether it can be done on a self-help basis.
Diagnosis of Phobias
According to the Diagnostic and Statistical Manual (DSM), the criteria to be diagnosed with a specific phobia are as follows:
1. Marked fear or anxiety about a specific object or situation (such as flying, heights, animals, receiving an injection, seeing blood).
Note: In children, the fear or anxiety may be expressed by crying, tantrums, freezing, or clinging.
2. The phobic object or situation almost always provokes immediate fear or anxiety.
3. The phobic object or situation is actively avoided or endured with intense fear or anxiety.
4. The fear or anxiety is out of proportion to the actual danger posed by the specific object or situation and to the sociocultural context.
5. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.
6. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
It is also important that the symptoms are not better explained by a different mental health disorder.
Levels of fear shown by phobia patients may vary by situation, or by proximity to the feared stimulus, or based on other contextual factors such as the presence of other people and duration of contact. Fear may also occur in anticipation of a feared event or when imagining it. Fear is consistently felt in response to the phobic stimulus, and can sometimes take the form of a panic attack.
Individuals with phobias will actively try to avoid the feared situation or stimulus- minimising or avoiding contact will be a top priority.
Individuals are often willing to go to great lengths of planning and inconvenience to avoid their feared situation, for example walking longer routes to work to avoid the street with the dog, or taking very long drives to avoid having to fly. Individuals may have suffered with the phobia for many years and have made drastic changes to their lives as a result.
Features Supporting Phobia Diagnosis
People with phobias often show increased physiological arousal when in contact with their feared situation or object. The exact nature of this will vary between phobia categories. Situational, natural environment and animal phobias often lead to increased activation in the parasympathetic- or fight and flight- nervous system. Blood-injection-injury phobia is more likely to lead to a fainting or near-fainting reaction caused by a brief rise in heart rate and blood pressure followed by a significant drop in both heart rate and blood pressure.
Patients with specific phobia are at a higher risk of suicide than the normal population- in fact they may be up to 60% more likely to attempt suicide. This will be in large part due to the fact that phobias have a very high co-morbidity with other personality and anxiety disorders.
Prevalence of Phobias
In an average 12-month period roughly 7-9% of the population will be diagnosed with a specific phobia in the United States. Prevalence rates are comparable in Europe and Australia, and slightly lower in Asia, Africa and Latin America.
Women are more likely to develop a phobia than men; the ratio is around 2:1. The most common specific fear among men is heights, while women most often fear animals. Animal, environment and situational phobias are more common among women while blood-injection-injury phobias are equally common across genders.
Phobias are very commonly experienced in conjunction with another mental health condition- comorbidity of this kind is the norm rather than the exception. Depression is commonly experienced along with phobias, especially in older adults. Other disorders frequently experienced along with specific phobia include generalised anxiety, bipolar disorder, substance related disorders, somatic symptom related disorders and personality disorders. Since phobias have an early onset age, they are often considered the primary disorder.
Development and Course
Phobias sometimes develop as a result of a traumatic triggering event- a phobia of dogs beginning after an attack by a dog, for example. Similarly, observing others in life-threatening or traumatic situations can also lead to the development of a phobia. Unexpected panic attacks can also trigger the onset of a phobia- for example having an unexpected panic attack while on a subway train may lead to a fear of train travel, or enclosed spaces or something similar. For others, there is no apparent trigger that leads to the onset of a phobia.
It is unclear whether the age of onset reported by most phobia patients is in relation to the start of the phobia, or the start of their fear in general. Patients may fear certain objects or situations from a young age but these fears may not meet the criteria for a phobia diagnosis until much later. Research shows that on average there is a period of nine years between fear beginning and fear reaching sufficient intensity and impairment to be classified as a phobia.
There are thought to be three main routes by which a phobia can develop: classical conditioning following a traumatic event, vicarious learning (watching others react fearfully in the presence of a particular stimulus), and instruction or information received from others (for example parents or the media) (Rachman, 1977). Research data suggests that conditioning following trauma accounts for 36% of cases, while vicarious learning and information account for a further 8% each. This means that around 50% of phobic patients do not recall how their phobia began (Kendler, Myers, & Prescott, 2002).
Issues with Phobia Classification
The four categories are also somewhat less descriptive and informative to a patient than simply naming the phobia based on what is feared. “Specific phobia of storms” or “specific phobia of the ocean” is much more meaningful to a patient than “specific phobia, natural environment category”.
Treatments for Specific Phobia
Specific phobias are the most treatable of all anxiety disorders. Recovery rates are generally very high- for certain phobias as many as 90% achieve significant, long-lasting reduction in phobia symptoms as a result of treatment. Often, a single session is enough to produce these changes (e.g. Öst, 1989; Öst, Brandberg, & Alm, 1997; Öst, Salkovskis, & Hellström, 1991).
Phobia treatment, as with all treatments of anxiety, does not aim to teach patients to control or “fix” their anxiety, but rather teaches that anxiety is a normal and safe thing to experience. Treatment therefore aims to promote fear tolerance.
Exposing yourself to your feared situations and stimuli is a highly effective form of treatment for phobias. By experiencing the source of your fear, you are able to learn that your fearful predictions do not come true. Exposure therapy therefore aims to help patients approach and engage with feared stimuli which pose no (or little) actual threat. Learning to face the feared situations or stimuli without relying on anxiety-reducing coping skills or “safety behaviours”. Exposure is highly effective, sometimes curing a phobia in a single session.
Exposure to the feared stimulus or situation is the core of phobia treatment. In preparation for this, patients are normally asked to create a fear “hierarchy” of situations that provoke fear, ranking them from least to most frightening. Patients then gradually expose themselves to each situation on the list, working their way up the list. Patients normally exposure themselves to each item on the list for at least an hour, which allows enough time for negative thoughts and emotions to surface and subside. Exposure is completed on a daily basis, and may be completed with a therapist or without. The aim is simply to remain in the presence of the feared situation until all fear has subsided.
Exposure targets the fear and avoidance processes which maintain phobias, rather than those that would lead to its development. This is partly because the processes which maintain phobias are much more well understood than those which lead to their development- the exact reasons why some people are more vulnerable to phobia development than others are unclear (Clark, 1999).
Exposure helps people to learn safe associations with their feared stimuli, rather than simply un-learning or weakening previously-learned associations of threat and danger. This view of exposure is known as the inhibitory learning perspective. During exposure, a patient who holds the belief “snakes are dangerous” does not lose this belief during exposure- they will hopefully gain the new belief “snakes are safe”, but this does not remove the original belief.
This means that, while the new belief will take precedence and reduce the fear this patients feels around snakes, the original belief can reappear in certain situations (such as a change of context or a long passage of time) (Bouton, 2002). It’s therefore very important that exposure treatment covers as many different contexts as possible and strongly reinforces the new, helpful beliefs, so as to prevent the reappearance of phobia symptoms. While fear tends to generalise across a wide range of situations (a person who fears spiders is likely to fear similar creatures as well, for example), safety needs to be learned in each specific situation individually.
According to the inhibitory learning framework, exposure treatment needs to be planned to maximise the strength of the new, helpful beliefs being formed. Exposure therefore aims to not only prove that the feared situation is in fact safe, but to correct the unhelpful beliefs which have a role in fear maintenance. This includes dealing with beliefs around anxiety itself- for example teaching the patient undergoing treatment that they are far more capable of coping with the experience of fear than they expect.
Types of Exposure
In vivo exposure
In vivo exposure involves patients coming into direct contact with the feared stimulus, such as a live spider.
Developed by Wolpe (1958, 1973), based on his theory of “reciprocal inhibition”, systematic desensitization involves teaching the patient to relax using progressive muscular relaxation (PMR) techniques during imagined confrontation with the feared situation or stimulus. Patients complete systematic desensitisation in three stages: learning PMR exercises, constructing a ranked list or hierarchy of fears, and then imagining contact with each of their feared situations in turn while using PMR to stay relaxed.
Imaginal exposure involves the patient imagining coming into contact with the feared stimulus. Unlike systematic desensitization, no training in relaxation techniques is required.
Virtual reality and computer assisted exposure
This modern approach lets patients come into contact with digital representations of their feared situation, offering a form of exposure they may view as safer and less nerve-wracking than in vivo exposure. Both virtual reality (VR) and computer assisted (patients viewing the feared stimulus on a screen) forms of exposure exist.
Eye movement desensitization and reprocessing (EMDR)
EMDR was originally developed by psychologist Francine Shapiro (1989) for the treatment of post-traumatic stress disorder (PTSD).
During EMDR, the patient is instructed to focus on a disturbing or frightening image, memory, emotion, or thought, while the therapist moves a finger across the patient’s visual field and the patient tracks the finger’s movement. Eye movement of this kind has been linked to re-categorising and changing the thoughts related to the memory being processed. Through a separate treatment in its own right, EMDR still involves a degree of imaginal exposure- in fact some argue this is the real reason it is effective in treating phobias (Renfrey & Spates, 1994).
Applied tension (AT).
Applied tension is mainly used in treating of blood or injection phobias. Patients with these phobias often fear passing out in their presence, such as when having an injection or witnessing an injury. In AT, Patients are exposed to blood/injury stimuli while tensing their muscles in order to raise their blood pressure. Raising blood pressure in this way makes fainting impossible (Öst et al., 1991; Öst, Sterner, & Fellenius, 1989).
Features of Exposure Therapy
Cognitive Preparation or Psychoeducation
For phobia treatment to be successful, the following three elements must take place:
- Patients must be presented with information that is incompatible with their maladaptive beliefs about the danger of the phobic stimulus
- Behaviours that interfere with the patient acquiring this new information must be removed
- This new info must be strengthened in the patient’s mind and generalised to as many different relevant situations as possible (Foa, Huppert, & Cahill, 2006).
Since exposure is the key component of any phobia treatment, psychoeducation can be seen as a means of cognitively preparing the patient for the exposure process. The rationale for treatment also needs to be outlined in a way that the patient can understand and accept. The patient finding the treatment credible, and being motivated to engage with it, are significant predictors of treatment success (e.g., Öst, Stridh, & Wolf, 1998).
Going through a recent example of a fearful situation is a good way to begin understanding how anxiety affects you. The following kinds of questions can be used to develop an understanding of your own anxiety:
- Was there a specific trigger to your anxiety?
- How severe was the anxiety, and how long did it last?
- What was the anxiety like? How did it feel in your body?
- Did you do anything to try and control or reduce the anxiety you felt? What effect did these actions have?
- How did the situation resolve, and how did you feel afterwards?
It can also be useful to come to an understanding of the history of your anxiety. Anxiety is something that is learned, after all. Ask yourself:
- When did you first become fearful around X?
- What else was happening in your life at that time? Were there any other major sources of stress or worry?
- How did your parents (or main caregivers) act when anxious? How did they react when you showed signs of worry?
- What has occurred in your life that could have influenced the worry you feel about X?
Since exposure is about tacking the ways in which anxiety maintains itself, rather than the ways in which it started, finding answers to these questions is by no means essential.
Identifying Your Triggers
It is very important to come to a good understanding of the exact contexts and situations which trigger your anxiety. Generally, these cues or triggers fall into three categories: external cues, internal bodily sensations, and mental activity.
These are usually the most obvious- the things in the world which provoke feelings of anxiety. You can identify external triggers using questions such as:
- What kinds of situations cause you to feel afraid?
- What do you fear will happen in these situations, exactly?
- What situations do you avoid for fear of something bad happening?
- What actions do you use to keep yourself from feeling anxious during these kinds of situations?
Internal Bodily Triggers
For many people with phobias (and other forms of anxiety), internal sensations and changes are another source of anxiety. You may fear sudden unexplained feelings as being a sign of danger, or find some of the physical symptoms of anxiety very distressing.
To identify any internal triggers to your anxiety, ask yourself:
- What bodily sensations cause you the most worry when you feel them?
- What changes to your body make you feel afraid?
- What sensations or feelings cause you to worry about your health?
- What physical signs or feelings do you fear that other people will notice?
Mental activities such as thoughts and memories may trigger anxiety if they are particularly unpleasant. To identify mental events which produce anxiety, ask yourself:
- What thoughts or memories do you fear experiencing?
- Are there any memories or thoughts that you try to avoid or shut out?
- What triggers these unpleasant thoughts and memories?
- What form do these thoughts take- are they images? Sounds? Memories of past events?
- What is it about these thoughts that is unpleasant for you?
- Do you experience these thoughts as nightmares, or just when awake?
It can also be useful to identify the feared consequences of being placed in your feared situation or having to confront your feared stimulus. Try to go deeper than just general statements here- what specifically do you fear will happen? If you’re afraid of large crowds, for example, why? What is it about them that’s frightening? Do you fear being judged by others, or panicking in a place you can’t control, or do you fear for your physical safety with so many people around?
Many people rely on certain actions or behaviours to feel safe in the presence of their feared stimuli. These safety behaviours can become problematic, as discussed in the section on safety behaviours above.
Factors that May Interfere with Exposure Success
Lack of engagement with the exposure work is the main reason for treatment not working. Exposure may be stressful, but seeing it through is truly the most effective way to overcome phobia (see Sanderson & Bruce, 2007). For example, research shows that compliance with exposure homework in the first weeks of treatment predicts level of improvement 2 years later.
Even when exposure is completed, negative expectations can get in the way of recovery, so it is important to understand and be comfortable with the procedure before making a start on exposure.
Duration of Exposure
It’s important to stay in your exposure sessions for adequate time during phobia treatment. The idea is that you remain in the presence of the feared stimulus long enough to provoke a fear response, and then for that fear to subside. Staying in the presence of the phobic stimulus for longer durations, and for at least a minute with no fear has been shown to make the whole process more effective (Marshall, 1985).
Having phobias of multiple different situations or triggers is relatively common (Hofmann, Lehman, & Barlow, 1997). A patient may, for example, be fearful of both driving and enclosed spaces- both of these phobias could impact them while in a car.
In situations like this, treatment simply needs to address each issue in turn. The patient (and therapist) should decide which aspect to work on first, and try to remove all fear around that situation before moving on to the next. In the above example regarding cars and enclosed spaces, exposure could take place around being a passenger in a car, followed by an exposure session in a dark enclosed room, followed by a session of driving a car. Other exposure sessions may need to target other aspects of the fear around cars, for example exposure to the discomfort of being too hot or of the loud noises of other vehicles, and so on. It is important to be thorough when conducting a list of feared situations and stimuli, so that all forms of fear are extinguished.
Influence of Other Unpleasant Emotions and Sensations
Disgust Fear is undoubtedly the main emotional experience in phobias, but certain phobic stimuli may also provoke feelings of disgust. Phobias of spiders, vomiting, and any blood or injury related situations are likely to include some component of disgust alongside fear. Fear and disgust appear to operate separately in phobias: levels of one do not necessarily affect the other, so removing both is important for recovery. Disgust levels do decrease during exposure in a similar way to fear levels, although some research suggests they do so at a slightly slower rate (Olatunji et al., 2002).
Nausea Feelings of nausea are common in many phobias (Haug, Mykletun, & Dahl, 2002). In particular, a fear of vomiting can be an issue during exposure as the patient will be reluctant to take part in exposure for fear of throwing up. Often the fear of vomiting is linked to a fear of losing control- this should be worked on using cognitive treatments aimed at increasing the patient’s ability to tolerate uncertainty (see Keefer et al., 2005). Once the patient has become comfortable with the idea of losing control due to vomiting, exposure may proceed.
Lightheadedness/Fainting Concerns about feeling lightheaded or fainting are common in phobias relating to the blood, illness and injury category. Fainting in the presence of the feared stimulus (needles, images of gruesome injury and so on) is a relatively common issue in this kind of exposure (Sarlo, Buodo, Munafo, Stegagno, & Palomba, 2008). This particular issue can be addressed using a specially designed technique, Applied Tension (Öst, Fellenius, & Sterner, 1991), which involves tensing of the muscles in such a way as to raise blood pressure, making fainting impossible.
Shame Phobias can be extremely debilitating. Certain fears may lead to a person needing to make drastic changes to their lifestyle, or becoming very dependent on others. Feelings of embarrassment and shame around this may surface, along with negative self-evaluations relating to the fear. Exposure should be conducted in a way that accounts for this, and does not put the patient through any unnecessary public embarrassment.
When Skill Deficits Accompany the Phobia
People who have been suffering with phobias for most of their lives (remember that most phobias develop in childhood) may not have had chance to learn the appropriate skills to function in the situations they fear. This can hinder the exposure process. A man who has feared dogs all his life, for example, will not have learned the correct way to handle and react to dogs, and so is more likely to get a negative reaction from any dog he encounters. Driving is another example where fear would keep someone from learning the necessary skills, thereby making safe exposure more difficult. Treatment should therefore teach the appropriate skills before exposure is attempted, to reduce the risk of harm and increase the patient’s confidence in the feared situation.
When Patients Use Cognitive Avoidance During Exposure
Patients who agree to take part in exposure can sometimes engage in mental attempts to distract themselves from the situation and their fear. Avoiding fully engaging with the fear in this way may seem like a perfectly natural way of coping with the feared situation, but in reality it makes the exposure process less effective. Mental distraction or avoidance of all kinds is linked to poorer treatment outcome (Rentz et al., 2003). If you are planning to face situations you are afraid of it’s important to fully face them, in order to experience and then overcome your fear, rather than half experiencing it and allowing it to linger.
The Change Process- Understanding Mixed Feelings
Often we have mixed feelings about the idea of change- some part of us wants it but some part doesn’t-perhaps we’re fearful of the unknown aspect of change, perhaps we don’t feel ourselves capable of it. We will also hold beliefs about the change process. These beliefs can either help or hinder you on the journey.
Ask yourself the following questions:
- What do you believe about the change process you’re currently in?
- Do you find this change process easy? Do you think it should be easy? Why/why not?
- What are the challenges involved in changing?
- What are the positives and negatives of change?
Some possible answers to these questions might include:
- I don’t have time to devote to overcoming my fears
- I’ve tried to overcome my phobia before and failed
- I have bigger worries and priorities than my fears
- I never know where to begin looking at changing
- It’s easier to just manage my fear by working around the issue than try to change it
- It’s hard to keep going when I’m not sure I’m going to succeed
- I’ve had this fear for so long there’s no change of changing now- you can’t teach an old dog new tricks
- I’ll never be able to change- I’m not strong/brave enough
- If I change now, it would mean admitting I’ve been living in a dysfunctional way for years
These kinds of fears are perfectly rational- going through a big change process like overcoming a phobia is a significant undertaking. It is therefore perfectly normal to have some mixed feelings about the idea of changing in this way, and it’s important to consider all sides fully. Thinking through both the positives and negatives is a great way to fully consider changing and can make the process feel more manageable. Thinking about possible negatives can also help prepare you for difficulties and setbacks along the way.
Let’s look at this another way. Here’s a question (and it may seem like an odd one): what are the possible benefits of keeping your phobia?
Here are some answers that may come to mind:
- It would be easier to just live with the fear and not have to go through all this
- I’m used to my fear and can manage it. Better the devil you know!
- I’ve gotten used to managing my fear- I just need to avoid certain situations. Changing would mean adjusting how I live
- If I keep my fears, I don’t really have to acknowledge them
- Overcoming my fear will require lots of time and effort
- If I avoid trying to change, I avoid the risk of failing
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