PHOBIA REACTION

Sigmund Freud is the father of psychoanalysis and is sometimes considered the father of modern
psychology. His ideas and concepts attempted to explain the dynamics of the unconscious mind.
According to Freud’s structural theory, the mind consists of three parts: the id, ego, and superego.

What Is a Phobia?
A phobia is an overwhelming and unreasonable fear of an object or situation that poses little real
danger but provokes anxiety and avoidance. Unlike the brief anxiety most people feel when they
give a speech or take a test, a phobia is long-lasting, causes intense physical and psychological
reactions, and can affect your ability to function normally at work or in social settings.

Theory of Phobias
The psychoanalytic theory of phobias is based largely on the theories of repression and
displacement. It is believed that phobias are the product of unresolved conflicts between the id
and the superego. Psychoanalysts generally believe that the conflict originated in childhood, and
was either repressed or displaced onto the feared object. The object of the phobia is not the
original source of the anxiety.

What are Phobias?

Phobic Reactions in Social Phobia

Social phobia, or social anxiety disorder, is a fear of judgment by others. It's an intense fear of
embarrassing or humiliating yourself in small or large groups. Social phobia or social anxiety
disorder
can be extremely life-limiting. You may find yourself basing educational and career moves on the
likelihood of being exposed to your feared situation. You might turn down dates or stay home from parties.
Social phobia can also lead to self-replicating cycles in which your phobia causes you to act oddly,
reinforcing your fear of acting oddly in public.

Phobic reactions to what triggers your social phobia may include:

 being overly concerned you will offend someone
 an intense fear of having a conversation with strangers
 avoiding any situation where you will be the center of attention, such as a birthday party
 anticipating the worst case scenario during a social situation
 Intake Interview for Social Anxiety

Social phobia is also known as Social Anxiety Disorder (SAD). Your therapist is asking
questions to rule out other psychological issues like depression during the intake interview.

He or she may ask if you have an intense and persistent fear of:
 People judging you in social situations
 Being humiliated by your actions
 People noticing your signs of anxiety, including sweating and shaking

Your therapist might also question you about your overall mood, asking you to think about
whether you spend more days than not feeling the following:
 Depressed or sad
 A disinterest in life
 Guilty or worthless

Phobic Reactions in Agoraphobia

Agoraphobia is commonly thought of as a fear of wide, open space. Actually, this anxiety disorder
is a fear of being unable to escape to safety or find help when you start having a phobic reaction.
The physical symptoms match those of specific phobia. Agoraphobia is perhaps the most
pervasive and difficult to manage of all the phobias. Agoraphobia is essentially the fear of having
a panic attack. When attempting to confront agoraphobia, you may have a panic attack brought
 on by the agoraphobia. This, in turn, may reinforce your belief in your inability to control panic
attacks, making the agoraphobia even worse. Thankfully, once the disorder is recognized, there
are methods of coping with agoraphobia.

Intake Interview for Agoraphobia

During your intake interview for agoraphobia, your therapist will ask if you feel fear or
anxiety when you:
 Use public transportation
 Are in an open space, such as a stadium or bridge
 Are in an enclosed space, such as an elevator or classroom
 Wait in line or are in a crowd
 Leave the house by yourself

To make an agoraphobia diagnosis, he or she may ask you if:

 You do what you can to avoid the situation
 Your fear is out of proportion to the actual potential for danger
 Your fear causes significant problems in your personal life or at work

Maladaptive thoughts during a phobic reaction to agoraphobia can include:

 I'm losing my sanity.
 I might lose control and have an obvious phobic reaction in public and others may stare.
 I won't be able to get out of here if I start to have a phobic reaction.

Certain behaviors are characteristic of agoraphobia, including:

 not being able to leave your residence for long periods of time
 an aversion to being far from home
 needing someone you trust when going out

Phobic Reactions in Specific Phobia

Specific phobia presents as an intense, exaggerated, and persistent fear of a situation or object.
The number of specific phobias is only limited by the number of nouns and includes, a fear of
bathing (ablutophobia), a fear of the number 8 (octophobia), and the fear of death (thanatophobia).
Some specific phobias are fairly easy to avoid if they do not regularly appear in your daily life. If
you have a fear of heights (acrophobia), it may take as little effort as avoiding high places. Some
phobias, such as the fear of spiders (arachnophobia) can be difficult to avoid anywhere. Even
phobias, such as the fear of thunderstorms (astrophobia) can be managed to some degree.
You may experience embarrassment when asking if a new friend has a dog or turning down a
camping trip for fear that boating may be involved.
However, if you have a specific phobia, you may be fearful of new situations. You may worry that
the object of your fear will be present. (And in this you begin to fear your fear.) It is this fear of
your fear that can turn a specific phobia into something which significantly disrupts your life.

A phobic reaction to specific phobia happens when you anticipate or encounter your trigger and
includes:
 feelings of imminent doom
 feeling dizzy or light-headed
 nausea or diarrhea
 avoidance tactics to prevent an encounter with your trigger
 ringing in your ears

Intake Interview for Specific Phobia

Specific phobia is one of the most common psychological problems. As with the other types of
phobia, it shares symptoms with other psychological disorders, including social phobia and
agoraphobia. This is why answering your therapist's questions honestly is so important to get a
correct diagnosis.
Questions your therapist might ask you during an intake interview for specific phobia include:
 Do certain situations make you feel sudden terror, fright, anxiety, worry, or nervousness?
 Are you overcome with thoughts of bad things happening to you or of being injured?
 Do you have a persistent fear that interferes with your daily life, including at home and at work?
 Have you ever distracted yourself to avoid thinking about your trigger?

Diagnostic Criteria for Phobias

By Lisa Fritscher

When diagnosing a phobia, mental health professionals must use clinical skills and judgment
alongside the written list of diagnostic criteria found in the Diagnostic and Statistical Manual.
Many of the symptoms of phobias are very similar to those of other mental disorders as well as
physical illnesses. A phobia can be defined as an intense and irrational fear. There are three types
of phobias, specific phobia, social phobia, and agoraphobia. Each type of phobia has its own unique
diagnostic criteria.
Differential Diagnosis.
One of the most important steps in diagnosing a phobia is deciding whether the symptoms are
better explained by another disorder. Phobias can be traced to specific, concrete fears that adult
sufferers recognize as irrational.
The fact that the fear is concrete separates phobias from disorders such as generalized anxiety
disorder, in which the anxiety is more broad-based. Phobia sufferers are able to pinpoint an exact
object or situation that they fear.
Being able to recognize the fear as irrational separates anxiety disorders from the psychotic
disorders such as schizophrenia. People who suffer from psychotic disorders genuinely believe
that the fear is based on a real danger, though the nature of the danger appears illogical to others.

Common Criteria
Each type of phobia has its own unique set of diagnostic criteria.

There are some overlaps. Diagnostic criteria that are similar to all phobias include:
 Life-Limiting: A phobia is not diagnosed unless it significantly impacts the sufferer’s life in some
way.
 Avoidance: Some people with clinically diagnosable phobias are able to endure the feared
situation. However, attempts to avoid the feared situation are an important criterion for
diagnosing a phobia.
 Anticipatory Anxiety: People with phobias tend to dwell on upcoming events that may feature
the feared object or situation.

Diagnosing a Specific Phobia

In order for a specific phobia to be diagnosed, one or more objects or situations must be identified
as the cause of fear. People with specific phobias often have other anxiety disorders as well, making
it difficult to accurately pinpoint the diagnosis.

When to Seek Help for Phobic Reactions

Your phobic reaction merits a trip to the doctor when your symptoms interfere with your ability
to make money, maintain healthy personal relationships, and perform essential daily tasks, such
as bathing or grocery shopping.
Genetic and environmental factors can cause phobias. Children who have a close relative with an
anxiety disorder are at risk of developing a phobia. Distressing events, such as nearly drowning,
can bring on a phobia. Exposure to confined spaces, extreme heights, and animal or insect bites
can all be sources of phobias.
People with ongoing medical conditions or health concerns often have phobias. There’s a high
incidence of people developing phobias after traumatic brain injuries. Substance abuse and
depression are also connected to phobias.
Phobias have different symptoms from serious mental illnesses such as schizophrenia. In
schizophrenia, people have visual and auditory hallucinations, delusions, paranoia, negative
symptoms such as anhedonia, and disorganized symptoms. Phobias may be irrational, but people
with phobias do not fail reality testing.
Agoraphobia
Agoraphobia is a fear of places or situations that you can’t escape from. The word itself refers
to “fear of open spaces.” People with agoraphobia fear being in large crowds or trapped outside
the home. They often avoid social situations altogether and stay inside their homes.
Many people with agoraphobia fear they may have a panic attack in a place where they can’t
escape. Those with chronic health problems may fear they will have a medical emergency in
a public area or where no help is available.

Social Phobia
Social phobia is also referred to as social anxiety disorder. It’s extreme worry about social
situations and it can lead to self-isolation. A social phobia can be so severe that the simplest
interactions, such as ordering at a restaurant or answering the telephone, can cause panic. People
with social phobia often go out of their way to avoid public situations.

Specific Phobia
Presents as an intense, exaggerated, and persistent fear of a situation or object. The number of
specific phobias is only limited by the number of nouns and includes, a fear of bathing
(ablutophobia), a fear of the number 8 (octophobia), and the fear of death (thanatophobia).

A phobic reaction to specific phobia happens when you anticipate or encounter your trigger and
includes:
 Feelings of imminent doom
 Feeling dizzy or light-headed
 Nausea or diarrhea
 Avoidance tactics to prevent an encounter with your trigger
 Ringing in your ears

Symptoms of Phobias
Phobic symptoms can occur through exposure to the feared object or situation, or sometimes
merely through thinking about the feared object.

Typical symptoms associated with phobias include:

 Dizziness, trembling, and increased heart rate
 Breathlessness
 Nausea
 A sense of unreality
 Fear of dying
 Preoccupation with the feared object
 pounding or racing heart
 shortness of breath
 rapid speech or inability to speak
 dry mouth
 upset stomach
 nausea
 elevated blood pressure
 trembling or shaking
 chest pain or tightness
 a choking sensation
 dizziness or lightheadedness
 profuse sweating
 a sense of impending doom

Psychological and Emotional Effects of Phobias

 Businessmen shaking hands
 Phobias can impact your life emotionally in many ways.
  Phobias often have a far-reaching effect, causing difficulties in many areas of life. You may wonder
if what you are feeling is normal. Phobias can impact your life emotionally in several ways.
 Phobias can cause severe anxiety and the emotional and physical responses that accompany
anxiety.
 Phobias can be isolating. Some phobias (especially agoraphobia) can lead you to avoid social
situations.
 Not only have you left alone, but then have time to wonder why you can't be like everyone else.
 Phobias can be embarrassing. You may be embarrassed due to your phobia alone (you're afraid of
what?) and by the decisions, you may need to make due to your phobia
 Phobias can leave you feeling helpless. Just as others wonder why you can't simply not be afraid,
you may feel at a loss for being unable to control your phobia. This feeling of helplessness can
also leave you feeling much less control over your whole life.

Other Types of Phobias

Many people dislike certain situations or objects, but to be a true phobia, the fear must interfere
with daily life. Here are a few more of the most common ones:

 Glossophobia: This is known as performance anxiety, or the fear of speaking in front of an

audience. People with this phobia have severe physical symptoms when they even think about
being in front of a group of people.
 Acrophobia: This is the fear of heights. People with this phobia avoid mountains, bridges, or the
higher floors of buildings. Symptoms include vertigo, dizziness, sweating, and feeling as if they’ll
pass out or lose consciousness.
 Claustrophobia: This is a fear of enclosed or tight spaces. Severe claustrophobia can be especially
disabling if it prevents you from riding in cars or elevators. <Learn more about claustrophobia,
from additional symptoms to treatment options.
 Aviophobia: This is also known as the fear of flying.
 Dentophobia: Dentophobia is a fear of the dentist or dental procedures. This phobia generally
develops after an unpleasant experience at a dentist’s office. It can be harmful if it prevents you
from obtaining needed dental care.
 Hemophobia: This is a phobia of blood or injury. A person with hemophobia may faint when they
come in contact with their own blood or another person’s blood.
 Arachnophobia: This means fears of spider.
 Cynophobia: This is a fear of dogs.
 Ophidiophobia: People with this phobia fear snakes.
 Nyctophobia: This phobia is a fear of the nighttime or darkness. It almost always begins as a
typical childhood fear. When it progresses past adolescence, it’s considered a phobia.

Treatment for Phobias

Treatment for phobias can involve therapeutic techniques, medications, or a combination of both.

 Cognitive behavioral therapy

 Cognitive behavioral therapy (CBT) is the most commonly used therapeutic treatment for
phobias. It involves exposure to the source of the fear in a controlled setting. This treatment can
decondition people and reduce anxiety.
 The therapy focuses on identifying and changing negative thoughts, dysfunctional beliefs, and
negative reactions to the phobic situation. New CBT techniques use virtual reality technology to
expose people to the sources of their phobias safely.
 A good mental health professional will customize a treatment plan for you, which may include
both talk therapy and medication. A physician is more likely to add medication to an agoraphobia
or social phobia treatment plan than for a specific phobia.
 The Therapeutic Goals of Psychoanalysis

The Goals of Exposure Therapy

Your treatment goals for specific phobia are likely to be met through the cognitive behavior
therapy method known as exposure therapy. During this desensitization process, the therapist
will gradually expose you to stimuli related to your fear in a safe and controlled environment.
You've reached your goals when your distorted thinking diminishes to a functional level or
disappears.

The Therapeutic Goals of Psychoeducation

The goal of psychoeducation is to restructure your thought patterns in order to overcome your
irrational or overestimated fear and usually the first line of treatment for specific phobia. The
therapist will help you learn to let your thoughts be helpful instead of debilitating. The response
rate to therapeutic desensitization techniques is 80 to 90 percent.

Goals of Agoraphobia Treatment

The goals of agoraphobia treatment are to learn:

 Your fears are not likely to come true

 Your anxiety will gradually decrease in public and that you're capable of managing your
symptoms until they do
 The factors that trigger your panic attacks, or panic-like symptoms, or make them worse
 Techniques to deal with your symptoms
 How to change the unwanted and unhealthy behaviors through self-guided desensitization
techniques?

Goals of Social Phobia Treatment

Your treatment plan for social phobia is likely to include a combination of talk therapy,
medication, and role-playing. The goals of treatment for social phobia, or social anxiety disorder,
include helping you to:

 Change the negative thoughts you have about yourself

 Develop confidence in social situations, especially the ones you fear most
 Improve your coping skills

Friends and Family as Resources for Phobia Support

Friends and family are the first lines of support for those battling any disorder, and phobias are
no exception. Your loved ones can help you manage your fears by performing tasks ranging from
talking you through a guided visualization to previewing a potential trigger situation for you.
Unless your loved one happens to be a mental health professional, though, he or she may be
clueless about how best to help. Many people begin to shy away from those with phobias or other
mental health concerns - not due to lack of compassion, but because they simply do not know
what to do.
Getting the support, you need begins with telling your loved ones about your phobia, so you
should learn how to tell your friends and family.
Once you have shared your phobia, you can start to ask for help. Give your loved one’s concrete
ideas and suggestions as to what they can do for you. "Can you come with me to the doctor?" or
"Do you mind if I call you after my date tonight?" are examples of clear and precise requests.

Support Groups for Phobias

Although your friends and family are your first line of support, they can't be expected to meet all
of your needs. A support group can act as the next line of support. Support groups are groups of
people who share similar disorders. They meet on a regular basis to discuss their concerns, share
ideas and coping strategies and socialize with each other.
Some support groups are more formalized, with a moderator who guides each session’s
discussions, often around a theme. Others are more relaxed and free-form, allowing the
discussions to flow naturally.
 Traditional support groups meet in person. As the Internet has become a ubiquitous part of
people’s lives, many web-based support groups have sprung up. Some researchers question the
therapeutic value of these groups, where people may or may not be who they say they are. Yet,
others feel that such groups are a wonderful first step for those who suffer from severe social
anxiety disorder or agoraphobia, which might keep them from attending in-person support group
meetings.
You can find both in-person and online support groups through a simple Internet search. Most
groups list their membership requirements, meeting times and other important information
online.

Organizations and Internet Resources

There are many organizations that provide resources for people who suffer from phobias and other
anxiety disorders. Although most organizations are reputable, it's always wise to be cautious.
Some excellent organizations include:
National Alliance on Mental Illness
This national organization is a wonderful place to start. You can participate in an online
community, find local resources and read a wealth of useful information. Membership requires a
small fee, but much of the information is available to non-members as well.

Books and Magazines

Phobias are a relatively common disorder, and many sufferers have published books about their
experiences. Reading about someone else’s experiences can help to combat the isolation that many
people with phobias experience.
If you're battling with phobias, your natural tendency may be to avoid many of your previous
social contacts. Trying to rely on just one or two people is a common and understandable reaction,
but in the long run, it's not healthy for your relationships.
Instead, work on expanding your network of support. Most people are happy to help, provided
they know what to do. Ask for specific help rather than making more general requests. Also,
coordinate efforts between your entire network to ensure that all of your needs are met.
Finally, learn to accept the answer "no" gracefully. Some people are incapable or unwilling to
perform certain tasks, but that doesn't have to cause friction in your friendships. Focus on the
other ways those people play an important role in your life.
Coping with a phobia is an ongoing battle, and it requires support from a variety of sources.
Although finding that support may seem daunting at first, the rewards are well worth the
challenges.

A medication commonly prescribed to help you reach your therapeutic objectives include:
 Antidepressants
 Anti-anxiety medication
 Beta-blockers

Antidepressants and anti-anxiety medications can help calm emotional and physical reactions to
fear. Often, a combination of medication and professional therapy is the most helpful.
 CASE STUDY of PHOBIC REACTION

SOCIAL PHOBIA

Social Phobia/Anxiety Case Study: Jim

by Thomas A. Richards, Ph.D., Psychologist

 Jim was a nice looking man in his mid-30’s. He could trace his shyness to boyhood and his social
anxiety to his teenage years. He had married a girl he knew well from high school and had almost
no other dating history. He and his wife, Lesley, had three children, two girls and a boy.
 At our first meeting, Jim was very shy and averted his eyes from me, but he did shake hands,
respond, and smile a genuine smile. A few minutes into our session and Jim was noticeably more
relaxed. "I’ve suffered with this anxiety for as long as I can remember", he said. "Even in school,
I was backward and didn’t know what to say. After I got married, my wife started taking over all
of the daily, family responsibilities and I was more than glad to let her."
 If there was an appointment to be made, Lesley made it. If there was a parent-teacher conference
to go to, Lesley went to it. If Jim had something coming up, Lesley would make all the social
arrangements. Even when the family ordered takeout food, it was Lesley who made the call. Jim
was simply too afraid and shy.
 Indeed, because of his wife, Jim was able to avoid almost all social responsibility -- except at his
job. It was his job and its responsibilities that brought Jim into treatment.
 Years earlier, Jim had worked at a small, locally-owned record and tape store, where he knew the
owner and felt a part of the family. The business was slow and manageable and he never found
himself on display in front of lines of people. Several years previously, however, the owner had
sold his business to a national record chain, and Jim found himself a lower mid-range manager in
a national corporation, a position he did not enjoy.
 "When I have to call people up to tell them that their order is in," he said, "I know my voice is
going to be weak and break, and I will be unable to get my words out. I’ll stumble around and
choke up.... then I’ll blurt out the rest of my message so fast I’m afraid they won’t understand me.
Sometimes I have to repeat myself and that is excruciatingly embarrassing........"
 Jim felt great humiliation and embarrassment about this afterwards: he couldn’t even make a
telephone call to a stranger without getting extremely anxious and giving himself away. That
was pretty bad! Then he would beat himself up. What was wrong with him? Why was he so
timid and scared? No one else seemed to be like he was. He simply must be crazy! After a day
full of this pressure, anxiety and negative thinking, Jim would leave work feeling fatigued, tired,
and defeated.
 Meanwhile, his wife, being naturally sociable and vocal, continually enabled Jim not to have to
deal with any social situations. In restaurants, his wife always ordered. At home, she answered
the telephone and made all the calls out. He would tell her things that needed to be done and she
would do them.
 He had no friends of his own, except for the couples his wife knew from her work. At times when
he felt he simply had to go to these social events, Jim was very ill-at-ease, never knew what to
say, and felt the silences that occurred in conversation were his fault for being so backward. He
knew he made everyone else uncomfortable and ill-at-ease.
 Of course, the worst part of all was the anticipatory anxiety Jim felt ahead of time – when he knew
he had to perform, do something in public, or even make phone calls from work. The more time
he had to worry and stew about these situations, the more anxious, fearful and uncomfortable he
felt.

 REMARKS: Jim presented a very typical case of generalized social phobia/social anxiety. His
strong anticipation and belief that he wouldn’t do well at social interactions and in social events
became a self-fulfilling prophecy, and his belief came true: he didn’t do well. The more nervous
and anxious he got over a situation, and the more attention he paid to it, the more he could not
perform well. This was a very negative paradox or "vicious cycle" that all people with social
anxiety get stuck in. If your beliefs are strong that you will NOT do well, then it is likely you
will not do well. Therefore, thoughts, beliefs, and emotions need to be changed.
 The depression (technically "dysthymia") that comes about after the anxious event continued to
fuel the fire. "I’ll never be able to deal with this," Jim would tell himself, thus constantly
reinforcing the fact that he saw himself as a failure and a loser.
 Unusual in this situation is that Jim’s wife remained loyal to him, understood his problem to some
extent, and even seemed to enjoy her role as the family’s "social director". The more and more
she did for Jim, the more and more he could avoid. It got so bad that Jim, who loved to listen to
new albums and read new books -- could not even go to stores or to the library. He would tell
his wife what to buy and she would buy it. She even kept track of when the library books were
due and made sure she took them back on time.
 This family situation is unusual because most people with social anxiety/social phobia have an
extremely difficult time making and continuing personal relationships -- because of self-
consciousness and the need for more privacy than most other people. In fact, social phobia ranks
among one of the highest psychological disorders when it comes to failed relationships, divorce,
and living alone.

 TREATMENT: for Jim consisted of the normal course of cognitive strategies so that he would
relearn and rethink what he was doing to himself. He was cooperative from the beginning, and
progressed nicely doing therapy. He took each of the practice handouts and spent time each day
practicing. He made a "special time" for himself that his family respected and he used this place
and time to practice the cognitive strategies his mind had to learn.
 His biggest real-life fear, speaking to another person in public, was not really a speaking problem;
it was an anxiety problem. There was nothing wrong with Jim’s voice, his reading ability, or his
speaking ability. Jim was a bright man who had associated great anxiety around these social
events in public situations.
 The course of treatment here is NOT to practice! In fact, practicing would just draw attention to
what Jim perceived was the problem: his voice, his awkwardness, his perceived inability to speak
to others. Thus, it would reinforce the very behaviors we do not want to reinforce.
 Instead, Jim worked on paradoxes. We deliberately goofed-up. We tried to make as many
mistakes as possible. We injected humor into the situation and found that when he exaggerated
his fears, he thought this was funny. Although more is involved than just this, the concept here
is to de-stress the situation and enable the person to see it for what it is: NO BIG DEAL! If you
make a mistake, SO WHAT? Everyone else does too!
 Over the weeks, before group therapy began, Jim did a number of interesting things in public that
began proving to him that he was NOT the center of attention, and it just didn’t matter if he made
a mistake or two. After all, he was human just like everyone else. It’s this idea of perfectionism,
of always having to "do your best" that must be broken down. Jim was human; humans make
mistakes; so what? It was certainly nothing to get upset about. In fact, as time went by, it become
even more funny and humorous, rather than humiliating or embarrassing.
 After completion of the behavioral group therapy, Jim had an opportunity for advancement in his
company, which he now felt comfortable to take. The promotion entailed holding weekly
meetings in which he was in charge. He would have to do some public speaking and respond to
his employees’ questions. By this time, Jim was feeling much more comfortable and much less
anxious about the whole situation. "I think I’ll deliberately goof up," he joked to me before the
start of his new job. "It would be interesting to see how everyone else responds."
 To say that Jim did not have any anticipatory anxiety before taking this position or before making
his weekly presentations would be inaccurate. The difference was now they were manageable.
They were simply minor roadblocks that could be overcome. Jim’s thinking about social events
and activities had changed a great deal since the first day I saw him in therapy.
 I talked to Jim a few months ago and everything was going well. His responsibilities at work had
increased slightly, but Jim now had the ability and beliefs to deal with them. He was much more
confident and had a feeling of being in control. He was doing more around the house and his wife
was a little surprised at his metamorphosis. Luckily, this did not change the marriage dynamics
adversely, and the last time I talked with him, Jim had become a father again: another little boy.
 "He’s the last," Jim said, laughing over the phone, "I can’t get too distracted. I’ve got too many
speeches to give now."
A STRANGE CASE of AGORAPHOBIA:
The case is of Mrs. E. L, who is a 91 years old woman at the time of initial evaluation, living with her
husband of 60 years. She was seen through a home care program of Kent Hospital. Initial consultation
was done in July 2008. We decided to write this case study after a written consent given to us by the
patient.
Chief Complaint & History of Present Illness:
The Patient Mrs. E. L had intense fear of falling and dying, along with fears of losing
consciousness; not to be found in time; and might be buried alive. She had been home bound
for the last 17 years. She had a fear that something bad will happen, if she will go out of her
apartment. She stayed mostly in her bed, and did not even allow her husband to leave the
apartment. She believed, that she might get hurt or buried alive if she leaves the safety of her
bed. She also believed that she might not be found in time, should something bad happen to
her. The patient was quite fearful of dying, thinking she may go to hell, although she could
not describe anything that would make her deserve that fate. When her brother died in 1971,
she managed to go to the hospital but did not want to go to his room to see him. Her niece
reported that in the 1950s, when the patient’s husband was working, she couldn’t tolerate
being home alone. It was unclear if the patient met the criteria for Panic disorder; however,
her niece also reported she may sometimes have panic like symptoms. These include shortness
of breath; tightness in her chest; palpitation; sweaty hands; tremors and sudden jolts of fear
of dying. Her brother would pick her up and she would stay all day with his family until her
husband returned from work to pick her up at the same time every day. Over the years, her
condition worsened to a point where she even refused to step out of her apartment. As the
time progressed, so did her agoraphobia, eventually forcing her to be confined to the corners
of her bed. She was then provided with services such as a bedpan and sponge baths.

In 2008, during the month of July, Mrs. E. L called her husband, who was in the next room,
like any other day. But this time she did not get a response from him. She immediately started
having bad thoughts and ideas of what could have happened to him; so she called 911. This
all took place from her bed. Instead of going to check up on his whereabouts in their own
home, the agoraphobia took a drastic turn, which clouded her rational decision-making in the
most critical time. The safety of her husband was jeopardized, yet she still could not leave her
cloister of safety and comfort. Mrs. E. L denied feelings of depression, hopelessness and
worthlessness. She also denied loss of concentration. She had no leisure activities and simply
lied in bed. She did not listen to the radio or watch TV. She denied symptoms of mania or
psychosis and also denied suicidal or homicidal ideation.

Psychiatric History:
Treated at Butler in 1960 with ECT for depression and anxiety.

Medical History:
Patient has a slight problem with hearing. Past history includes ectopic pregnancy in 1956, S/P
bilateral oophorectomy; S/P cholecystectomy; Cataract for which she has refused surgery. After
the initial assessment in 1998 she was found by the home care team to be very anemic and has
been hospitalized and found to have colon cancer, which was surgically removed.

Mental Status Exam:

The patient is an elderly white female who appears to be physically healthy and appears younger
than her age. She was cooperative but seemed to be in distress, and sometimes even tearful. She
also had a hearing problem, which was causing some difficulty in communicating with her. Her
speech was of regular rate and volume. Thoughts were goal directed, but somewhat
circumstantial and ruminative on the fear of leaving her bed and being alone. Her mood was
anxious, but not depressed. She denied any symptoms consistent with obsessions and compulsions
other than obsessive thoughts of fear of death. She was alert and oriented to time, place and
person. Concentration and memory were intact. She denied any suicidal thoughts. Her insight
and judgement was good, apart from her fear of being alone and excessive worries.

Initial Diagnosis
 Axis I agoraphobia without panic disorder
Axis II None
Axis III Anemia, SP surgical resection of colon cancer, cataract
Axis IV Home bound for 17 years.
Axis V GAF 30

Treatment:
Three years ago she was started on Sertraline (Zoloft) 25 mg PO qd. She tolerated the
medication without any side effects. As time allowed, later on during the course of treatment,
the medication was increased to 50 mg PO qd. Patient was also given behavioral therapy and
exposure therapy and her home attendant was educated to carry out the proposed plan.
Patient was encouraged in the beginning to leave her bed for few minutes to few hours. After
a few weeks she was able to walk up to the living room. Slowly and gradually she was
encouraged to go to a different room each day in the apartment. At one point she was escorted
up to the front door of the apartment. Finally, she managed to build enough courage and will
power to step out of her apartment into the hallway; It took months before she was able to
come down the lobby. Sertraline was subsequently titrated up until a dose of 150 mg pod qd.
For few weeks she would only come to the stairs accompanied with her caregiver. She was
continuously encouraged to gradually come out of her apartment. In July of this year after
our home visit, she came down to the parking lot to see us off.

Follow-Up & Current Mental State Examination

Patient was regularly seen for the next three years. Her condition improved with no relapse
in the severity. She was last seen in November 2011. She seemed to be at ease while having
breakfast with her husband in the kitchen. Her speech was of normal rate and volume,
although she had some para phasic errors. Conversation was very difficult due to her hearing
problem. She denied feeling depressed, upset or anxious home, however reported feeling
afraid of going outdoors.
She reported being confused at times, but could not elaborate and provide specific details or
examples of times where she was confused. Her thoughts and ideas were goal directed and
coherent but somewhat disorganized. She denied any problems with appetite and sleep. There
was no evidence of paranoia, hallucinations, delusion or other psychotic symptoms. The
patient was only oriented to her name, but not to the day, month or year. She had a difficult
time paying attention and concentrating. Insight was questionable and judgement was intact.

Current Diagnosis
Axis I Agoraphobia without panic disorder
Dementia of the Alzheimer’s type, late onset, uncomplicated
Axis II None
Axis III Anemia, S/P surgical resection of colon cancer, cataract
Axis IV Home bound for 17 years
Axis V GAF 30

Current Treatment Issues

She was started on Aricpet 5 mg PO qd and later on increased to 10 mg pop d. Maintain behavioral
interventions. Continue to live in her apartment and to slow down cognitive decline.

Care Giver & Family’s Response

The patient lived with her husband. The husband was very cooperative and helpful to the
clinicians and her wife as well. Some other family members included some relatives; they were
very empathic with the patient.

Discussion
Agoraphobia is a condition where people become troubled or bothered in unfamiliar environments
or surroundings, where they believe that they have little or no control. Places which may spark
this anxiety include open spaces like parking lots and malls, big crowds, and even traveling.
Agoraphobia is often, but not necessarily in combination with a fear of social embarrassment,
 because usually these sufferers fear the onset of an acute panic attack; Together, agoraphobia and
social panic attacks is called “Social Agoraphobia,” which may be a branch of Social Anxiety
Disorder. Fearing the onset of another panic attack, the sufferer is frightful and avoidant when it
comes to going back to a location where a prior attack has taken place. Some refuse to leave their
homes even in medical emergencies because the fear of being away from their safe haven is too
much to handle.
Agoraphobics may also suffer from temporary separation anxiety disorder when certain
individuals in their household leave temporarily. For example, a parent, or spouse who may leave
for certain errands for a short period of time, may be sufficient enough to induce some level of
anxiety or a panic attack. Another common disorder that may be associated with agoraphobia is
thanatophobia, the fear of death. The anxiety level of these persons often increases when
contemplating the idea of eventual death, which may be done consciously or subconsciously, while
connecting this idea of death to the epitome of separation from comfort and safety.
Agoraphobia patients can experience sudden and abrupt panic attacks when traveling to places
where they may feel helpless and out of control or even get embarrassed. During a panic attack,
Epinephrine, a vital hormone, is released from the Adrenal medulla in large amounts, which
triggers the body's sympathetic nervous system, also known as the natural innate “Fight or flight”
response. A panic attack is usually abrupt and spontaneous in onset, building to eventual maximal
intensity within 10-20 min. Patients must fit a certain criteria of panic attacks, as mentioned in
the DSMIV; The affected person must have “four or more of these symptoms within ten minutes
of the beginning of an attack in order to meet the panic attack criteria” (DSMIVTR). These
symptoms include, heart palpitations, sweating, shaking, shortness of breath, heart attack like
pain in the chest, nausea, vomiting, chills or hot flashes, feeling of helplessness, and a sense of
being out of control.
To this day, the exact cause of Agoraphobia is still unknown, but clinicians and therapists who
have treated or tried to treat this disorder offer probable hypotheses. This condition has been
associated with the presence of other anxiety disorders, stressful environment triggers, and even
substance abuse. It is exceptionally difficult to study the brain and the underlying causes of
psychiatric illnesses. The amygdala, a part of the brain's Limbic system, is responsible for the
formation of memories; control of emotions; and the response to stressful stimuli. It has been
implicated as a vital part of anxiety disorders. It is believed and hypothesized that the amygdala
in patients with panic disorders is hypersensitive and acts as an internal suffocation monitor or
alarm system when facing a trigger for an attack. This basically means that the patient's brain
sends the body false signals that not enough oxygen is being received, causing the affected person
to increase his or her breathing rate, also known as tachypnea, which is one of the hallmarks of
an anxiety or panic attack. These attacks usually happen at unpredictable times, due to the
propensity of the amygdala being in overdrive. Various external agents like drugs
(Benzodiazepine)8 and smoking tobacco are considered as the causes of agoraphobia, usually with
panic disorder. The exact mechanism of tobacco induced agoraphobia (with or without panic
disorder) is not well understood. Attachment theory has also been described as one of the causes
of agoraphobia. Treating such a complex situation where many patients are not very cooperative
could be clinically challenging. However, exposure treatment can be a useful way to treat patients
with panic disorder and agoraphobia.

The above mentioned case of the 91-year-old woman perfectly fits into the definition of
agoraphobia. She was properly managed with drug therapy and exposure therapy. Eventually the
severity of the symptoms was reduced. Although she was not 100 percent phobia free, yet we
believe it was a grand success to be able to see her leaving her room and eventually reaching the
front door of her apartment. Case studies like the one mentioned above could play an integral role
to help psychiatrists and psychologists understand that proper care and regular appointments by
a licensed psychiatrist or psychologist can be helpful in reducing the severity of the symptoms of
psychiatric illnesses irrespective of the severity of the condition.

Conclusion
We report a case of an agoraphobic woman who was severely agoraphobic to an extent that she
did not leave her bed for many years. Continuous and gradual psychotherapy eventually improved
her condition. Twenty years later she was able to leave her room which we believe was a grand
success for the doctors involved in her treatment. This case study suggests that agoraphobia can
be a serious debilitating mental condition and gradual treatment with regular follow ups can
 improve the patient’s condition. We believe this is true for all severe psychiatric illnesses. Regular
appointments and follow up with proper care and management can improve the mental health of
the patients irrespective of the severity of their symptoms.

THE SPECIFIC PHOBIA

A Really Bad Case of a Snake Phobia

An example of the exposure therapy of phobias.

The specific phobias, such as animal phobias, or the fear of lightning, are easier, in general, to
treat than agoraphobia. Agoraphobia spreads from place to place because the basic fear is not of
that place or set of circumstances, but of the feeling the phobic person has in those situations. If
agoraphobics are afraid of getting panicky and losing control of themselves, as they are, they will
have that fear in any place from which they cannot quickly, and easily, extricate themselves. On
the other hand, the fear of dogs, for example, is not likely to spread to other places and things.
Just avoiding dogs will usually be enough to allow people afraid of dogs to live their lives
comfortably. But not always.

Example 1.)
 A woman who had a singularly disruptive fear of snakes came for treatment to our Anxiety and
Phobia Center. Usually, avoiding snakes is much easier than avoiding dogs. I live in Westchester
County, as she did, and I haven’t seen a snake outside of a nature center or pet store in the last
forty years. She was so afraid of snakes, however, that she had not left her house alone for over
ten years—on the odd chance that she would encounter a snake. That was her only fear. She felt
at ease in those places—elevators, theaters, restaurants, and so on—that agoraphobics typically
avoid. She entered an eight-week treatment program along with other more typical phobic and,
of course, the trained Phobia Aides we use, almost all of whom had been phobic, themselves, in
the past.
 During out first group session, she asked me if she would be able to recover completely.
 “Sure,” I told her. “But to recover completely, you will have to confront snakes closely. In the end,
you will have to hold them in your hands.”
 She began to cry.
 After the meeting, the Aides complained to me that I should not have, in this very first meeting,
confronted her with what she obviously thought was impossible. I think they were right. If I had
scared her too much, she might have left treatment. I wish I were sensitive and adroit enough to
say the right thing reliably; but I cannot. I tend to say what I think. I can no more pretend to be
circumspect than I can pretend to be neat, rather than messy. I would not be able to pull it off. On
the other hand, there are some advantages to being outspoken. The patients always know exactly
what I think. In any case, this particular patient was not dissuaded from continuing in treatment.
 Besides the weekly group meetings, where progress and difficulties are reported, treatment
involves the patient exposing herself, with the help of the Aides, to snakes—the idea of snakes,
the fact of snakes--in a series of experiences of graduated difficulty, starting with:
 Reading about snakes. I like phobic to become very knowledgeable, if possible an expert, about
whatever they fear, in the case of snakes, their habits and habitats, whether they are poisonous or
not, what they like to eat, how they have evolved. The more the patient knows, the better.
 Looking at pictures of snakes. Not easy. Even a drawing of a snake could elicit a gut-wrenching
feeling at first. But with more pictures and photographs, this became less and less upsetting.
 Holding a toy snake. Still difficult. The patient had to get used to a stuffed snake first, then a toy
snake that squiggled at the end of a stick.
 Getting a snake skin, and keeping it in different places around the house.
 Looking at a snake in a pet store, first from a distance, then closer and closer. It turns out a snake
in a glass cage is very boring. It doesn’t snap or snarl. It sleeps most of the time.
 Going to a nature center where non-poisonous snakes slither around the floor.
 Holding a snake.
  By the end of eight weeks, this patient was holding, and demonstrating, snakes in the nature
center. One of the unexpected things she discovered, she told me, was that the snake always
slithered away from her when she inadvertently dropped it.
 Months later she was still fine. Her husband, however, was complaining about all the snake skins
he found around the house.

Example 2.)
 The two cases described below are good examples of specific phobias that have markedly affected
each person's life. Names and details of the individuals described have been changed to protect
their privacy. The first case is detailed, the second just provides the major features of the phobia
 Elevator Fears
 Dick was a 61-year-old male who worked for in a provincial government office as an accountant.
He enjoyed his work and the people he worked with. He had worked for the government in this
position, or similar positions, for the last 25 years. His salary was quite good and he had excellent
benefits. However, prior to making an appointment with me he was seriously considering
retirement. His reason was that his office, in fact the whole accounting department, had recently
been consolidated from several different locations. This was done to improve efficiency. For Dick
the problem with the consolidation was that he had a marked fear of small, enclosed spaces such
as elevators. When his office first was moved, Dick tried to use the stairs to get to his office. He
found this very difficult because of an arthritic left knee. Because of his fear and his physical
problem, he began to dislike going to work. A friend of his suggested that he gets therapy for his
elevator fears.
 Dick recognized that his fear was out of proportion to the actual dangers involved in elevator
travel. However, this did not keep him from avoiding travel on all elevators.
 Dick's problems began when he was a young child and was locked in his bedroom closet by his
older brother. It was done as a prank, but Dick became very panicked and pounded on the door,
but only was released an hour later. After that event he avoided enclosed spaces of all types. He
even had to have a light on in his bedroom at night.
 Because he recognized the irrationality of his fear (he did not know of anyone who had been
harmed in an elevator) he willingly agreed to do exposure therapy. He suggested we start with
him entering an elevator, but with the door remaining open and the elevator stationary. After
doing this several times, he suggested letting the elevator door close, but not move. He knew
that he could open the door at any time, but I encouraged him to let his fear wane before opening
the door. If he opened the door while he was very fearful, it could strengthen the fear. Because
of his knowledge that he could let himself out, he was able to remain in the elevator with the door
closed. After about two minutes I suggested he come out. He said that his fear was quite bad
initially, but he said to himself, “The elevator is not moving and I can get out whenever I want.”
These self-statements replaced his initial thoughts that he would be caught on the elevator and
not be able to get out.
 After doing this he suggested that we go down one floor on the elevator. We did this several
times. During the next session he suggested going one floor by himself. He did this several times
going both up and down one floor.
 After the fourth session where he had been able to ride the elevator by himself up or down five
floors he suggested he take the elevator up one floor at his work place and walk the remainder of
the floors. Fortunately, as it turned out, a friend of his boarded the elevator at the same time he
did. He felt that he could not explain why he was only going to ride one floor and went all the
way to his office. He called to report what had happened, telling me that although initially very
frightened, he calmed down when his friend started talking to him. I only saw Dick for one more
session to provide him with relapse prevention information. This included telling him that he
should talk to himself if he became fearful (realistic thoughts rather that fear thoughts), he should
remain in the situation until his fear calmed down rather than bolting away, and he should praise
himself for seeing things through.
 Animal Fears

Facts:
 On average, specific phobias begin in childhood, between seven to eleven years with most cases
starting before age ten
 Approximately 5% of children and 16% of adolescents will have a specific phobia in their lifetime
  Girls are more likely to experience a phobia than boys at a rate of 2:1
 Phobias are different than common childhood fears. While young children generally become less
afraid of things such as strangers, the bath, or the boogie monster, as they mature, children with
phobias typically become more afraid as they mature. Furthermore, phobias rarely go away on
their own
 Phobias do not decrease with appropriate reassurance and provision of information. For example,
a dog phobia persists despite telling your child that grandmas dog is kind, has no teeth to bite
because it is old, and will not scratch

Physical Sensations:
 Increased heart rate
 Sweating
 Trembling or shaking
 Shortness of breath
 Feeling of choking
 Chest pain or discomfort
 Upset stomach
 Numbness
 Chills or hot flashes
 Looking flushed

Emotions:
 Anxiety/fear
 Embarrassment
 Shame
 Helplessness
 Sadness
 Anger

Behaviors:
 Avoiding the feared stimuli or locations where the stimuli might exist
 Making parents check things first (e.g. make sure a room is free of bugs before bedtime)
 Asking a parent to be present or available
 Running away
 Crying
 Clinging
 Tantrums

Common Situations or Affected Areas

 Refusal if known feared stimuli might exist
 Avoiding parks, recreational areas, and outdoor space
 Refusal to attend appointments at doctors, dentists, hospitals, etc.

Treatment:
 Distressed man visits psychotherapist
 Treatment includes different types of psychotherapy.
 Phobias are highly treatable, and people who have them are nearly always aware of their disorder.
This helps diagnosis a great deal.
 Speaking to a psychologist or psychiatrist is a useful first step in treating a phobia that has already
been identified.
 If the phobia does not cause severe problems, most people find that simply avoiding the source of
their fear helps them stay in control. Many people with specific phobias will not seek treatment
as these fears are often manageable.
 It is not possible to avoid the triggers of some phobias, as is often the case with complex phobias.
In these cases, speaking to a mental health professional can be the first step to recovery.
 Most phobias can be cured with appropriate treatment. There is no single treatment that works
for every person with a phobia. Treatment needs to be tailored to the individual for it to work.
 The doctor, psychiatrist, or psychologist may recommend behavioral therapy, medications, or a
combination of both. Therapy is aimed at reducing fear and anxiety symptoms and helping people
manage their reactions to the object of their phobia.