Many people report anxiety attacks which seem to be related to alcohol, and wonder what effects quitting will have in the short and long run. From my own experience, I had serious panic attacks which gradually, steadily went away after I quit. So the following article, while not strictly based on behavioral approaches, is intended to give some background information about anxiety attacks, panic disorders, and phobias.
(posted by Hopkins Technology)
U.S. Department of Health and Human Services Public Health Service Alcohol, Drug Abuse, and Mental Health Administration
Phobias take many forms. Some people are terrified of dogs, even tiny dogs with wagging tails. Some people stiffen with fright at the mere thought of talking in front of a group. Some can’t fly. Some tremble and hide at the crack of thunder. Some can’t ride an escalator. Some are struck by panic attacks for no apparent reason. And some never leave their homes.
Fears such as these are very common. Millions of Americans are afflicted with phobias or panic disorder. They suffer intensely. To escape their fear, they go to great lengths to avoid the object, place, or situation that provokes it. They change jobs merely to avoid an elevator ride, for example, or cut back their social life. Some wear down their families with their clinging dependency. Nearly all lose out on much of life.
Many people go from doctor to doctor seeking cures for the physical symptoms that accompany their phobias. Often, even the doctor fails to recognize that stomach pains, high blood pressure, rapid heart beat, and other symptoms may be related to intense fear. Unless questioned, patients may not think to mention their fears. Doctors may not ask. While the bills keep mounting, the medical condition fails to improve.
The many phobic people who think their fears are silly, childish, or trivial often try to conceal them. While hiding from their fears, they hide their phobias from others, further limiting their experience of life.
It is better to tell someone. Much of the pain and disruption - perhaps most of it - can be remedied. New treatments for phobias are remarkably effective. But few people, including doctors, know about them.
If you or someone you know is excessively fearful - afraid out of all proportion to the cause - then you may gain some understanding of the problem from this pamphlet. It describes what experts know about phobias and panic. It may help you.
Anxiety is the emotion you feel when a person, object, situation, or impulse seems dangerous to you. If you’re crossing a street and suddenly notice a car speeding toward you, you feel afraid that you will be hit, and you dash out of the way. This fear and the behavior it provokes probably save your life. If you’re fed up with your boss and want to hit him, the sick feeling in the pit of your stomach - the anxiety you feel when you anticipate the consequences of slugging your boss - keeps you from carrying through on your impulse. The anxiety and your control of your behavior probably save your job.
While “normal” anxiety is adaptive - that is, it helps you to survive and be productive - too much anxiety can be crippling. People who suffer from certain patterns of signs and symptoms related to anxiety are considered by mental health specialists to have anxiety disorders. Phobias and panic attacks are the most common of these disorders. (Other anxiety disorders - generalized anxiety disorder, obsessive-compulsive disorder, posttraumatic stress disorder, and atypical anxiety disorder - are each characterized by somewhat different symptoms. They will not be discussed here.)
Both phobias and panic disorder are marked not only by great anxiety in situations that are relatively safe, but also by an exaggerated avoidance of the source of distress. Depending on the type of phobia or panic, the person may shy away from floor-to-ceiling windows in a highrise, refuse an invitation to speak in front of a church group, or stay out of crowded shopping malls. People with these disorders don’t actually have to encounter what they fear.
They become intensely anxious just by anticipating that they might soon be in the feared situation, brooding over it in their imagination.
The fears can start in childhood or adulthood. Some people have suddenly become terrified of things they’ve been doing for years. For example, a flight attendant began having panic attacks on her 500th flight.
Some people can sidestep the thing they fear without much difficulty. Some, especially adults, can hide their distress and conceal their phobias. Even those who usually adjust their lives to fit their phobias are sometimes able to confront what they fear, “toughing it out,” suffering all the while. While children may outgrow their phobias, adults usually do not get rid of them unless they receive treatment.
Recognized even in ancient times, phobias and panic are known around the world, probably in every human culture. The most recent and thorough studies show that, in the United States, phobias are the most common of all mental disorders. Seven out of every hundred Americans have phobias. Eight out of every thousand have panic disorder. Compared to men, women more often suffer from most types of phobia and panic disorder.
The reason that phobias and panic are more common in women is now known. Investigators speculate that men may be more likely to drown their fears, since alcohol abuse is more common in men than women. This is just one of many possible explanations, however. Differences in biological makeup or social and psychological experiences may also be responsible. For example, in our society some girls are encouraged to be more fearful and less independent than males.
Mental health professionals now recognize three types of phobia - simple phobia, social phobia, and agoraphobia (with and without panic attacks) - and a separate diagnosis for people who repeatedly experience severe attacks of panic.
The most common of the various phobias is simple phobia, the unreasonable fear of some object or situation. Bees, germs, heights, odors, illness, and storms are examples of the things commonly feared in simple phobias.
If you have a simple phobia, it might have begun when you actually did face a risk that realistically provoked anxiety. Perhaps, for example, you found yourself in deep water before you learned to swim. Extreme fear was appropriate in such a situation. But if you continue to avoid even the shallow end of a pool, your anxiety is excessive and may be of phobic proportions.
Simple phobias, especially animal phobias, are common in children, but they occur at all ages. The best evidence to date suggests that between 5 and 12 percent of the population have phobic disorders in any 6-month period.
The recognition by most phobics that their fears are unreasonable doesn’t make them feel any less anxious. Simple phobias do not often interfere with daily life or cause as much subjective distress as most other anxiety disorders.
The person with a social phobia is intensely afraid of being judged by others. Even at a gathering of many people, the social phobic expects to be singled out, scrutinized, and found wanting. Thus, the person with a social phobia feels compelled to avoid social situations with such apprehensions.
If you have a social phobia, you might be afraid to go to a party because you fear that other people will laugh at your clothing or think you are hopelessly stupid because you won’t be able to think of anything to say. Like people with simple phobias, you work hard to avoid these anxiety-provoking situations.
People with social phobias are usually most anxious over feeling humiliated or embarrassed by showing fear in front of others. Ironically, they are often so crippled by the inhibitions resulting from such fears that they, in fact, may have difficulty thinking clearly, remembering facts, or expressing themselves in words. Even success in social situations fails to make them feel more confident. They are likely to think something like, “Next time I’ll fall on my face.”
Although studies of the incidence of social phobias are so far only preliminary, most experts believe social phobias are not as common as simple phobias. But because they result in considerable distress, people who suffer from them are more likely to seek treatment than are people with simple phobias. Social phobias tend to begin between the ages of 15 and 20 and, if left untreated, continue through much of the person’s life. Often, social phobias suffer from symptoms of depression, and many also become dependent on alcohol.
Another group of anxious people are subject to devastating episodes of panic that are unexpected and seemingly without cause. Such unpredictable panic attacks are marked by an overwhelming sense of impending doom and a host of bodily symptoms. The person’s heart races and breathing quickens, as he gasps for air. (In the interest of brevity and grace of style, the pronoun “he” will be used throughout this pamphlet when either sex could be the topic of discussion). Sweating, weakness, dizziness, and feelings of unreality are also common. The person having a panic attack fears he is going to die, go crazy, or at least lose control.
Panic disorder is diagnosed when patients experience repeated episodes of such panic. Although people with simple or social phobias may sometimes experience panic, they are clearly responding to an encounter - or an anticipated encounter - with the object or situation they fear. Such is not the case with panic disorder, when the fear strikes from nowhere, seemingly “out of the blue.”
People with simple and social phobias can also predict that they will feel fear every time they come close to a cat, climb to the roof of a tall building, or encounter whatever else they fear. People with panic disorder, by contrast, never can predict when they will suddenly be struck by panic. Some situations may seem more “dangerous,” especially those that make escape difficult, but an attack does not invariably occur in those situations.
Panic disorder, which runs in families, afflicts some 1.2 million Americans. For most, panic attacks begin sometime between the ages of 15 and 19.
Many people who suffer from panic attacks go on to develop agoraphobia, a severely handicapping disorder that often prevents its victims from leaving their homes unless accompanied by a friend or relative - a “safe” person. The first panic attack may follow some stressful event, such as a serious illness or the death of a loved one. (The agoraphobic often doesn’t make this connection, though.) Fearing more attacks, the person develops a more-or-less continual state of anxiety, anticipating the next attack, avoiding situations where he would be helpless if a panic attack occurred. It is this avoidance behavior that distinguishes agoraphobia from panic disorder. Two different types of anxiety appear to afflict the person with agoraphobia - panic and the “anticipatory anxiety” engendered by expectations of future panic attacks.
If you have agoraphobia, chances are it developed something like this: One ordinary day, while tending to some chore, taking a walk, driving to work - in other words, just going about your usual business - you were suddenly struck by a wave of awful terror. Your heart started pounding, you trembled, you perspired profusely, and you had difficulty catching your breath. You became convinced that something terrible was happening to you, maybe you were going crazy, maybe you were having a heart attack, maybe you were about to die. You desperately sought safety, reassurance from your family, treatment at a clinic or emergency room. Your doctor could find nothing wrong with you, so you went about your business, until a panic attack struck you again. As the attacks became more frequent, you spent more and more time thinking about them. You worried, watched for danger, and waited with fear for the next one to hit.
You began to avoid situations where you had experienced an attack, then others where you would find it particularly difficult to cope with one - to escape and get help. You started by making minor adjustments in your habits - going to a supermarket at midnight, for example, rather than on the way home from work when the store tends to be crowded.
Gradually, you got to the point where you couldn’t venture outside your immediate neighborhood, couldn’t leave the house without your spouse, or maybe couldn’t leave at all. What started out as an inconvenience turned into a nightmare. Like a creature in a horror movie, fear expanded until it covered the entire screen of your life.
To the outside observer, a person with agoraphobia may look no different from one with a social phobia. Both may stay home from a party. But their reasons for doing so are different. While the social phobic is afraid of the scrutiny of other people, many investigators believe that the agoraphobic is afraid of his or her own internal cues. The agoraphobic is afraid of feeling the dreadful anxiety of a panic attack, afraid of losing control in a crowd. Minor physical sensations may be interpreted as the prelude to some catastrophic threat to life.
Agoraphobics may abuse alcohol in an effort to keep the anticipatory anxiety in check. Their pattern of abuse appears to be different from the binging characteristics of alcoholism, however. The agoraphobic usually takes small amounts of alcohol, avoiding loss of control. Other drugs may also be abused.
Agoraphobia typically begins during the late teens or twenties. The best surveys done to date show that between 2.7 percent and 5.8 percent of the U.S. adult population suffer from agoraphobia. Women are affected two to four times more often than men. The condition tends to run in families.
Recent surveys have found that many people are afraid to leave their homes. Most likely, they are not all suffering from agoraphobia. Some people may stay confined because of depression, fear of street crime, or other reasons. These surveys also show, however, that many agoraphobics may have never suffered a panic attack. This finding suggests that their agoraphobia may have developed in ways different from that outlined above.
Panic and agoraphobia have received a great deal of attention from clinical investigators in recent years. Some believe that panic attacks are a severe expression of general anxiety, while others think that they constitute a biologically distinct disorder, possibly related to depression, possibly indistinguishable from agoraphobia. This controversy will probably be resolved through more research in the coming years.
Given the dramatic symptoms of phobic and panic disorder, it is surprising that they are sometimes difficult to recognize, even for medical professionals. Some patients, especially those with simple phobias, are able to conceal the severity of their handicap. Agoraphobia is often not detected because its physical symptoms become the center of concern for both patient and doctor. Health problems, such as peptic ulcer, high blood pressure, skin rashes, tics, tooth grinding, hemorrhoids, headaches, muscle aches, and heart disease, often occur together with anxiety disorders.
Phobias may cover up other problems. School phobia, a complex condition in which a youngster refuses to attend school, is one example; often the underlying problem is the child’s anxiety over separating from his parents. (A mental health professional can easily distinguish between school phobia and other causes of missing school.)
Just as panic and phobias can masquerade as other illness, some physical diseases may be mistaken for anxiety disorders. For example, people can become anxious as the result of such medical conditions as head injury, withdrawal from alcohol and drugs, and even pneumonia. In these cases, the panicky feelings usually disappear when the condition clears up. Phobic behavior also occurs in conditions that are not diagnosed as phobias, such as the phobic-like avoidance of sexual contact in a person whose principal problem is sexual.
Reactive hypoglycemia - a rapid decline in blood sugar followed by compensatory changes in adrenalin and other hormones - can produce many symptoms of panic, such as sweating, heart palpitations, and tremor. Most likely, this medical condition mimics panic disorder.
More puzzling is the relationship between panic attacks and agoraphobia, on the one hand, and depression, on the other. About half of people subject to phobias and panic are demoralized or depressed more often than the average person. Many agoraphobic patients develop their symptoms shortly after suffering a loss (which can trigger depression), and some either have histories of depressive episodes themselves or have relatives who do.
Whether phobias cause depression or depression causes phobias is unknown. Panic and anxiety can wear down a person until he or she feels demoralized. Alternatively, phobia and panic might result from depression and its symptoms - difficulties with sleep, appetite, and concentration, fatigue, lack of pleasure, and feelings of worthlessness.
Yet another possibility is the simple coexistence of anxiety and depression, neither causing the other. Some underlying biological process - an inherited vulnerability, perhaps - may be common to both anxiety and depression.
Phobias and panic, like all anxiety disorders, disturb many areas of a person’s functioning. Take the woman who has agoraphobia. Her BEHAVIOR changes when she has to quit her job because she believes she is unable to ride the bus. Her THINKING goes awry when she judges the risk she faces. The memory of past FEELINGS of panic on the bus, when she was sure she would die, produces alterations in her PHYSIOLOGY as her heart pounds, her head gets dizzy, and her hands sweat. Her behavior, thinking, emotions, and her body’s physiological responses are all involved in her agoraphobia.
Evidence of these effects has guided research investigators who have tried to understand the causes of anxiety disorders. They have formed their theories by observing patients, listening carefully to what they say, and measuring their functioning in the laboratory. Scientists then go beyond these observations to test theories, either in the clinic or in scientific experiments. These experiments show that other aspects of anxiety and related disorders are not as clearly evident. Some of the most influential or promising theories and bodies of research are described below.
One possible cause of anxiety that is difficult for a nonspecialist to observe is psychological conflict arising from emotions and impulses that remain unconscious (outside of the person’s awareness). Much of the theory proposed by Sigmund Freud early in this century assumes that such unconscious forces, mostly deriving from childhood, profoundly influence adult life, including abnormal anxious states. These influences, for the most part, are inferred from the memories and associations of patients who undergo intensive, prolonged therapy. Until the last two or three decades, Freud and the psychoanalytic investigators who revised his theories were the dominant force in explaining and treating anxiety-related conditions. Although now out of fashion in academic settings, the ideas of the psychoanalytic school have influenced thinking throughout society, especially in clinics where people are treated for mental health problems.
In the view of psychoanalysts, anxiety is a signal of danger - a danger that is not real and present, but rather, is carried over from the memories and imaginations of childhood. Often, these dangers involve fantasies of loss or love (or actual separation from loved ones) or other fantasies that express guilt or sexually related events. When these fantasies are activated in adulthood - perhaps because something happens that the patient associates with the fantasies - they give rise to anxiety. The anxiety may be conscious or unconscious. In either case, it makes the person act defensively - that is, attempting to get away from the threat or, more often, to stop the fantasy from ever occurring by regulating or inhibiting the wishes that give rise to fantasies of danger. Because this defensive behavior relieves the anxiety, it tends to be repeated: It is, in other words, learned.
Modern psychodynamic research (that which focuses on mental conflicts) has put a great deal of emphasis on the anxiety that accompanies real or feared separation from a caretaker during childhood. Individuals who, as children, became extremely anxious whenever they were separated from their parents seem to be especially likely to develop agoraphobia later in life. Some 42 percent of agoraphobic patients report a history of childhood separation anxiety. This statistic suggests that agoraphobia may build on a foundation already present in early life or represent the aftermath of unresolved childhood separation anxiety.
In contemporary psychodramic models, the person with agoraphobia avoids situations that symbolize or threaten separation from a loved one. This view explains why a death or other kind of loss may trigger agoraphobia. It also may explain why some agoraphobics can venture out when accompanied by a spouse, child, or friend.
Psychoanalytic theory from Freud to the present day has given some role to learning as a necessity for the development of abnormal anxiety states. Another school of thought puts learning squarely at the center in its theory of anxiety. In the simplest learning model, an individual may learn fear through direct experience (e.g., being bitten by a snake) or indirectly by witnessing injury to someone else, by observing fear reactions of others, or by being warned of an object’s dangers. More likely, however, the reaction is the result of an association between an unpleasant, fearful response and the chance presence of the object that later is viewed as threatening. As early as 1920, one experimental psychologist showed that a young boy could be trained to fear a harmless white rat if frightened by a loud noise every time the rat was nearby. Because the adult with a phobia seldom remembers such an event, the fear seems unreasonable.
Knowledge about learning also sheds light on the possible way in which agoraphobia develops. As with simple phobias, the person who first experiences panic attacks in the presence of a certain set of circumstances - alone in a crowd, for example - may learn to associate awful sensations of panic with all crowds. Repeating the experience, or anticipating it, may reproduce the feeling of threat. Avoiding crowds reduces the discomfort. Because the avoidance behavior is rewarded, the person is more likely to avoid crowds in the future. Avoidance also reduces the opportunity for the person to test whether crowds actually do cause panic. By foregoing this kind of potentially corrective experience, the person further strengthens the phobia.
Observers studying anxiety, including Freud, have long predicted that the brain and the central nervous system would be found to be functioning abnormally in patients with serious anxiety disorders. Their predictions remained speculations, however, because they were limited by the methods and knowledge of their times. All that has changed. Because of recent technological advances, much of the research now being done on anxiety and related disorders focuses on the brain. Biological research workers also attempt to understand anxiety disorders by experimentally producing anxiety in human beings and other animals. Others look for physical symptoms that often accompany phobias or panic to see if they may play a role in causing the disorders.
In light of what scientists would like to know about the role of the brain in anxiety disorders, this work has just begun. Research on neurotransmitters, the chemicals that carry messages from one nerve cell to another, has not found serious malfunctions associated with anxiety. But indirect measures suggest some abnormalities, particularly in the neurotransmitters norepinephrine, GABA, serotonin, and possibly adenosine.
Scientists are, however, still far from being able to say whether faulty brain function reflects the Cause of anxiety disorders - some genetic fault coded into the person’s hereditary apparatus, for example. Experts disagree about the meaning of some research findings. Much of the work, for example, has focused on the brain’s processing of drugs that reduce anxiety. Such work suggests, but does not prove, how the brain functions during episodes of severe anxiety. Another problem so far has been that most research necessarily is confined to animals; whether the results apply to human beings is not certain. Pieces of the neuroscientific puzzle have been found, and they are beginning to fall into place.
Investigators have identified several substances over the past few years that can actually produce panic attacks in people who have already experienced them (but not in people who haven’t). This line of evidence suggests that patients who are subject to panic attacks may be biologically different from other people. It also offers clues to just what those differences might be. The ability to induce panic attacks gives research investigators a powerful tool for understanding them.
The most thoroughly studied of these anxiety-producing chemicals is sodium lactate. The use of this substance to induce panic attacks is based on the observation that some people who suffer extreme episodes of anxiety produce an excessive amount of the chemical lactate after routine exercise. For these people, exercise can actually set off a panic attack. Researchers have found that sodium lactate triggers panic attacks in a full 80 percent of patients with panic disorder, but in less than 20 percent of normal people. Lactate infusions may provide a means of suggesting which patients are biologically prone to panic attacks and thus apt to respond to drug treatments. It is unlikely, however, that lactate infusions will ever be a sure test.
Although less intensively studied, caffeine is another substance that can produce panic attacks in susceptible persons. Caffeine, of course, is common in coffee, tea, cola, and other soft drinks, and many other foods such as chocolate. About half of panic disorder patients have panic experiences after consuming caffeine equivalent to four or five cups of coffee. (Normal people also experience panic, but only after they ingest much higher amounts of caffeine.) Caffeine is thought to produce its effects by blocking the action of a brain chemical known as adenosine, a naturally occurring sedative. Clinical investigators have found that many people with panic attacks avoid caffeine after noticing that it causes attacks.
Other types of biological research are also under way. One of the oldest experimental approaches tests physiological responses - for example, heart rate, blood pressure, sweating, or characteristics in the skin. Another type of research examines the role of hormones. But none of these studies has as yet been integrated with what is being learned from studies of the neurotransmitter systems in the brain.
Several studies have shown that patients suffering from agoraphobia and panic disorder have different physiological reactions to fear-producing stress than the average person has. Differences of this type may be present from birth and may explain why some individuals are more susceptible than are others to anxiety disorders.
Several years ago, a number of investigators reported that some agoraphobic patients have a mild heart condition known as mitral valve prolapse or MVP. Like agoraphobia itself, the condition tends to run in families. MVP can give rise to heart palpitations, which some experts believe might trigger panic attacks. It is also possible, however, that chronic anxiety and panic attacks may produce MVP or that both panic attacks and MVP may be symptoms of an underlying nervous system disorder. Finally, it still remains unclear whether there is any difference in the frequency of mitral valve prolapse in panic patients when compared to the general population.
Malfunctions in the thyroid gland have been reported in about one in ten patients who are prone to panic attacks. The relationship between these conditions, which can also cause heart palpitations, and panic is still in the early stages of investigation.
Because breathing difficulty is a hallmark of panic attacks, research scientists have recently become interested in hyperventilation, a condition marked by rapid breathing. The symptoms are similar to those experienced sometimes when blowing up a balloon: dizziness, inability to pay attention or concentrate, and tingling sensations around the mouth and fingers.
The role of history - as recorded in our genes, passed on through our cultures, or learned in our families - is also under study. Barely under way are attempts to learn the relative contributions of nature and nurture to the development of phobias and panic disorder. Some investigators are studying families, because phobias and panic are more common in the relatives of patients than in the general population. Whether this tendency is inherited - passed on genetically - or learned by growing up or simply living close to other anxious people is not known, although some evidence suggests that the link is at least partly genetic.
Clues to what causes anxiety disorders also come from naturalistic observations of animals and human societies very unlike our own. Something like a phobia seems to occur in many animals. Some dogs who have never been touched by anything but a loving hand will cower and slink away at the sight of a broom. Their fear, as well as the common human fear of snakes, may hark back to some earlier stage in evolutionary development. In human societies, cultural differences seem to produce surprising variations in anxiety disorders - the age at which they begin, the course they follow, the symptoms, the distribution among different social groups, the source of anxiety, the experience of the emotion, and the consequences in the life of the sufferer.
Some fears are shared across cultures, suggesting that they enhanced the chances of surviving in the evolutionary history of the human race. Most phobias are directed toward a relatively small number of objects and situations, though there is no reason to believe that these items cause unpleasant experiences more frequently than many others. Phobic fear of truly dangerous electrical outlets, for example, is rare, while fear of seldom-encountered snakes and harmless insects is common. People in our culture are more likely to receive a shock from an outlet than a bite from a snake or one of these insects.
Scientists have sought to explain this paradox by speculating that humans may have an inborn predisposition to fear certain things. This so-called preparedness theory is consistent with the fact that most common phobias (darkness, animals, etc.) involve objects and situations that date from primitive times and were, in the distant past, serious sources of danger.
Despite all the research being done on the anxiety disorders - an activity that has accelerated in the last few years - none of the theories that are tested in the various types of studies is adequate to explain what causes phobias and panic. The explanation is probably not far off, however. As they are now propounded, theories about the causes of different types of anxiety disorders tend to cluster either around psychological and social factors or around biological factors. Simple phobias are usually explained in terms of early experience and learning, while agoraphobia and panic (and sometimes social phobia) are becoming increasingly understood as at least partially biological in origin. Most likely, all phobias and panic result from a mixture of influences, although that mixture probably changes with the type of phobia and individual differences among patients. Many theories reflect an implicit assumption that the more serious disorders, such as panic attacks and agoraphobia, are more likely to have a biological basis than the troubling, but less disabling, simple phobias.
Even though the causes of phobia and panic are not well understood, treatments for these disorders are often very effective. Therapists use a variety of techniques, their choice usually linked to their beliefs about the cause of the disorder. But, upon examination, it turns out that many of these techniques share a common feature: They all seem to require that patients* confront the source of their discomfort. Some therapists ask their patients to confront a feared situation in imagination, while others require a real-life confrontation. Some therapists define the source of fear as the external object or situation the patient identifies as fearful, while others find a deeper source within the patient - in the unconscious, in thoughts, or in physical sensations. Still another difference is that one therapist might set up an explicit program for confronting feared objects and situations, while another might use drugs or psychotherapy to prepare the patient to confront fearful situations in everyday life.
*The term “patient,” usually heard in medical settings, will be used here interchangeably with the term “client,” more typically used by psychologists and social workers.
For the first two-thirds of this century, phobias, like other emotional disorders, were treated almost exclusively by psychoanalysis or related forms of psychotherapy. In psychoanalysis, unconscious conflict is seen as the source of anxiety. The goal of therapy is to bring that conflict to light, analyze what it means to the patient, and substitute present-day realistic appraisals for fearful ones that are based on the limited understandings of childhood. Psychoanalytic techniques include free association (encouraging the patient to say whatever comes into his mind), analysis of dreams, and analysis of the relationship between the patient and the therapist. Other forms of psychotherapy are usually more directive in their techniques: Instead of waiting for the patient’s memories and feelings to emerge and drawing inferences from these patterns of association, some therapists actively try to provoke or suggest sources of conflict and direct their patients through “homework” assignments.
Unfortunately, psychoanalysis and related forms of psychotherapy prove disappointing in the treatment of phobias. Patients usually find the therapy helpful in resolving conflict, decreasing general anxiety, and identifying and modifying feelings and thoughts associated with panic attacks and phobic avoidance. But the phobic symptoms themselves often remain. Freud himself acknowledged the limitations of pure psychoanalysis in treating phobias (and anticipated the development of behavioral techniques), saying: “One can hardly ever master a phobia if one waits ‘til the patient lets the analysis influence him to give it up...One succeeds only when one can induce them through the influence of the analysis to go about alone and to struggle with their anxiety while they make the attempt.”
Just such an approach has been found to be effective in helping phobic patients stop avoiding the thing they fear (see section on exposure therapy below). Many therapists find that such improvements are more lasting if patients undergo psychotherapy as well, either individually or in groups. By monitoring situations that seem to give rise to the panic attacks, for example, an agoraphobic can identify thoughts and feelings that are troublesome. The therapist can then help the patient to work out a course of action that might realistically change the source of distress and to give up the habitual style of avoiding it by retreat into phobic behavior. Therapists can also help the patient to become more assertive when involved in conflict with other people and train him in skills needed for other social situations. The support of a caring therapist may be crucial for long-term success of any treatment technique.Part 2