Posts tagged: phobia


Dr. Holzmacher's Business Logo for Orlandopsych.comPanic is not a disorder unto itself, and neither is a panic attack.  The modern conceptualization is that panic is a form of anxiety that may or may not include agoraphobia.  This last term is taken from the Greek, and literary means “fear of the marketplace”.  It is a fear of being unable to escape in a crowded situation, fear of bridges, and fear of travel in any kind of conveyance.   Much of the fear is anticipation of having a panic attack in these sort of situations.  The fear is heightened if the person believes the situation is such that no one will come to their assistance.  The agoraphobia is rarely initiated by a specific trauma, as is a post-traumatic stress disorder.  It is also not secondary to a fear of being socially embarrassed, as is a social phobia.  All these anxiety disorders impel one to flee the situation, but for different reasons.  Situations that involve travel or crowds  are feared and consequently avoided.  Many agoraphobics do not experience panic, but most suffer with the disorder.

Many agoraphobics develop anticipatory anxiety of being in public places, then avoid these situations for fear of having an attack.  Phobic avoidance develops over time, which reinforces the avoidant behavior.  The combined disorder of agoraphobia with panic tends to be more functionally debilitating than either disorder in isolation.  Anticipation of a fearful situation reaches the point of panic, and the panic is so startling that a person would do anything to avoid another panic attack.

Many patients complain of panic, but rarely do they meet the criteria.  Most people experience acute unpleasant anxiety and label that as panic.  Several symptoms overlap with generalized anxiety, but a few are better indicators of true panic than the rest.  The onset of panic and anxiety may be sudden, but panic tends to peak within ten minutes and then subside.  Generalized anxiety has less intensity at the onset, and tends to take a long time to resolve-if ever.  There are intense fears of dying or going insane while enduring a panic attack.  It almost seems like a medical problem when the heart beats so strongly.  A miasma of nausea, dizziness, palpitations, chest pains and shortness of breath overwhelm one to the point they fear dying.  Sweat pours forth in buckets.  Generalized anxiety often is accompanied by sweat, but typically not as intense or circumscribed.

The good news is that most people who believe they are experiencing panic are actually experiencing acute anxiety.  The onset of panic is so strong and unforgettable, that it creates a cycle of fear and avoidance.  Generalized anxiety does not have specific fears that could be avoided.  Many people have agoraphobic symptoms, but fortunately, few will fall prey to the disorder.  It is commonplace for people to fear bridges, especially if they can see through a metal roadbed.  It is also normal to have fear of being trapped while waiting in line, or have a fear of being immobilized in a crowded elevator.  It is rare these mild anxieties develop into a Panic Disorder with Agoraphobia.

Treatment of all phobias is cognitive-behavioral in nature.  The main thrust of the therapy is to gradually expose the patient to the feared object.  The hope is to decouple the feared situation from the biological and psychological reaction. A psychologist will have the person imagine driving over a bridge, and discuss their emotional and cognitive apprehensions.  As the therapy progresses, the psychologist will attempt increased contact with the feared situation until the person masters their reaction.  Another method is to directly expose the patient to the feared situation in an aggressive fashion, which often alleviates the anticipatory anxiety of the next exposure.  There is a greater risk of being overwhelmed or even traumatized by this second sort of treatment, such that it should only be attempted with professional assistance.  Medication is not advised for long-term control of panic, but temporary usage can assist the therapy by lowering the overall level of anticipatory anxiety.  Please leave your comments regarding this article in the space provided below.

Anxiety Disorders

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Most people have experienced situational apprehension and “butterflies” in the proverbial stomach.  We get jitters and particular fears.  Clinically significant anxiety can be torturous.  Even when not the primary symptom, it can significantly increase the suffering from depression and psychosis.  Anxiety prevents people from engaging in necessary activities, like flying and driving.  It prevents some people from leaving their home.  Chronic anxiety can manifest in physical illness.  Many symptoms of anxiety overlap with physical ailments; for example, heart disease.  As it is very difficult to separate symptoms of heart disease from anxiety, I often have patients note anxiety test items they believe to be secondary to their medical condition.  Tachycardia (racing heart), diaphoresis (sweaty), clamminess, blurred vision and thoughts of dying could be a myocardial infarction or acute anxiety.  Persistent negative rumination over years may adversely effect one’s cardiopulmonary status.  Patients with chronically low blood oxygen saturation and elevated blood carbon dioxide will typically suffer with anxiety.  Anxiety secondary to medical factors will make even the calmest person feel terrible.

From these thoughts one can gather that it is best to be cautious in diagnosing anxiety.  It is safest to first rule out a medical problem, since the psychological symptom of anxiety is not, fortunately, a fatal one.  Younger woman should rule out a mitral valve prolapse, for example, before embarking on the time and expense of mental health treatment.  If you suffer from anxiety and chronically labored breathing, consider having your medical doctor check oxygen saturation.

It is often easier for a clinician to diagnosis phobias and panic than generalized anxiety.  Phobias elicit anxiety over particular stimuli; typically not anxious removed from the unpleasant stimuli.  Panic involves stark symptoms that are unique to the phenomenon.  One of the most bizarre is the scotoma, or alarming narrowing of one’s visual field-like looking backward through a telescope!  I have created a separate subcategory for panic, and invite people to leave their thoughts on panic in that category.  Many patient’s come to me complaining of panic, but not many of them actually have the disorder.  This is fortunate for them.

Most symptoms of anxiety respond to cognitive-behavioral psychotherapy and/or medications.  Often the greatest hurdle is obtaining and accurate diagnosis.  The next big hurdle is the various prescription pads filled with benzodiazepines (Valium, Librium, Xanax, etc.).  I recommend using medication in combination with cognitive-behavioral therapy, but do not support the use of medication without any behavioral therapy.  If one starts with psychotherapy as the solo treatment, the psychologist can always seek medication consultation at a later time.  If one starts off with medication, it can complicate the process of psychotherapy, and make one unsure as to which is the most beneficial.  The take home message is to take heart, help is available, and typically effective.  Please leave your comments regarding this post in the space provided below.

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