by Merry Sue Baum
Until she was 39, Sharon never had a problem driving. The very day she got her license at 17, she headed to the Jersey Shore. The South Plainfield resident zipped down the Garden State Parkway, crossed the Driscoll bridge and in a little less than two hours was enjoying sun and surf. Years later, she chauffeured her two kids to their daily activities and happily took her turn behind the wheel on family vacations.
But suddenly Sharon (not her real name) developed a fear of driving over bridges. If she was a passenger, she would climb into the back seat and cover her head until the crossing was completed. When she was the driver, she would go as far as 20 miles out of her way to avoid a bridge.
"I just couldn't do it," she recalls. "If I came upon a bridge unexpectedly, I would get nauseous, and my heart would pound so hard I'd think it was going to pop out of my chest. I would sweat, and I could hardly swallow, that's how dry my mouth would become." Sharon says worst of all, she would feel as if she were floating above her body and was about to fall backwards: "I would hunch over the steering wheel and grip it tightly to try to keep from falling. It was horrible."
Sharon had a phobia and when faced with the situation of which she was terrified, she would have a panic attack. Before long, she also became frightened of highway driving. The anticipation of traveling on a multi-lane freeway, with cars zooming past, nearly paralyzed her. Sometimes she would get rides from others, but that meant explaining the situation, which she found humiliating. "I got to the point that I'd stay home rather than go through the terror," she says. "The fear became debilitating."
Although most people don't feel comfortable discussing their phobias, the disorder is not at all uncommon. The National Institute of Mental Health estimates that in any given year some 19.9 million Americans suffer from them, and 2.4 million are prey to panic disorder, a malady that often accompanies phobias. Practitioners agree that 80 percent of those who seek treatment can eventually manage their fears.
When fear is irrational, intense, excessive and
interferes with daily functioning, it becomes a psychiatric problem.
Gerald Leventhal, PhD
A secretary at a New Jersey university, Sharon finally sought help when one of her job requirements became traveling locally, sometimes over bridges and on highways. "At first I made excuses to my boss, but you can't do that forever," she says. "And I just didn't want to live like that any longer."
The American Psychiatric Association (APA) places these ailments under the rubric "anxiety disorders" in its official classification system, "Diagnostic and Statistical Manual of Mental Disorders," Fourth Edition (DSM-IV). It defines a phobia as an intense, recurrent, unreasonable fear of an object, activity or situation not induced by trauma, a chemical substance or a medical condition. To be diagnosed as phobic, the APA says a person must almost invariably have a severe anxiety response to a stimulus and avoiding it must interfere with the daily routine, occupation or social life. And while the sufferer knows the fear is unreasonable, he is nevertheless unable to control it.
There are three distinct types: specific phobia, social phobia and agoraphobia. (See Signs of the Times) Sharon's fear of bridges and highways is specific. An individual with this affliction has an irrational fear of at least one particular stimulus. It can be an animal or insect; an occurrence or object in the natural environment, such as lightning, thunder or the dark; blood, injection and/or injury; or situations, like going through tunnels or being confined in a small space. A favorite of Hollywood filmmakers, specific phobias have been exploited in movies like "Arachnophobia," "Ben" and "Vertigo."
A person who is unreasonably afraid of becoming humiliated in social situations or of embarrassing himself in front of others has a social phobia. The most common is the fear of public speaking, but those affected avoid doing other things in public as well. They might refuse to eat, use a phone or write, because someone may see their hands shake. Social phobics often avoid parties or family gatherings, lest someone thinks they're inarticulate, stupid or clumsy.
People with this affliction are not necessarily shy. In fact, they usually feel comfortable with others most of the time. In certain situations, however, they become extremely uneasy. Often their fears are self- fulfilling, which usually leads to increased anxiety and avoidance.
Perhaps the most incapacitating of all is agoraphobia, which in Greek means "fear of the marketplace." A person with this disorder is afraid of being in places from which escape could be difficult or embarrassing, or in which help may not be available in case of a panic attack. A sufferer may insist on sitting in an aisle seat at the theater, for instance, or always wear a beeper. Some become territorial, traveling only a fixed route within an area they've deemed "safe," while others avoid using public transportation. In severe cases, individuals become completely housebound, sometimes for years.
"Fear is an adaptive human response that helps protect us and keeps us safe," says Gerald Leventhal, PhD, assistant professor of clinical psychiatry at UMDNJ-New Jersey Medical School. "It's good to have a healthy fear of things that are truly dangerous. If we didn't, we wouldn't survive." But when fear is irrational, intense, excessive and interferes with daily functioning, it becomes a psychiatric problem, he explains.
The accompanying panic disorder is a state in which a person experiences attacks, like Sharon's. According to the APA, the diagnosis is appropriate if the symptoms don't occur in conjunction with life-threatening situations or organic causes - such as medication, caffeine or an overactive thyroid.
They must be recurrent, followed by at least a month of persistent concern about having another or worrying about its consequences, and resulting changes in behavior must occur. Finally, at least four of the following symptoms must be present: shortness of breath; accelerated heart rate; choking or smothering sensation; chest pain or discomfort; sweating; dizziness, faintness or feelings of unsteadiness; nausea or stomach distress; sense of unreality; tingling sensation; hot or cold flashes; trembling; fear of loss of control, going crazy or death.
Since depression is common in people who suffer
anxiety disorders, antidepressants play a dual role. People with these afflictions
often feel hopeless. They ask themselves, 'Why can't I relax at a party like other
people and have fun?' Those around them who don't understand, tell them to 'get a
grip' or to 'grow up.' It's very hard on the self-esteem.
Mary Swigar, MD
Leventhal says sometimes it can be difficult to determine whether a phobia sparked the panic attack or vice versa. A phobic may have a panic attack as a result of being exposed to the stimulus that terrifies him, or he may become phobic as a result of the attack.
"If a woman has her first attack in the grocery store, let's say, she'll associate that store with the fear she experienced there," he explains. "Although the surroundings had nothing to do with the attack itself, going to the store becomes the phobic stimulus."
A first attack is usually preceded by a series of stressful events, such as the death of a loved one, followed by an illness, then
perhaps the loss of a job, Leventhal says. "It's like a pot boiling over. The neurological and psychological mechanisms that keep us on an even keel break down."
In Sharon's case, a serious ankle operation - which could have severely limited her ability to walk on her own - was followed by two cancer surgeries and then the death of her father.
Phobias and panic disorder usually manifest themselves between the late teens and mid-30s, but can begin at any time. There's a slightly higher incidence in women than men, and the cause is still being debated.
Some researchers think there are biological reasons, such as physical defects in the regulation of the involuntary nervous system and in the arousal center in the brain, or chemical imbalances in the brain, Leventhal says. Still others maintain that a traumatic event - such as a car accident, being publicly humiliated, or attacked by a dog - can condition people to become phobic. And there is evidence that genetics plays a role.
Researchers can't explain why in some people, particularly children, phobias disappear over time without treatment, while in others they don't. And, there is no profile of a typical phobic. "They're generally average folks who are hard-working and capable, but become overwhelmed by stress," Leventhal says.
Whatever the cause, cognitive behavior therapy - a method that combines exposure to the feared stimulus, relaxation and altering thinking - is an effective form of treatment. "The psychologist or psychiatrist sets up a hierarchy of steps, gradually exposing the patient to the ultimate source of her fear," he says. "The therapist, a trained family member, or a former phobic guides her through the process."
The phobic also learns breathing exercises and other relaxation techniques and how to change his thought processes. "A patient faced with a phobic stimulus is taught to think about the situation differently and more realistically," Leventhal says. "He is encouraged to think, 'I've been afraid before and I've come out okay,' rather than, 'I'm going to lose control and go crazy.'"
Therapy can also include having the person imagine the feared situation. For example, a patient who is afraid of the confines of an MRI imaging tube is advised to practice relaxing for a few weeks, if possible, before the test is done. About 15-20 minutes each day is spent lying still and envisioning himself in the tube. Then he practices relaxation and breathing techniques and thinks of a pleasant scenario. "It's like learning to ride a bike or type," Leventhal notes. "It takes hard work and perseverance, but a patient can develop a remarkable capacity to relax."
Treatment often includes the use of medication. Mary Swigar, MD, associate professor of psychiatry at UMDNJ-Robert Wood Johnson Medical School, says there has been a pharmacological revolution in treating anxiety disorders since the introduction of serotonin reuptake inhibitors, such as Prozac and its cousins.
"These drugs were first marketed as antidepressants, but we've found they're also effective in calming the anxieties connected with phobias and panic disorder," she says.
"Since depression is common in people who suffer anxiety disorders," Swigar notes, "antidepressants play a dual role. People with these afflictions often feel hopeless. They ask themselves, 'Why can't I relax at a party like other people and have fun?' And frequently those around them who don't understand the disorder tell them to 'get a grip' or to 'grow up.' It's very hard on the self-esteem."
Beta-blockers are also used to suppress the physical manifestations of a panic attack, such as tachycardia and tremors, Swigar explains, adding that they're particularly useful if a person can anticipate the attack. Monoamine oxidase inhibitors (MAOs) are still used, although not as commonly as they once were. "There are dietary restrictions with these drugs, "she says. "A patient can't eat cheese, drink beer or wine." Swigar adds that drugs, such as narcotics and decongestants cannot be taken along with MAOs.
She notes that benzodiazephines are also still prescribed: "These are the Valium-type drugs. They don't become addictive, but they can be habit-forming and cause fuzzy-headedness."
I have patients as young as 3 and 4 years old. A child
doesn't know that his fear is excessive or unreasonable, so we use other gauges.
Lawrence Shampain, MD
Swigar points out that people with these disorders need to be especially careful how they manage the physical aspect of their lives. She points out that they may walk around dehydrated. "Busy people often do," she notes. "But anxious people tend to perspire more, and if they get into a situation where they hyperventilate, a portion of every exhalation is water vapor." The psychiatrist adds that they should try to control the stress in their days as much as possible: "The individual should make sure things don't get so compressed and hectic that an anxiety response is triggered."
Adults coping with the everyday stresses of life aren't the only ones who suffer from these disorders. Children are plagued as well.
"It's normal for kids to have transient fears," explains Lawrence Shampain, MD, who practices at University Behavioral HealthCare in Piscataway. "We consider a debilitating fear a phobia in a child when it lasts for six months."
A clinical assistant professor of psychiatry at the school, Shampain says the most common phobias among children are fear of the dark followed closely by animals, insects and snakes. In adults, he notes, the top fears are usually situational. And while a phobic adult becomes anxious and panics when faced with the stimulus, children cry, have tantrums, freeze or cling to a parent or other trusted caretaker.
"I have patients as young as 3 and 4 years old," he says. "A child doesn't know that his fear is excessive or unreasonable, so we use other gauges."
Parents, family members and often the child's close friends play a very important role in treatment. They sometimes inadvertently reinforce his fears. Take the case of a 7-year-old patient of Shampain's who was afraid to play in front of his house for fear he would be kidnapped. His mother admitted telling her son he might be abducted there, because it was easier for her to keep an eye on him when he was in the back yard.
In another instance, an adolescent patient was afraid to drive alone or at night. But her boyfriend was more than willing to take her anywhere she wanted to go.
"I asked him to join us in therapy one day," Shampain says, "and explained that although his intentions were well meant, he wasn't helping her."
The psychiatrist says parents - particularly those whose children are afraid of water - are often tempted to use a technique known as "flooding." An example would be having a person who is terrified of water jump into the deep end of the pool. Shampain strongly advises against it, saying: "The child usually becomes even more frightened than before."
He says he uses very little medication with kids and doesn't ask them to imagine the stimulus that frightens them. "Most children don't have the ability to stay focused on something that terrifies them," he explains. "They back away - they don't want to face it."
Shampain observes that unlike adults, kids with anxiety disorders don't want to continue with their daily routines if they're not feeling 100 percent: "They'll have physical complaints and want to stay home from school, for example. One of the things we teach them is that they can get through a day successfully, even if they are anxious. Most importantly, we try to get them to understand that what they fear will most likely never really hurt them."
Sharon, too, is coming to understand that. After a little more than a year in therapy, she can now drive over bridges, although she is still somewhat anxious. "But I don't panic anymore," she says, proudly. She is also beginning to do some highway driving. A goal she hopes to reach by the end of the summer is to drive alone, as she once did, to her favorite place, the Jersey Shore.
Illustrations by Ted Pitts