Keywords: phobia, fear, phobic response, anxiety disorders
Anxiety disorders have been identified as the most prevalent mental health problem in the United States. According to the Epidemiologic Catchment Area (ECA) study sponsored by the National Institute of Mental Health, the 1-month prevalence rate for anxiety disorders is 7.3% (Regier et al., 1998). Among anxiety disorders, phobic disorders are the most common, with a prevalence rate of 6.2%. According to the Diagnostic and Statistical Manual of Mental Disorders-IV-Text Revision (DSM-IV-TR; American Psychiatric Association [APA], 2000), phobias are classified into three categories: agoraphobia with or without panic attacks, social phobia, and specific phobia.
An element common to phobias is the feeling of fear that individuals experience when they encounter the phobic situation or object. Fear is a basic emotion that acts as an alarm in response to present danger (Barlow, 2002). When in a feared situation, the natural tendency is to engage in the "fight-or-flight" response. There arises an overwhelming urge to escape the situation and to avoid any encounter in the future. If the situation cannot be avoided, it is endured with discomfort and dread (Dziegielewski & MacNeil, 1999). Clinically, fear is most evident in panic attacks, in which the individual experiences extreme feelings of fear and danger and an overwhelming urge to escape the situation. However, research has indicated that no important differences exist between panic attacks experienced by individuals with panic disorder and the reactions experienced by individuals with specific phobia when they encounter their feared object or situation (Craske, 1991). In fact, the DSM-IV-TR only discriminates these two responses by the presence or absence of an external cue, whereby an unexpected, or uncued, panic attack occurs in the context of panic disorders, while situationally bound or situationally predisposed panic attacks occur in the context of specific phobias and social phobias. Thus, fear and panic are beginning to be believed to be equivalent experiences.
Panic can manifest itself physically, somatically, and cognitively in the form of a full-blown panic attack or a limited-symptom panic attack. The DSM-IV-TR defines a panic attack as a discrete period of intense fear or discomfort, in which at least four (or more) of the following symptoms developed abruptly and reached a peak within 10 minutes: palpitations, pounding heart, or accelerated heart rate; sweating; trembling or shaking; sensations of shortness of breath or smothering; feeling of choking; chest pain or discomfort; nausea or abdominal distress; feeling dizzy, unsteady, lightheaded, or faint; derealization (feeling of unreality) or depersonal-ization (being detached from oneself); fear of dying; pares-thesias (numbness or tingling sensations); and chills or hot flashes. Limited-symptom attacks require the same criteria, except that fewer than four symptoms of panic are required.
While panic attacks are most often thought of in regard to panic disorder, with and without agoraphobia, panic attacks can also be experienced in specific phobia and social phobia. One study examining specific phobias found that 47% of individuals with a phobia of heights, 20% of individuals with an animal phobia, 50% of individuals with a blood/injection phobia, and 36% of individuals with a driving phobia experienced a panic attack when encountering the phobic situation or object (Antony, Brown, & Barlow, 1997). Thus, the panic attacks or panic-like symptoms can exist among all of the phobias and may play an important role in the maintenance of the phobia. Zitrin, Klein, Woerner, and Ross (1983) found in their study that while individuals received treatment for agoraphobia and specific phobia, the occurrence of panic attacks would decrease, but avoidance behavior continued because anticipatory anxiety remained high. After continued treatment, in the absence of the panic attacks, the anticipatory anxiety decreased, followed by a decrease in phobic avoidance. Therefore, when the panic symptoms were no longer negatively reinforcing the avoidance behavior, the individual was able to face the phobic situation or object.
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