Panic Attacks treatment in Cambridge and London

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Hypnotherapy for Panic Attacks in Cambridge- The Hypnosis Clinic

Panic attacks can exist as a symptom on its own, often panic attacks can be present as part of an anxiety disorder. Panic attacks can develop from learned behaviour from family members, or develop at times of anxiety, severe stress or from specific seeding events.

Testimonial " I am very good thank you. I haven't had any panics in weeks now. I am much relaxed about everything and the way I deal with things and it makes me feel much better. I am exercising very regurlarly, it's great to feel fit again (i reckon that the huge drop of fitness in April was partly the cause of these panics too). Of course it happens sometimes when I am stressed that I rethink about my heart but it goes away soon because I'm more rational about it. I am in control now and I feel good about it. I really wanted to thank you for helping me out,
you have been fantastic.

Hypnotherapy for panic attacks can give a rapid resolution, often we would expect changes after the first 90 minute session.  Leaving the sufferer calm, relaxed and with techniques to cope with future attacks, so that the fear of panic attacks is reduced to zero.

For a discussion with a formally trained hypnotherapist  phone your nearest practitioner whose number you will find from the contacts page or telephone 0779 210 82 72 or click on .

Hypnotherapy for panic attacks can be used to combat the symptoms, listed below.  To break habitual behaviours.  Desensitise the sufferer from stressors.  Once under control, it is possible to look back at the original seeding event in a dispassionate calm environment.  Although therapy can take several sessions, a course of three sessions will alleviate major symptoms.

The symptoms of Panic Attacks are

• Shortness of breath and smothering sensations.
• Choking sensations.
• Palpitations and elevated heart rate.
• Chest discomfort or pain.
• Sweating.
• Dizziness unsteady feelings or faintness.
• Nausea or abdominal distress.
• Depersonalisation or de-realisation.
• Numbness or tingling sensations.
• Flushes or chills.
• Trembling or shaking.
• A fear that the patient is dying, having a heart attack or stroke.
• A fear the patient is going crazy or they are about to do something uncontrolled.

Contact   The Hypnosis Clinic at [email protected]

In order for a doctor to make a diagnosis of panic attack four or more of these symptoms must present, develop quickly and reach a peak in 10 minutes.

Other common conditions that are associated with panic attacks are agoraphobia, social phobia, specific phobias.

Hypnosis can alleviate anxiety by direct suggestion and by behavioural training both in trance and using self hypnosis can alleviate anxiety and help break mind loops of anxiety.

Extreme Anxiety can cause panic attacks, blushing, profuse sweating, trembling, and other symptoms of anxiety, including difficulty talking and nausea, and over all feeling of dread or other stomach discomfort, irregular heartbeat.

The experience of anxiety can range from mild uneasiness and worry to severe panic. At a reasonable level, short bursts of anxiety can motivate us and enhance our performance. If anxiety becomes too severe or chronic, however, it can become debilitating.

Anxiety typically involves an emotional component (e.g. fear, nervousness), a physical component (e.g. trembling, dry mouth, heart racing, stomach churning) and a cognitive component (frightening thoughts, e.g. I'm going to fail/make a fool of myself/loose control). These can then affect our behaviour, for example by putting off or stopping work, avoiding people, not sleeping, or drinking too much.

What is anxiety?

Anxiety is a normal response to feeling threatened. People differ as to how vulnerable they feel in different situations: this can be influenced by past experiences as well as by the beliefs and attitudes they hold about these situations.

Some general situations which often cause anxiety include:

• leaving home
• coping with work and exams
• dealing with relationships or the lack of relationships
• sexuality issues
• preparing to leave university.
• new job
• moving to new area

But sometimes it is specific situations that are anxiety provoking

• apprehension about going into new or social situations
• having to deal with people in authority
• worrying about whether you have chosen the right course or job
• panic about preparing for and facing exams or making a presentation
• fears about health.

The experience of anxiety can range from mild uneasiness and worry to severe panic. At a reasonable level, short bursts of anxiety can motivate us and enhance our performance. If anxiety becomes too severe or chronic, however, it can become debilitating.

You've probably been introduced to the area already. Freud - anxiety can be adaptive if it motivates people to learn new ways of approaching life's challenges. Becomes a problem if we experience it in the absence of a visible cause or in response to stimuli which others do not find anxiety provoking.

Most theories of anxiety begin with the autonomic nervous system, which connects the central nervous system to the other organs of the body and helps to regulate their functions, like breathing, heartbeat, perspiration, blood pressure. The ANS is divided into two parts, the sympathetic system and the parasympathetic system. When we appraise a situation as fear-producing the sympathetic nervous system raises heartbeat and respiration rate - the fight or flight response. The parasympathetic nervous system on the other hand is involved in returning our heartbeat and other functions to resting level.

People differ in how the respond when anxious - some  may sweat, others may suffer a pounding heart and so forth, the exact profile of anxiety reactions will differ for different people.

People may also differ in terms of their readiness to become anxious. Anxiety may be a personality trait (Spielberger, 1966; 1972; 1985) which might originate in  constitutional differences or be developed through early experiences. Anxiety may also be a temporary state. Again, people  differ in their tendency to see situations as threatening. Walking through a forest may be threatening for one but enjoyable for another. Changes through life course may occur too. E.g. children are afraid of the dark but this wears off in adulthood.

Appraisal: In order for these responses to be activated we undertake some sort of appraisal of the situation - a primary appraisal - if we appraise it as threatening we may then go on to a secondary appraisal where we assess whether we have the resources to deal with it (Lazarus and Folkman, 1984)

In the US anxiety disorders are relatively widespread, affecting 15-17% of the adult population in any given year (Kessler et al, 1994; Regier et al, 1993; Eaton et al, 1991; Blazer et al, 1991; Davidson et al, 1991). Rovner (1993) estimated that the cost to the US economy was $46.6 billion in 1990.

Anxiety involves feelings of uncertainty, helplessness and physiological arousal. Sometimes referred to as part of the group 'neuroses' - characterised by anxiety, personal dissatisfaction and inappropriate but not psychotic behaviour DSM IV groups them as 'anxiety disorders'.

Explanations for anxiety disorders

1) Cultural, social and environmental

People in threatening situations are more likely to suffer mental health problems, chief among them anxiety with exaggerated startle reactions, sleep disturbance and specific fears and avoidance behaviour (Baum and Fleming, 1993; Melick et al, 1993).  In the aftermath of the Three Mile Island nuclear accident researchers studied the psychological impact on people living nearby and discovered that mothers of pre-school children in the neighbourhood displayed five times the rate of anxiety and depression disorders compared to mothers of comparable age in comparable families outside the area. Although some of the symptoms subsided the three mile island mothers were still showing elevated rates of anxiety and depression a year later.

Anxiety might be related to social change. The US population seems to be showing increased rates of anxiety problems, e.g. Weissman et al (1978) discovered rates of 1.4% for phobias and 2.5% for generalised anxiety. By the 1990s these had increased to 11% and 3.8% respectively (Regier et al, 1993; Blazer et al, 1991; Eaton et al, 1991). There are higher rates of anxiety disorder in urbanised countries (Compton et al, 1991; Hwu et al, 1989). With technological changes come some new kinds of fears e.g. in a survey reported by Swingle, 1993) 55% of Americans said they were afraid of using video recorders, answering machines or walkmans and 32% said they were intimidated by computers and were afraid of damaging the machine.

Poverty is linked with anxiety disorders. Blazer et al (1993) discovered that  for those with incomes below $10,000 a year the rate of anxiety disorders is twice what it is for those with higher incomes. In the US this has also been tied to race. E.g. according to Belle (1990) and Bennett (1987) African Americans have the highest rate for generalised anxiety disorder (6% compared to 3.5% for whites). African American women have much higher phobia rates (20%, as opposed to 9% for whites) in any given year.

2) Psychodynamic explanations

According to Freud (e.g. 1917; 1933) we experience realistic anxiety when we are confronted with a genuine external danger, whereas we experience neurotic anxiety if we are prevented from expressing our id impulses. Moral anxiety arises from our being threatened or punished for expressing our id impulses, as a result of which these impulses themselves come to be perceived as threatening. Specific fears result from overuse of the defence mechanisms of repression, where people push the feared object deeper and deeper into unconsciousness, and displacement, where they attach the fear to otherwise neutral objects. Generalised fear results from a breakdown of defence mechanisms, perhaps where they have not been sufficiently developed in childhood.  More recently, object relations theory suggests that children with strict or punitive parents come to fear being attacked by 'bad objects' or losing 'good objects' (Cirese, 1993; Zerbe, 1990). Alternatively, if parents do not treat children in a confident relaxed and supportive manner the self will not develop appropriately and the child may develop disintegration anxiety where the self is perceived as lacking support and develop defensive processes to safeguard their damaged self (Zerbe, 1990). These individuals may be overwhelmed by the stress of adulthood and suffer from self fragmentation (Diamond, 1987).

In support of these psychodynamic positions, experimenters have manipulated people's anxiety. For example Rosenzweig (1933; 1943) arranged for subjects to fail half the problems on a test they believed was important. They remembered less about the questions on which they failed. Luborsky (1973) looked at transcripts of therapy sessions and showed that people reacted to topics that they were anxious about by changing the subject, forgetting what they were talking about and denying negative feelings. In cultures where children are punished more, adults seem to have more fears and anxieties (Whiting et al, 1966). Where parents are overprotective, children seem to be more anxious (Jenkins, 1968; Eisenberg, 1958). Some other studies have been less supportive, for example Raskin et al (1982) looked at people presenting with anxiety disorders and did not find a history of harsh discipline or disturbed childhood behaviour

4) Humanistic and existential explanations

These propose that people become anxious when they have difficulty in accepting themselves honestly and when their defensive postures stop them looking at themselves with acceptance. When children fail to receive unconditional positive regard from others they may become overly critical of themselves and set themselves overly high self standards. These conditions of worth mean that anxiety provoking self judgments break through. Therapists then try to surround the person in unconditional positive regard and create the conditions whereby people can come to believe in themselves and stop evaluating themselves unfavourably. This idea has received some support (Chodorkoff, 1954), but there has been little independent verification of humanistic theories. By nature, humanistic therapists are skeptical of scientific evaluations of their work.

According to existentialists, people are governed by an existential anxiety, a fear of the limits and responsibilities of human existence (Tillich, 1952). Existential analysts have suggested that people, in modern technological competitive societies deny their fears and freedom of choice and lead inauthentic lives, where they are overly concerned with conforming to the standards of society (May, 1965; Bugenthal, 1965). Again, little systematic research has been conducted on this perspective because of the belief of many such therapists that their subject matter is not adequately captured by scientific research.

5) Behavioural explanations - learning to fear.

In 1922 Bagby described a case where a child acquired a phobia (of running water) as a result of an aversive experience. This appeared to reflect the recently discovered principles of conditioning. This was part of a search to find other ways in which fear could be learned. Watson and Rayner (1920) and Little Albert acquiring a fear of rats and Jones (1924) and Little Peter being conditioned out of his fear of rabbits. With the development of social learning theory in the 1960s Bandura and Rosenthal (1966) argued that fear may be learned from watching others being fearful.  Once we have acquired the fear we will tend to avoid  the fear-producing object and thus will experience a reduction in anxiety. Hence, we learn to avoid the feared object.

Some authors have detected specific instances where fears seem to arise from unpleasant events (Ost, 1991; Merckelbach et al, 1991). Others have not found this relationship (Marks, 1987; Keuthen, 1980), This theory has been extended to include the idea of preparedness - that evolution prepares us to be more afraid of certain objects, like animals, darkness, heights etc. (e.g. Marks, 1977; Seligman, 1971).

6) Cognitive explanations

Assume that anxiety is caused by maladaptive assumptions. E.g. Ellis (1977; 1984) suggests that people are inclined to seek approval from everyone, to despair if things are not the way they want them, and keep dwelling on the possibility of fearsome events occurring. Hence people are inclined to overreact and experience fear when confronted with new life events. In a related theory, Beck describes how some people constantly make assumptions that imply they are in immanent danger (Beck & Greenberg, 1988). Experimental evidence has supported some of the features of these models of anxiety. When people are told to repeat to themselves anxiety provoking statements they show more respiratory changes and emotional arousal (Rimm & Littvak, 1969). Beck et al (1974) found that people suffering from free floating anxiety reported negative assumptions and automatic thoughts about physical injury, Illness or death; mental illness; psychological impairment or loss of control, failure or inability to cope; and rejection, depreciation and domination.

Cognitive theorists believe that people whose lives have been punctuated by unpredictable negative events are more likely to be vigilant in trying to predict what may go wrong in the world around them and be inclined to interpret ambiguous stimuli as threats (Pekrun, 1982). People in laboratory studies  respond more fearfully to unpredictable or un-warned negative events compared to predictable ones or those which they are warned about (Weinberg and Levine, 1980).

7) Biological explanations

These have concentrated on the kinds of neurotransmitters and subsystems of the brain involved in anxiety states. Like many other 'mental disorders', important clues emerged through observation of the action of drugs. Benzodiazepines (Valium, Xanax and Librium) were observed to reduce anxiety in the 1950s and the development of brain scanning techniques in the 1970s helped researchers to pinpoint that these drugs seemed to be most active in the hypothalamus and limbic system, in binding to receptor sites (remember what we did about neurotransmitters and their receptors a few weeks ago?) (e.g. Gray, 1987; Costa, 1985; Hollister, 1982).

The benzodiazepines bind to receptors which are designed to receive the neurotransmitter GABA (gamma amino butyric acid). GABA is an inhibitory neurotransmitter - it makes the neuron receiving it less likely to 'fire'. The elevated rate of neural firing in fear reactions is believed to be brought back to resting level by the GABA producing neurons which inhibit the cells which receive them from firing.

Perhaps people with anxiety disorders do not have a working GABA feedback system, e.g. by not secreting enough GABA, by secreting other chemicals which interfere with the action of GABA or having GABA receptors which do not readily bind to the  neurotransmitter. Benzodiazepines act on GABA receptors and increase their ability to bind GABA (Leonard, 1992; Costa and Guidotti, 1979)

This explanation is not complete, as it is known that a number of chemicals, not just GABA, can bind to GABA receptors (Bunney and Garland, 1981). GABA is used very widely in the brain - about 40% of neurons can secrete GABA, so which ones are responsible?

References

Bagby, E. (1922) The etiology of the phobias, Journal of Abnormal Psychology, 17, 16-18.

Bandura, A. & Rosenthal, T. (1966) Vicarious classical conditioning as a function of arousal level, Journal of Personality and Social Psychology, 3, 54-62.

Baum, A. and Fleming, I. (1993) Implications of psychological research on stress and technological accidents, American Psychologist, 48, (4), 665-672.

Beck, A.T. & Greenberg, R.L. (1988) Cognitive therapy with children and adolescents In Frances, A.J. & Hales, R.E. (Eds.) American Psychiatric Press Review of Psychiatry (vol. 7) Washington DC: American Psychiatric Press.

Beck, A.T., Laude, R. & Bohnert, M. (1974) Ideational components of anxiety neurosis, Archives of General Psychiatry, 31, 319-325.

Belle, D. (1990) Poverty and women's mental health, American Psychologist, 45, (3) 385-389.

Bennett, M.B. (1987) Afro-American women, poverty and mental health: A social essay. Women and Health, 12 (3-4), 213-228.

Blazer, D.G., George, L.K., & Hughes, D. (1991) The epidemiology of anxiety disorders: An age comparison, In Salzman, C. & Lebowitz, B.D. (Eds.) Anxiety in the elderly, New York: Springer.

Bugenthal, J.F. (1965) The existential crisis in intensive psychotherapy, Psychotherapy: Theory, Research and Practice, 2, (1), 16-20.

Bunney, W.E. and Garland, B.L. (1981) Receptor function in depression, Advances in Biological Psychiatry, 7, 71-84.

Chodorkoff, B. (1954) Self perception, perceptual defence and adjustment, Journal of Abnormal and Social Psychology, 49, 508-512.

Compton, W.M., Helzer, J.E., Hwu, H., Yeh, E., McEvoy, L., Tipp, J.E., & Spitznagel, E.L. (1991) New methods in cross cultural psychiatry: Psychioatric illness in Taiwan and the United States, American Journal of Psychiatry, 148, (12), 1697-1704.

Costa, E. (1985) Benzodiazepine-GABA interactions: A model to investigate the neurobiology of anxiety, In Tuma, A.H. & Maser, J. (Eds.) Anxiety and the anxiety disorders, Hillsdale, N.J.: Erlbaum.

Costa, E. and Guidotti, A. (1979) Molecular mechanisms in the receptor action of benzodiazepines, In Okun, G.R. & Cho, A.K. (Eds.) Annual Review of Pharmacology and Toxicology (vol. 19) Palo Alto, CA: Annual Reviews Inc.

Cirese, S. (1993) Personal Communication to Comer, R.J. (1995) Abnormal Psychology, New York: W.H. Freeman.

Davidson, J.R., Hughes, D., Blazer, D.G., & George, L.K. (1991) Post-traumatic stress disorder in the community: An epidemiological study, Psychological Medicine, 21, (3) 713-721.

Diamond, D. (1987) Psychotherapeutic approaches to the treatment of panic attacks, hypochondriasis and agoraphobia, British Journal of Medical Psychology, 60, 85-90.

Eaton, W.W., Dryman, A., & Weissman, M.M. (1991) Panic and phobia, In Robins, L.N. & Regier, D.A. (Eds.) Psychiatric disorders in America: The epidemiologic catchment area study, New York: Maxwell Macmillan International.

Eisenberg, L. (1958) School phobia: A study in the communication of anxiety, American Journal of Psychiatry, 114, 712-718.

Ellis, A. (1977) The basic clinical theory of rational emotive therapy, In Ellis, A. & Greiger, R. (Eds.) Handbook of rational emotive therapy, New York: Springer.

Ellis, A. (1984) Rational emotive therapy, In Corsini, R.J. (Ed.) Current psychotherapies, (3rd Edition) Itasca, IL: Peacock.

Gray, J.A. (1982) The psychology of fear and stress, Cambridge: Cambridge University Press.

Hollister, L.E. (1982) Plasma concentration of tricyclic antidepressants in clinical practice, Journal of Clinical Psychiatry, 43, (2) 66-69.

Hwu, H.G.,  Yeh, E.K. & Chang, L.Y. (1989) Prevalence of Psychiatric disorders in Taiwan defined by the Chinese Diagnostic Interview Scale, Acta Psychiatrica Scandinavica, 79, 136-147.

Jenkins, R.L. (1968) The varieties of children's behavioural problems and family dynamics, American Journal of Psychiatry, 124, (10), 1440-1445.

Jones, M.C. (1924) The elimination of children's fears, Journal of Experimental Psychology, 7, 382-390.

Kessler, R.C., McGonagle, K.A., Zhao, S., Nelson, C.B., Hughes, M., Eshleman, S., Wittchen, H.U. & Kendler, K.S. (1994) Lifetime and 12 month prevalence of DSM-III-R psychiatric disorders in the United States , Archives of General Psychiatry, 51, 8-19.

Keuthen, N. (1980) Subjective probability estimation and somatic structures in phobic individuals, Unpublished Manuscript, State University of New York at Stony Brook.

Lazarus, R.S.  & Folkman, S. (1984) Stress, appraisal and coping, New York: Springer.

Leonard, B.E. (1992) Effects of pharmacological treatments on neurotransmitter receptors in anxiety disorders, In Burrows, G.D., Roth, S.M., & Noyes, R. (Eds.) Handbook of anxiety, (vol. 5) Oxford: Elsevier.

Luborsky, L. (1973) Forgetting and remembering (momentary forgetting) during psychotherapy, In Mayman, M. (Ed.) Psychoanalytic research and psychological issues, (Monograph 30), New York: International Universities Press

Marks, I.M. (1987) 'Fears Phobias and rituals: Panic, anxiety and their disorders' New York: Oxford University Press.

Marks, I.M. (1977) Phobias and obsessions: Clinical phenomena in search of a laboratory model, In Maser, J. & Seligman, M. (Eds.) Psychopathology: Experimental models, San Francisco: W.H. Freeman.

May, R. (1961) Existential psychology, New York: Random House.

Melick, M.,  Logue, J. & Frederick, C. (1982) Stress and disaster, In Goldberger, L. & Breznitz, S. (Eds.) Handbook of Stress, New York: Free Press.

Merckelbach, H., Arntz, A. and deJong, P. (1991) Conditioning experiences in spider phobics, Behaviour Research and Therapy, 29, (4), 333-335.

Ost, L.G. (1991) Acquisition of blood ad injection phobia and anxiety response pattern in clinical patients, Behaviour Research and Therapy, 29, (4) 323-332.

Pekrun, R. (1982) Expectancy-value theory of anxiety: Overview and implications, In Forgays, D.G. & Sosnowski, T. & Wrzesniewski, K. (Eds.) Anxiety: Recent developments in cognitive, psychophysiological and health research, Washington, DC: Hemisphere Publishing Corporation.

Raskin, M., Peeke, H.V.S., Dickman, W., & Pinkster, H. (1982) Panic and generalised anxiety disorder: Developmental antecedents and precipitants, Archives of General Psychiatry, 39, 687-689.

Regier, D.A., Narrow, W.E., Rae, D.S., Manderscheid, R.W., Locke, B.Z., & Goodwin, F.K. (1993) The de facto US mental and addictive disorders service system: Epidemiologic catchment area prospective 1 year prevalence rates of disorders in services, Archives of General Psychiatry, 50, 85-94.

Rimm, D.C. & Litvak, S.B. (1969) Self verbalisation and emotional arousal, Journal of Abnormal Psychology, 74, (2), 181-187.

Rosenzweig, S. (1933) The recall of finished and unfinished tasks as affected by the purpose with which they were performed, Psychological Bulletin, 30, 698.

Rosenzweig, S. (1943) An experimental study of repression with special reference to need persistive and ego defensive  reactions to frustration, Journal of Experimental Psychology, 32, 64-74.

Rovner, S. (1993) Anxiety disorders are real and expensive, Washington Post, April 6th, p WH 5.

Speilberger, C.D. (1966) Theory and research on anxiety, In Speilberger, C.D. (Ed.) Anxiety and behaviour, New York: Academic Press.

Speilberger, C.D. (1972) Anxiety as an emotional state, In Speilberger, C.D. (Ed.) Anxiety: Current trends in theory and research, (vol. 1) New York: Academic Press.

Speilberger, C.D. (1985) Anxiety, cognition and affect: A state-trait perspective, In Tuma, A.H. & Maser, J. (Eds.) Anxiety and the affective disorders, Hillsdale, N.J.: Erlbaum.

Swingle, C. (1993) Technophobia, USA Today, 26th July, P. B1.

Tillich, P. (1952) Anxiety, religion and medicine, Pastoral Psychology, 3, 11-17.

Watson, J.B. & Rayner, R. (1920) Conditioned emotional reactions, Journal of Experimental Psychology, 3, 1-14.

Weinberg, J. and Levine, S. (1980) Psychobiology of coping in animals: The effects of predictability, In Levine, S. & Ursin, H. (Eds.) Coping and health, New York: Plenum.

Whiting, J.W. et al (1966) Six cultures series: Field guide for a study of socialisation, New York: Wiley.

Zerbe, K.J. (1990) Through the storm: Psychoanalytic theory in the therapy of anxiety disorders, Bulletin of the Meninger Clinic, 54, (2), 171-183.

Second part of anxiety disorders

Some of the more noteworthy instances are:

1) Generalised or free floating anxiety. Diffuse vague unpleasant feeling of fear and apprehension. Worries about unknown dangers or risks inherent in everyday events. Symptoms may include rapid heart rate, loss of breath, loss of appetite, sweating, fainting, diarrhoea, nausea, frequent urination, tremors. With f-f anxiety, there's no obvious cause of the worry, nor is it easily attributed to recent life experience. The symptoms are i) Motor tension  muscle tension, shakiness, inability to relax, strained facial expression, easily startled ii) Autonomic reactivity sympathetic and parasympathetic activity contributing to the physical symptoms, heart, stomach respiration, sweating. iii) Apprehensive feelings about the future. iv) Hypervigilance scan the environment for dangers. Related to the hyperaroused state.

Generalised anxiety is defined as a disorder that does not involve a lack of contact with reality.

2) Panic disorder Like anxiety but intense and sudden. Periods of intense anxiety interspersed with normal functioning. symptoms similar to anxiety but may also include chest pains and palpitations. Some psycho sensory symptoms - distortion of light intensity, sound intensity, strange feeling in stomach, sensations of floating, turning, moving, feelings of unreality or loss of self identity. Attacks may be several seconds, a few hours or even days long. People with panic attacks may develop anxiety that they're about to suffer an attack, particularly in embarrassing situations, in public.

3) Phobias - Phobos Greek god of fear. Specific fear or anxiety, about a particular object or situation. Fears may not be linked to likelihood of happening e.g. more traffic accident fatalities than violent crime victims but more people worry about crime than car accidents (Sarason and Sarason, 1989). Fear may occur even if the phobic person imagines the object or situation. Phobias may develop gradually without there being a specific event or situation which sets it off. Some e.g. fear of cats, cars, staircases are part of everyday life to most of us; others e.g. fear of snakes, heights, pain are felt to some degree by most people. Torgensen (1979) typology of phobias from study of phobic patients:

i) separation fears - crowds, traveling alone, being alone at night.

ii) Animal fears - mice, rats, insects, spiders

iii) Mutilation fears - open wounds, operations, blood or bleeding.

iv) Social fears - speaking in public, being watched.

v) Nature fears - heights, mountains, cliffs, the sea.

Sometimes people develop cumbersome ways of dealing with phobias, subway woman etc. avoiding phobia object. Most common phobias are about things that could really be dangerous (McNally, 1987). Maybe evolutionary e.g. fear of snakes more common than fear of electricity. Tend to be grouped into three categories, namely

i) Simple phobias - fear of a specific object like spiders or claustrophobia. Therapy might involve promoting associations between fear arousing stimuli and non anxiety responses.

ii) Social phobias fear and embarrassment in dealing with others. People may fear that the signs of their embarrassment may show to others, trembling, stuttering, blushing. May involve fear of asserting oneself, fear of making a mistake and fear of public speaking. May involve people feeling inadequate and having social and interpersonal inadequacies. Marks (1987) some techniques for dealing with social phobia. i) Respond to anxiety symptoms by approach rather than withdrawal. ii) Greet people properly with eye contact. iii) Listen carefully to people and make a mental list of possible topics of conversation. iv) Show that you want to speak, initiate conversation asking questions etc. v) Speak up without mumbling. vi) Tolerate some silences vii) Wait for cues from others in deciding where to sit, when to pick up a drink and what to talk about viii) Learn to tolerate criticism by introducing controversy deliberately at an appropriate point.

4) Agoraphobia. Literally fear of the market place. More generally fear of entering unfamiliar situations. May involve fear of leaving home or secure setting. May deteriorate or improve and object of fear may change. Agoraphobics can be divided into those who suffer panic attacks and those who don't. Agoraphobia can develop from panic attacks, because patients associate the panic with the situation in which it occurs. Ag. is sometimes associated with clinging dependent personality (Gittelman and Klein, 1984) and separation anxiety in childhood.

5) Obsessive compulsive disorders Obsessive people are unable to get an idea out of their minds. Compulsive people feel compelled to perform a particular act over and over. E.g. Lady Mac Beth and hand washing. Obsessions may involve doubt, hesitation fear of contamination or fear of one's own aggression. Compulsive behaviour may involve counting, ordering, washing etc. Sometimes purely cognitive, e.g. to prevent bad things happening recite series of words to self. Some people have obsessive thoughts but do not act on them, others have obsessive thoughts which lead to compulsive behaviour and a very few have compulsive behaviour without related obsessive thoughts. Obsessive compulsive people can be very cautious. O-C problems usually characterised by i) The obsession or compulsion intrudes insistently and persistently into the individual's awareness ii) A feeling of anxious dread intrudes if the thought or act is prevented for some reason. iii) The obsession or compulsion is experienced as foreign to oneself as a psychological being. iv) The individual recognises the obsession as absurd or irrational but can't do anything about it. v) Individual feels a need to resist it. O-C people may be very indecisive. O-C rituals may involve i) checking e.g. taps, locks ii) Cleaning or cleanliness iii) Slowness iv) Doubting own competence and conscientiousness. These tendencies increase during periods of stress. Obsessional thoughts can occur in psychotic behaviour, but in the latter cases people are more detached from reality. O-C problems are like phobias in that both involve anxiety. Sometimes associated with interpersonal problems.

6) Hysteria. Originally treated by Charcot in C19th. Organic complaints for which no organic cause had been found. Complaints of e.g. loss of sensation in the skin, pains, blindness, paralysis, tics, muscular contractions and seizures. Often accompanied by what Charcot called 'la belle indifference' - Patients did not seem to be concerned about their condition. Also, hysterical patients had their on theories about bodily functioning and the symptoms were compatible with these theories. Charcot used hypnosis an suggested to patients while they were in the trance that their symptoms would disappear - considerable success. Influenced Freud and Pinel. Pinel extended Charcot's work and believed that the onset of the hysterical symptoms was related to an upsetting event and that if patients expressed these feelings the symptoms could be relieved. In US now called somatoform disorder. Somatoform disorder includes i) Psychogenic pain disorder - pain without or in excess of what would be expected from organic symptoms. May be to do with trying to get attention from others or associated with actual or threatened interpersonal loss. ii) Hypochondriasis - where people show unrealistic fear of disease despite reassurance that his or her social or occupational functioning is not impaired. May include obsessive preoccupation with bodily organs and worry about health. Tend to misunderstand the nature of physiological activity and exaggerate symptoms when they occur (Kellner, 1987). iii) Somatization disorder involves multiple somatic complaints, often chronic, sometimes called Briquet's syndrome. Headaches, fainting, nausea, vomiting, abdominal pains, bowel trouble, menstrual and sexual problems, allergies. May induce doctors to perform operations. Woodruff et al (1974) compared 50 somatizing patients and 50 normal controls and found that three times as much body tissue had been removed from somatizing patients. S-D's usually accompanied by difficulties in social relationships, exaggerated displays of emotion and self-centred attitude. iv) Conversion disorders involve complaints by patients that they have lost all or part of some bodily function. Does not seem to be under voluntary control. Symptoms often follow stressful event. Psychoanalysis suggests that the symptom represents an underlying conflict. Sometimes symptoms conflict with medical knowledge, e.g. glove anaesthesia, where patients claim to have lost sensation in their hands, very unlikely neurologically. (But carpal tunnel syndrome??) Episodes may follow upsetting or challenging events. Symptoms may allow person to escape the aversive stimuli or get sympathy. Group hysteria also possible where people who live and work together may suffer similar symptoms.

Changing the subject a bit we have Stress Inoculation training. Based on the work of Ellis (1973) - Rational Emotive Therapy - people have problems because they feel it is necessary always to be totally competent, that they have no control over their feelings, that they must rely on others who are stronger, or that they cannot overcome their past misfortunes. As a result suffer self hatred, hostility, sense of worthlessness and inadequacy. RET tries to replace these beliefs with more positive methods of self evaluation. SIT gets client/patient to talk to him/herself differently about the problem. Several phases i) educational phase in which patient is encouraged to analyse problem rather than just panic. Told that fear involves a) physiological arousal and b) anxiety engendering thoughts, images and self statements. Get client to re-label the physical sensations as e.g. eagerness to demonstrate competence. Result is a change to a sense of learned resourcefulness instead of learned helplessness. The shift in cognitions may in itself lead to a shift in autonomic functions. Client is instructed in the application of specific phrases and skills. Practice and rehearsal. Instruction in muscle relaxation too. Example: Mucous colitis (Youell & McCullough, 1975). Client keep a record of the attacks and note the events that occurred prior to each attack. Majority of patients attacks seemed to occur after negative interpersonal encounter. Instructed to approach individuals who created these negative feelings and ask them if this is how they intended her to understand the transaction. Later in the therapy the client was asked to do concurrent hypothesis testing. Attacks declined over a 50 week period.

References

Bakal, D. (1979) 'Psychology and medicine' London: Tavistock.

Ellis, A. (1973) 'Humanistic Psychotherapy' New York: Julian Press.

Gittelman, R. & Klein, D.F. (1984) 'Relationships between separation anxiety and panic and agoraphobic disorders' Psychopathology (Supplement) vol. 17 ps 65-65.

Marks, I.M. (1987) 'Fears Phobias and rituals: Panic, anxiety and their disorders' New York: Oxford University Press.

McNally, R.J. (1987) 'Preparedness and Phobias: A review' Psychological Bulletin  vol. 101 ps283-303.

Meichenbaum, D, (1976) 'Towards a cognitive theory of self control' In Schwartz, G.E. & Shapiro, D. (Eds) 'Consciousness and self regulation: Advances in research' vol. 1 New York: Plenum.

Sarason, I.G. & Sarason, B.R. (1989) 'Abnormal Psychology' Englewood Cliffs N.J.: Prentice Hall

Torgersen, S. (1979) 'The nature and origin of common phobic fears' British Journal of Psychiatry, vol. 134 ps 343-351.

Woodruff ,R.A. Jr, Godwin, D.W. & Gruze, S.B. (1974) 'Psychiatric Diagnosis' New York: Oxford University Press.

Youell, K.J. & McCullough, J.P. (1975) 'Behavioural treatment of mucous colitis' Journal of consulting and clinical psychology vol. 43 ps 740-745.