Fear Factors
Understand Your Phobias (Rational or Otherwise).

By Christina Breda Antoniades
Special to The Washington Post
Sunday, August 10, 2008

There are plenty of people who coast across the Chesapeake Bay Bridge without even a flicker of anxiety, never giving a thought to any greater calamity than whether they forgot the sunscreen or made an error in judgment in packing the Speedo.

But for some people, the 4.3-mile span sparks feelings from mild consternation to outright panic. What if the bridge sways or collapses? What if an erratic driver forces them out of their lane and into the drink? Or worse still, what if they completely freak out and in a state of panic accidentally drive themselves into the bay?

Some can't even express exactly what it is that terrifies them; they just know how they feel: heart racing, back of the neck on fire, irresistible urge to flee at the mere mention of the b-r-i-d-g-e.

Of course, it's natural to have a little fear. "Some level of anxiety helps warn us when there's danger or motivates us to behave in a certain way," says Jerilyn Ross, a psychotherapist and director of the D.C.-based Ross Center for Anxiety and Related Disorders. "It's healthy."

In other words, if you're eyeball-to-eyeball with a black widow spider, the desire to run screaming from the room falls under the domain of self-preservation. That's good. But if you spend 20 minutes every morning inspecting your shoes to make sure an eight-legged monster isn't lying inside waiting to bite your big toe, fear has probably crossed the line into the irrational. Not so good.

In fact, if your anxiety is so intense that it causes you to alter the way you live, you might be classified as a having a phobia, an anxiety disorder characterized by intense, irrational fear of an object, situation or person. If so, you have company: About 19 million Americans suffer from specific phobias and 15 million more have a social anxiety disorder (the fear of being scrutinized in social situations and found lacking), according to the Anxiety Disorders Association of America.

People with fears and phobias often have physiological responses (sweating, a racing pulse or trembling, for example) as well as a cascade of thoughts about all the terrible things that are about to befall them. They might fear the actual object or situation (the plane they think is going to crash, for example), but many also feel great anxiety over their own potential responses. "They might feel like they will die, go crazy, pass out or just suddenly go charging out of the room," Ross says.

As intense as it can be, the fear itself isn't the real problem. "People don't lose control. They don't drive off the bridge, or pass out, or have heart attacks," Ross says. "The feeling is real, and it's something you need to address, but it is not harmful."

What is harmful, though, is the behavioral response: when people with phobias change the way they live to avoid the thing they fear. They turn down a job offer because they're afraid of public speaking, they drive long distances because they're afraid to fly, they avoid buildings taller than three floors because they're afraid of heights. "I've had people do everything from sitting low in the back seat to locking themselves in the trunk" to get over the Bay Bridge, says Ross, who adds that the bridge, the Capital Beltway and Metro's dizzying escalators are high on the list of locals' fears. Nationally, common fears include public speaking, snakes, spiders, heights, small spaces and elevators.

What's Wrong With You?

Generally speaking, people with intense fears or phobias know their reactions aren't rational. They're well aware that the plane probably won't crash, the dog won't bite, the elevator won't get stuck. But throwing statistics at them won't help. "They say, 'I don't understand why, but I feel like if I do it, I'll die,' " Ross says.

Just what's behind those feelings isn't always clear, either, but phobias often are not rooted in reality, says Bethany Teachman, assistant professor of clinical psychology at the University of Virginia, who points out that Americans have a greater fear of snakes and spiders than they do of handguns. Given that handguns cause far more deaths in the United States than critters do, the fear doesn't make a lot of sense. "It's kind of like we have a leftover response that once was adaptive," she theorizes. "We're sort of predisposed to become afraid of certain kinds of stimuli that were very threatening to our ancestors."

That said, phobias can also stem from personal experience (the person who gets bitten by a dog and afterward has an intense fear of every dog she sees, for example) or from witnessing or reading about traumatic events (which can also cause post-traumatic stress disorder, another anxiety disorder that can have overlapping symptoms).

"There are a lot of different pathways, but we think a certain person likely has certain vulnerabilities," Teachman says. Those vulnerabilities might be genetic or biological, but they might also be linked to our worldview. "If you see the world as a dangerous place or yourself as vulnerable, then you're likely to let something develop into a full-blown fear," she says. "You're going to interpret things differently than other people would."

That doesn't mean you're crazy or even weird if you have a phobia, Ross says. "You're not weak. There's nothing wrong with you. It just means you probably have an anxiety disorder." To deal with that, many people can take a do-it-yourself approach using a self-help book. Others will need to turn to a professional. Either way, if your fear is affecting your day-to-day life, "it's time to get help," Ross says.

Getting Beyond 'Help!'

If you're deathly afraid of something, the good news is that phobias are highly treatable and treatment is usually relatively quick, effective and lasting (and, better still, many insurance carriers cover treatment). "Generally all people need is eight to 12 sessions to get all the tools and techniques to overcome it," Ross says.

For a phobia such as the fear of spiders (arachnophobia), most people can even see significant benefit from a single three-hour session, Teachman says. And though it might take longer if you've had a phobia for many years, it's never too late to seek treatment. "I've treated a woman who was housebound for 30 years, and within five weeks I had her out and about," Ross says.

For most sufferers, help comes in the form of cognitive-behavioral therapy, which involves examining the thoughts behind the feelings and working to change the behaviors that stem from those thoughts. The therapy often includes learning relaxation techniques. It's sometimes done in conjunction with medication (anti-anxiety drugs or anti-depressants work well for chronic anxiety), but for most phobias, medication isn't a good long-term solution, Ross says.

Instead, therapy usually begins with the cognitive piece of the puzzle, which focuses on examining the messages you send yourself -- "I can't do it, I'm going to pass out, I'm going to die," Ross says -- and then working to change them. Practically, that means that instead of feeling your heart race and thinking, "I'm going to have a heart attack," you replace it with, "My heart is pounding because I'm anxious," and accepting and coping with the feeling, Ross says. She often suggests that patients imagine their fear as a wave. "If you fight it, you end up drinking it," she says. "I use the concept of just floating over it."

That thinking will come in handy during exposure therapy, the behavioral part of cognitive-behavioral therapy that involves gradually exposing yourself to the thing you fear. Doing so helps you realize that the situation, person or thing will not hurt you and, more important, that you can cope with facing your fear. It's a leap of faith, Ross admits, but patients who make the leap do see results.

The key to exposure therapy is the word "gradual." If you're afraid of crowded spaces, don't start by planning an all-day spending spree at the mall on a Saturday afternoon. Instead, pick a time and place that feels manageable, and work your way up. "Hang out in the mall parking lot for a while," Teachman says. "Then, when you're ready, just go into one store and hang out there for a while." Finally, work your way up to a multi-store visit and then a visit during the shopping rush.

As you go, concentrate on increasing your exposure, even if it's only in small increments, Ross says. "If you can't take one step closer, just put a toe closer," says Ross, who had one patient who was so afraid of elevators that she couldn't press the call button. "We started with me touching it and her holding my hand," she says. Eventually the woman graduated to pushing the button alone and, later, to riding the elevator by herself.

During exposure therapy, Ross also has patients label their anxiety level, from zero (no anxiety) to 10 (complete panic). When they hit five, "they're probably thinking catastrophic thoughts," says Ross, who then reminds them to stop.

Although it might be tempting to bow out as your anxiety rises, it's important to push yourself past that I-can't-do-it moment. "The goal is to stay in the situation long enough to see that the feelings will pass," Ross says. "You never want to leave a situation when your anxiety is above a five." Leaving reinforces your fear. But if you do yield to the urge to step back, don't beat yourself up. "Just be sure to go back into the situation as soon as possible," she says.

With enough exposure, most people ultimately realize that the worst case isn't going to happen. "The scale doesn't go to 11," Ross says. "Once you reach a panic attack, it doesn't get worse. And it doesn't go on forever. It's a huge relief for most people to discover that."

Virtual Exposure

Facing your fears, of course, is more practical in some cases than in others. If you're terrified of flying, gradually exposing yourself to an airplane might be helpful, but it's also a logistical nightmare (unless you happen to have your own airplane, in which case, you're probably more afraid of the soaring cost of fuel).

Enter virtual reality, which increasingly is being employed to handle the exposure-therapy piece of the puzzle, says Brenda Wiederhold, a clinical psychologist and director of the Virtual Reality Medical Center, which has three virtual reality centers on the West Coast.

Instead of stepping onto an airplane, a patient can strap on a headset and go through a simulated flight, with a 360-degree view that appears as the head turns. To enhance the experience, there are props: a steering wheel and gas and brake pedals if you're driving, and airliner seats if you're flying.

Unlike in the real world, Wiederhold says, "in the virtual world we can control the stimuli." That means there's no chance of a freak driving accident, a delayed flight or a fire alarm going off in a crowded mall.

There are some whiz-bang benefits, too. Patients can see a readout of their physiological response: their heart rate going up as they "drive" into a tunnel and then decreasing with more exposure, for example. "It improves their confidence and self-efficacy," Wiederhold says.

Compared with traditional cognitive-behavioral therapy, virtual reality is about as effective. In Wiederhold's studies, virtual reality had a 95 percent success rate after six sessions. The catch: There are only about 10 virtual reality centers in the United States, making access an issue.

But even if there isn't a center near you, you probably can find good old-fashioned exposure therapy, Wiederhold says. Your doctor can refer you to a professional (and see the box at left for other ways to find help). Wiederhold's advice: Whether it's virtual or traditional cognitive-behavioral therapy, find somewhere reputable to get help. "Life is short," she says. "Don't wait."