Symptoms, Treatment and Support

Obsessive-Compulsive Disorder is characterized by recurrent, unwanted thoughts (obsessions) and/or repetitive behaviors (compulsions). Repetitive behaviors are often performed with the hope of preventing obsessive thoughts or making them go away. Performing these so-called “rituals,” however, provides only temporary relief.

Defining obsessive-compulsive disorder (OCD)

What is obsessive-compulsive disorder (OCD)? Obsessive-compulsive disorder (OCD) is an anxiety disorder characterized by recurrent, unwanted, disturbing thoughts (obsessions) and/or repetitive, ritualized behaviors that a person feels driven to perform (compulsions). Like a needle getting stuck on an old LP, OCD causes the brain to get stuck on a particular thought or action that it just can’t let go. People with OCD often say the symptoms feel like a case of mental hiccups that won’t go away.  

The Obsessive Compulsive Foundation reports that 1 in 50 adults in the United States currently experiences OCD, and twice as many have experienced it at some point in their lives. Symptoms of OCD occur in people of all ages and may change in severity over time. Most people with OCD have both obsessions and compulsions, but a minority have obsessions alone (about 20 percent) or compulsions alone (about 10 percent). Compulsions generally accompany obsessions as a result of the brain’s attempt to dismiss or neutralize the obsessions.

Understanding obsessions

What are obsessions? Obsessions are involuntary, seemingly uncontrollable thoughts, images, or impulses that occur over and over again in a person’s mind. The person does not want to have these ideas, finds them disturbing and intrusive, and usually recognizes that they don’t really make sense. They commonly crop up when someone is trying to focus on an intentional thought or activity.

People with OCD may worry excessively about dirt and germs and be obsessed with the idea that they are contaminated or may contaminate others. Or they may have obsessive fears of having inadvertently harmed someone else (perhaps while pulling the car out of the driveway), even though they usually know this is not realistic. Obsessions are accompanied by uncomfortable feelings, such as fear, disgust, doubt, or a sensation that things have to be done in a particular way.

Some common obsessions include:

Understanding compulsions

What are compulsions? A compulsion is a repetitive behavior – a ritual – that a person feels driven to do and cannot seem to stop doing. Compulsions represent an attempt to manage an obsession by doing something to resolve it. For example, if someone is obsessed with being contaminated, that person might develop elaborate hand-washing rituals. If an obsessive worry is whether or not the door was locked, then a compulsive response might be to check the lock a certain number of times before leaving the house or going to bed.

The ritual is meant to bring relief from the anxiety caused by the obsession, though the ritual itself can cause anxiety if it becomes too demanding or time-consuming. Even if the ritual eases the discomfort caused by the obsession, it will probably return, and the person with OCD feels compelled to repeat the behaviors over and over again.

Some common compulsive behaviors are:

Signs and symptoms of obsessive-compulsive disorder (OCD)

What are the signs and symptoms of obsessive-compulsive disorder (OCD)? Most people, from time to time, go back and double-check that the iron is unplugged or the door is locked before leaving the house. That’s normal, but when someone worries constantly that the door is unlocked and makes a ritual out of checking the lock 40 times before being able to get in the car, that’s an indication that the person’s thoughts and behaviors have risen to the degree of obsessive-compulsive disorder (OCD). The adult with OCD recognizes his or her repetitive thoughts and behaviors as irrational but feels unable to break free from them.

OCD may be diagnosed when compulsive behaviors take up excessive time (an hour or more a day), begin to interfere with your normal activities, or cause great anxiety because they’re so demanding.

While the onset of obsessive compulsive disorder usually occurs during adolescence or young adulthood, younger children can manifest symptoms of OCD by showing the same behaviors adults with OCD exhibit.

It’s often misdiagnosed in youngsters and adults as another condition such as autism or is overlooked because it occurs with other disorders, such as depression, eating disorders, attention deficit disorders or Tourette’s syndrome. In addition, OCD is often underdiagnosed because people with OCD may feel embarrassed by their thoughts and behaviors and try (often successfully) to hide the signature behaviors of their condition or because they lack access to effective health care. On average, people with OCD see three to four doctors and spend over nine years seeking treatment before they receive a correct diagnosis. Studies have also found that it takes an average of seventeen years from the time OCD begins for people to obtain appropriate treatment.

Causes of obsessive compulsive disorder (OCD)

What are the causes of obsessive compulsive disorder (OCD)? Doctors aren’t certain of the causes of OCD. Many believe that all anxiety disorders are associated with feeling a lack of control that can be traced to the experience of insecure attachment in infancy and early childhood. The experience of insecure attachment can effect changes in the brain and also account for how the disorder  may occur across generations in one family.

There is evidence that the brains of people with OCD are different from people who do not have the disorder. Recent research suggests a link between OCD and how the brain chemical serotonin is distributed among the brain’s synapses. One group of scientists using PET scans noted inappropriate activity in the basal ganglia of the brains of people with OCD. What doctors do know is that OCD is a medical disorder; it isn’t the fault of the person with OCD or the result of a weak or unstable personality.

Other factors that may influence the onset of OCD include:

• Genetics: Links are still being studied, but the disorder does sometimes run in families, and identical twins have a 70 chance of sharing the disorder.
• Becoming a mother: A woman may sometimes develop OCD or see a mild condition worsen after having a baby.
• Illness may intensify fears about health and cleanliness and increase the compulsive activities associated with those fears, and abuse may lead to obsessions about violence or danger.
• Major life changes: problems in work or school, changes in residence, relationship changes and other major life transitions can create new worries, fears and obsessions or stir up old feelings.
• Streptococcal infection:  Recent studies have shown that a streptococcal infection may trigger OCD in children.

Treatment and help for obsessive-compulsive disorder (OCD)

What treatment is available for OCD? OCD is not usually curable, but it is highly treatable, in that effective treatment can greatly reduce the occurrence of obsessive thoughts and compulsive rituals. A combination of behavior therapy and medication seems to offer the best long-term improvement.

Exposure Treatment and Response Prevention

A type of behavioral therapy called exposure and response prevention is generally the first line of treatment for OCD.  In this treatment, you are repeatedly exposed to the source of your obsession. Then you are prevented from engaging in whatever compulsive ritual you use to reduce the anxiety brought about by your obsession. For example, if you are a compulsive hand washer, you might be asked to touch the door handle in a public restroom and then be prevented from washing up. As you sit with the anxiety, the urge to wash your hands will gradually begin to go away on its own. In this way, you learn that you don’t need the ritual to get rid of your anxiety.

Exposure treatment and response prevention is carefully planned out and controlled, with your therapist at your side to provide support. You will begin with a situation that provokes only a low level of anxiety. Once you’ve been exposed to this situation and have waited out the anxiety without engaging in your compulsion, you will move on to a more challenging situation. Continuing with the previous example, you might progress from touching the bathroom door handle to touching the toilet flush lever or even the toilet seat itself. With each successful exposure and response prevention, you’ll feel a greater sense of control over your obsessions and compulsions. Studies show that exposure and response prevention can actually “retrain” the brain to function differently, permanently reducing the occurrence of OCD symptoms. This type of behavioral therapy can even extinguish compulsive behaviors entirely.

Introduction

All babies cry, especially in the first few weeks after birth. They cry when they need something, but it does not always mean that something is wrong.

Sometimes it may be obvious why your baby is crying, for example, they may have soiled their nappy, want to feed or just need a cuddle. Other times, it can be more difficult to work out why they are crying. Finding out why your baby is crying is often a matter of working through all the possible options.

When a baby cries, it can be distressing for parents and carers. A crying baby can make you stressed and disturb the amount and quality of sleep you get. It is very important to give yourself some time out if you are faced with a baby who will not stop crying.

If your baby’s crying seems abnormal in any way (such as a very high-pitched cry, or a whimper), then seek medical advice. Crying can sometimes be a sign that your baby is unwell. Trust your instincts - you know your baby best. If in doubt, call NHS Direct on 0845 4647, where a trained nurse advisor will be able to assess your baby.

Causes

Because babies cannot talk, they use crying as a way of expressing themselves, and communicating their needs. Sometimes it can be hard to work out why your baby is crying. However, there are some common causes, which include:

• hunger,
• thirst,
• wet or soiled nappy,
• tiredness,
• trapped wind,
• being too hot or cold,
• loneliness (wanting bodily contact or your attention),
• boredom,
• being uncomfortable (such as clothing or covers being too tight), or
• being over-stimulated (such as too much noise or activity).

Colic

Colic is a very common condition in newborn babies, and usually begins a few weeks after birth. It can make babies not want to feed. Another sign of colic is when your baby pulls up their knees towards their chest. Babies with colic tend to have a loud, high-pitched cry, and are often very difficult to calm.

The cause of colic is not known. Some research has suggested that indigestion plays a role.

Other research argues that it occurs because in the first few weeks of life, your baby’s digestive system is still developing. Sometimes, the developing digestive system becomes sensitive to certain substances found in breast and formula milk, such as lactose (a natural sugar).

When to seek medical attention

Within a few weeks you will often start to recognise what your baby’s crying means. If you are concerned about the way your baby is crying, or their crying seems unusual then you should contact your GP, or call NHS Direct on 0845 4647.

Your baby’s cry can sometimes be a sign that they are unwell. If you suspect your baby is ill, look for other signs and symptoms, such as a high temperature, pale skin, sickness or diarrhoea. Always trust your instincts. If you think your baby is unwell, make sure you seek medical advice.

Recommendations

When your baby cries, it can be stressful for both you and your child. Sometimes, you will know what their cry means, and you can take the appropriate action. On other occasions, you may find it more difficult to stop your baby is crying.

The first step is to rule out all of the common causes of crying, such as hunger, or a soiled nappy (see ’causes’ section). If feeding or nappy changing does not help, then there are a number of other things you can try.

• Keep your baby close - try using a baby carrier or sling, so that you can maintain bodily contact.
• Give them something to suck - whether it is your breast, bottle, (clean) fingers or a dummy, sucking can often be very reassuring and settling for a baby.
• Play them some music - you could try playing some soothing, relaxing music. If this doesn’t work, you could try singing a song or lullaby. Some babies like background noise, like a washing machine, or vacuum cleaner.
• Give them a bath - a warm bath can often soothe a crying baby. Make sure you always check the temperature of the water beforehand.
• Move them around - gently rocking or bouncing your baby may help. Taking your baby out in the car or in their pram can also help.
• Get some fresh air - this can help both you and your baby. It will help you to feel less stressed, and it might soothe your baby too.
• Getting into a routineTry to avoid over-stimulating your baby with too much activity or new experiences, because this can make them restless and more prone to crying.

  Instead, it is best if you can try and introduce some sort of routine for your baby, such as a regular evening bath time and a quiet bedtime. This should help reassure your baby, and eventually may help them to cry less. Be aware that it can take approximately 12 weeks for your baby’s brainwave patterns to settle into a regular routine.

  Colic

  Sucking can give relief to babies with colic - you may wish to try offering your (clean) little finger, or a sterilised dummy.

  There are medicines available for the treatment of colic, which either work to ‘mop up’ tiny bubbles of trapped wind in the gut or break down the lactose in the milk to aid digestion. However, success is varied and the colic may not stop until your baby’s digestive system matures at around three to four months.

  Take a break

  It can be stressful and exhausting when your baby cries, particularly if your sleep is frequently being disturbed.

  If you have tried your best to comfort your baby, and you are confident that their crying or behaviour does not seem unusual; it is fine to leave your baby for a brief period, as long as they are safely in their crib or cot.

  You could try going into another room to watch television, listen to music or to practise some breathing or stretching exercises. If you feel it is best, you can check on your baby at regular intervals, to check they are still okay, and are not displaying any signs of abnormal crying or behaviour.

  Although it may seem difficult, it is still important that you have time to yourself when you are bringing up a baby. Where possible, ask a trusted family member or friend to help you out, even just for an hour. This will give you time away from the stress of the situation, and will help you return in a more relaxed state of mind.

  Dealing with stress and anger

  If your baby’s crying is making you feel stressed to the point where you are getting angry or are about to lose your temper; take a break. Leave your baby safely in their crib or cot, close the door, and take time out from the situation to calm down.

Introduction

Eating disorders are a broad group of serious conditions in which you’re so preoccupied with food and weight that you can often focus on little else. The main types of eating disorders are anorexia nervosa, bulimia nervosa and binge-eating disorder, and there are also many subtypes.

Most people with eating disorders are females, but males also have eating disorders. The exception is binge-eating disorder, which appears to affect almost as many males as females.

Treatments for eating disorders usually involve psychotherapy, nutrition education, family counseling, medications and hospitalization.

Signs and symptoms

The signs and symptoms of eating disorders vary with the particular type of eating disorder.

Anorexia nervosa
When you have anorexia nervosa (an-o-REK-se-uh nur-VOH-suh), you’re obsessed with food and being thin, sometimes to the point of deadly self-starvation. You may exercise excessively or simply not eat enough calories.

Anorexia symptoms may include:

• Thin appearance
• Abnormal blood counts
• Fatigue
• Dizziness or fainting
• Brittle nails
• Hair that thins, breaks or falls out
• Soft, downy hair covering the body
• Menstrual irregularities or loss of menstruation (amenorrhea)
• Constipation
• Dry skin
• Frequently being cold
• Irregular heart rhythms
• Low blood pressure
• Dehydration
• Bone loss

Emotional and behavioral symptoms of anorexia may include:

• Refusal to eat
• Denial of hunger
• Excessive exercise
• Flat mood or lack of emotion
• Difficulty concentrating
• Preoccupation with food

Red flags that family and friends may notice include:

• Skipping meals
• Making excuses for not eating
• Eating only a few certain “safe” foods, usually those low in fat and calories
• Adopting rigid meal or eating rituals, such as cutting food into tiny pieces or spitting food out after chewing
• Weighing food
• Cooking elaborate meals for others but refusing to eat them themselves
• Repeated weighing of themselves
• Frequent checking in the mirror for perceived flaws
• Wearing baggy or layered clothing
• Complaining about being fat

Bulimia nervosa
When you have bulimia, you have episodes of bingeing and purging. During these episodes, you typically eat a large amount of food in a short amount of time and then try to rid yourself of the extra calories by vomiting or excessive exercise. In between these binge-purge episodes, you may eat very little or skip meals altogether. You may be a normal weight or even a bit overweight.

Bulimia symptoms may include:

• Abnormal bowel functioning
• Damaged teeth and gums
• Swollen salivary glands in the cheeks
• Sores in the throat and mouth
• Bloating
• Dehydration
• Fatigue
• Dry skin
• Irregular heartbeat
• Sores, scars or calluses on the knuckles or hands
• Menstrual irregularities or loss of menstruation (amenorrhea)

Emotional and behavioral symptoms of bulimia may include:

• Constant dieting
• Feeling that you can’t control your eating behavior
• Eating until the point of discomfort or pain
• Self-induced vomiting
• Laxative use
• Excessive exercise
• Unhealthy focus on body shape and weight
• Having a distorted, excessively negative body image
• Going to the bathroom after eating or during meals
• Hoarding food
• Depression or anxiety

Binge-eating disorder
When you have binge-eating disorder, you regularly eat excessive amounts of food (binge), sometimes for hours on end. You may eat when you’re not hungry and continue eating even long after you’re uncomfortably full. After a binge, you may try to diet or eat normal meals, triggering a new round of bingeing. You may be a normal weight, overweight or obese.

Emotional and behavioral symptoms of binge-eating disorder may include:

• Eating to the point of discomfort or pain
• Eating much more food during a binge episode than during a normal meal or snack
• Eating faster during binge episodes
• Feeling that your eating behavior is out of control
• Frequent dieting without weight loss
• Frequently eating alone
• Hoarding food
• Hiding empty food containers
• Feeling depressed, disgusted or upset over the amount eaten
• Depression or anxiety

Eating disorders in youngsters
Eating disorders can affect people of any age. In children, it’s sometimes hard to tell what’s an eating disorder and what’s simply a whim, a new fad, or experimentation with a vegetarian diet or other eating styles. In addition, many girls and sometimes boys go on diets to lose weight, but stop dieting after a short time. If you’re a parent or guardian, be careful not to mistake occasional dieting with an eating disorder. On the other hand, be alert for eating patterns and beliefs that may signal unhealthy behavior, as well as peer pressure that may trigger eating disorders.

Causes

It’s not known with certainty what causes eating disorders. As with other mental illnesses, the possible causes are complex and may result from an interaction of biological, psychological, family, genetic, environmental and social factors. Possible causes of eating disorders include:

• Biology. Some people may be genetically vulnerable to developing eating disorders. Some studies show that people with biological siblings or parents with an eating disorder may develop one too, suggesting a possible genetic link. In addition, there’s some evidence that serotonin, a naturally occurring brain chemical, may influence eating behaviors because of its connection to the regulation of food intake.
• Psychological and emotional health. People with eating disorders may have psychological and emotional characteristics that contribute to the disorder. They may have low self-esteem, perfectionism, impulsive behavior, anger management difficulties, family conflicts and troubled relationships, for instance.
• Sociocultural issues. The modern Western cultural environment often cultivates and reinforces a desire for thinness. Success and worth are often equated with being thin. The media and entertainment industries often focus on appearance and body shape. Peer pressure may fuel this desire to be thin, particularly among young girls.

Risk factors

Certain situations and events might increase the risk of developing an eating disorder. These risk factors may include:

• Gender. Teenage girls and young women are more likely than teenage boys and young men to have eating disorders.
• Age. Although eating disorders can occur across a broad age range — from preadolescents to older adults — they are much more common during the teens and early 20s.
• Family influences. People who feel less secure in their families, whose parents and siblings may be overly critical, or whose families tease them about their appearance are at higher risk of eating disorders.
• Emotional disorders. People with depression, anxiety disorders and obsessive-compulsive disorder are more likely to have an eating disorder.
• Dieting. People who lose weight are often reinforced by positive comments from others and by their changing appearance. This dieting may be taken too far and lead to an eating disorder.
• Transitions. Whether it’s heading off to college, moving, landing a new job or a relationship breakup, change can bring emotional distress. One way to cope, especially in situations that may be out of someone’s control, is to latch on to something that they can control, such as their eating patterns, which can eventually lead to an eating disorder if taken to an extreme.
• Sports, work and artistic activities. Athletes, actors and television personalities, dancers, and models are at higher risk of eating disorders. Eating disorders are particularly common among ballerinas, gymnasts, runners and wrestlers. Coaches and parents may unwittingly contribute to eating disorders by encouraging young athletes to lose weight.
• Media and society. The media, such as television and fashion magazines, frequently focus on body shape and size. Exposure to these images may lead some people to believe that thinness equates to success and popularity.

When to seek medical advice

Because of its powerful pull, an eating disorder can be difficult to manage or overcome by yourself. Eating disorders can virtually take over your life. You may think about food all the time, spend hours agonizing over options in the grocery store, and exercise to exhaustion. You also may have a host of physical problems because of your eating disorder, such as irregular heartbeats, fatigue, bowel troubles and dizziness. You may feel ashamed, sad, hopeless, drained, irritable and anxious.

If you’re experiencing any of these problems, or if you think you may have an eating disorder, you’d probably benefit from a medical evaluation. Remind yourself that you’re not actually in control anymore — the eating disorder is. When everything revolves around what you eat and how you look, it’s difficult to take part in normal activities and live life to its fullest. You may not even be able to enjoy a simple meal with family and friends.

Unfortunately, many people with eating disorders resist treatment. If you have a loved one you’re worried about, urge him or her to talk to a doctor. But unless you have legal authority to do so, you can’t force loved ones to get treatment. If you think your child may have an eating disorder, talk to him or her. Your child may not be ready to acknowledge having an issue about food, but you may be able to open the door by expressing concern and a desire to listen. You may also want to consider contacting your child’s doctor about your concerns. You can get a referral to qualified mental health providers for treatment.

Screening and diagnosis

Eating disorders are diagnosed based on signs, symptoms and eating habits. When doctors suspect someone has an eating disorder, they typically run a battery of tests and exams. These can help pinpoint a diagnosis and also check for related complications. You may see both a medical doctor and a mental health provider for a diagnosis.

Physical evaluations
These exams and tests generally include:

• Physical exam. This may include such things as measuring height and weight; assessing body mass index; checking vital signs, such as heart rate, blood pressure and temperature; checking the skin for dryness or other problems; listening to the heart and lungs; and examining your abdomen.
• Laboratory tests. These may include a complete blood count (CBC), as well as more specialized blood tests to check electrolytes and protein, as well as liver, kidney and thyroid function. A urinalysis also may be done.
• Other studies. X-rays may be taken to check for broken bones, pneumonia or heart problems. Electrocardiograms may be done to look for heart irregularities. You may also have a bone density test.

Psychological evaluations
In addition to a physical exam, you’ll have a thorough psychological evaluation. Your doctor or mental health provider may ask you a number of questions about your eating habits, beliefs and behavior. The questions may focus on your history of dieting, bingeing, purging and exercise. You’ll explore how you perceive your body image and how you think others perceive your body image. You may also fill out psychological self-assessments and questionnaires.

Diagnostic criteria
To be diagnosed with an eating disorder, you must meet criteria spelled out in the Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric Association. Each eating disorder has its own set of diagnostic criteria. Your mental health provider will review your signs and symptoms to see if you meet the necessary diagnostic criteria for a particular eating disorder. Some people may not meet all of the criteria but still have an eating disorder and need professional help to overcome or manage it.

Complications

Eating disorders cause a wide variety of complications, some of them life-threatening. The more severe or long lasting the eating disorder, the more likely you are to experience serious complications. Complications may include:

• Death
• Heart disease
• Depression
• Suicidal thoughts or behavior
• Absence of menstruation (amenorrhea)
• Bone loss
• Stunted growth
• Nerve damage
• Seizures
• Digestive problems
• Bowel irregularities
• Tooth decay
• Ruptured esophagus
• High blood pressure
• Type 2 diabetes
• Gallbladder disease

Treatment

Eating disorder treatment depends on your specific type of eating disorder. But in general, it typically includes psychotherapy, nutrition education and medication. If your life is at risk, you may need immediate hospitalization to stabilize your health. You may have a treatment team of medical doctors, mental health providers and dietitians.

Psychotherapy
Individual psychotherapy can help you learn how to exchange unhealthy habits for healthy ones. You learn how to monitor your eating and your moods, develop problem-solving skills, and explore healthy ways to cope with stressful situations. Psychotherapy can also help improve your relationships and your mood. A type of psychotherapy called cognitive behavioral therapy is commonly used in eating disorder treatment. Family therapy and group therapy also may be helpful for some people.

Nutrition education
Dietitians and other health care providers can offer information about a healthy diet and help design an eating plan to achieve a healthy weight and healthy-eating habits. If you have binge-eating disorder, you may benefit from medically supervised weight-loss programs.

Hospitalization
If you have serious health problems or if you have anorexia and refuse to eat or gain weight, your doctor may recommend hospitalization. Hospitalization may be on a medical or psychiatric ward. Some clinics specialize in treating people with eating disorders. Some may offer day programs, rather than full hospitalization. Specialized eating disorder programs may offer more intensive treatment over longer periods of time.

Medications
Medication can’t cure an eating disorder. However, medications may help you control urges to binge or purge or to manage excessive preoccupations with food and diet. Medications such as antidepressants and anti-anxiety medications may also help with symptoms of depression or anxiety, which are frequently associated with eating disorders.

Prevention

Although there’s no sure way to prevent eating disorders, some steps may help. Pediatricians may be in a good position to identify early indicators of an eating disorder and prevent the development of full-blown illness. They can ask children questions about their eating habits and satisfaction with their appearance during routine medical appointments, for instance. Make sure children attend well-child doctor visits. These visits should include checks of body mass index and weight percentiles. Those checks can provide an early warning about overeating or undereating.

Family dining habits may also influence the relationships children develop with food. Try to eat at least some meals together as a family. Teach children about the pitfalls of dieting, and encourage healthy eating. If your child has symptoms of anxiety, depression or other mood disorders, seek medical care.

Parents and other adults also can cultivate and reinforce a healthy body image in children of any shape or size. Talk to children about their self-image and offer reassurance that body shapes can vary. Don’t allow children to be teased about their appearance. And encourage your own children or family members to refrain from joking about other children or adults who are overweight or have a large body frame. These messages of acceptance and respect can help build healthy self-esteem and resilience that will carry children through the rocky periods of adolescence.

In addition, if you notice a family member or friend with low self-esteem, severe dieting, frequent overeating, hoarding of food or dissatisfaction with appearance, consider talking to him or her about these issues. Although you may not be able to prevent an eating disorder from developing, reaching out with compassion may encourage him or her to seek treatment.

Self-care

When you have an eating disorder, taking care of your health needs often isn’t one of your priorities. But proper self-care can help you feel better during and after treatment and help maintain your overall health.

Try to make these steps a part of your routine. But don’t beat yourself up if you aren’t able to do so every day:

• Stick to your treatment plan. Don’t skip therapy sessions and try not to stray from meal plans.
• Talk to your doctor about appropriate vitamin and mineral supplements to make sure you’re getting all the essential nutrients.
• Don’t isolate yourself from caring family members and friends who want to see you get healthy and have your best interests at heart.
• Talk to your health care providers about what kind of exercise, if any, is appropriate for you.
• Read self-help books that offer sound, practical advice. Consider discussing the books with your health care providers.
• Resist urges to weigh yourself or check yourself in the mirror frequently. Otherwise, you may simply fuel your drive to maintain unhealthy habits.

Coping skills

In addition to getting professional treatment for your eating disorder, you can also follow these coping skills:

• Boost your self-esteem. Get involved in activities that interest you and that are personally rewarding. These may include learning a new skill, developing a hobby or participating in a social group in your church or community.
• Be realistic. Don’t accept what some of the media portray about what’s a normal weight and what’s an ideal body image.
• Resist the urge to diet or skip meals. Dieting actually triggers unhealthy eating and makes it difficult to cope with stress.
• Remind yourself what a healthy weight is for your body, especially at times when you see images that may trigger your desire to binge and purge.
• Don’t visit Web sites that advocate or glorify eating disorders. These sites can encourage you to maintain dangerous habits and can trigger relapses.
• Identify situations that are likely to trigger thoughts or behavior that may contribute to your eating disorder so that you can develop a plan to deal with them.
• Look for positive role models, even if they’re not easy to find. Remind yourself that the ultrathin models or actresses showcased in popular magazines often don’t represent healthy bodies.
• Acknowledge that you may not be the best judge of whether your eating habits and weight are healthy.
• Consider journaling about your feelings and behaviors. Journaling can make you more aware of your feelings and actions, and how they’re connected.

Introduction

It’s normal to feel nervous and awkward in some social situations. Going on a first date or giving a presentation may give you that uncomfortable feeling of having butterflies in your stomach, for instance.

For some people, though, common, everyday social situations cause extreme anxiety, fear and self-consciousness, and they may become impossible to engage in. You may go to great lengths and come up with many excuses to avoid dating or giving presentations. You may not even be able to eat with acquaintances or write a check at the grocery store, let alone go to a party with lots of strangers.

With anxiety this extreme, you may have social anxiety disorder. Social anxiety disorder is a chronic mental health condition that causes an irrational anxiety or fear of activities or situations in which you believe that others are watching you or judging you. You also fear that you’ll embarrass or humiliate yourself.

If you or a loved one has social anxiety disorder, take heart. Effective treatment — often with cognitive behavior therapy, medication and positive coping skills — can improve your quality of life and open up new opportunities.

Signs and symptoms

Social anxiety disorder can have emotional, behavioral and physical signs and symptoms.

Emotional and behavioral signs and symptoms of social anxiety disorder include:

• Intense fear of being in situations in which you don’t know people
• Fear of situations in which you may be judged
• Worrying about embarrassing or humiliating yourself
• Fear that others will notice that you look anxious
• Anxiety that disrupts your daily routine, work, school or other activities
• Avoiding doing things or speaking to people out of fear of embarrassment
• Avoiding situations where you might be the center of attention

Physical signs and symptoms of social anxiety disorder include:

• Blushing
• Profuse sweating
• Trembling or shaking
• Nausea
• Stomach upset
• Difficulty talking
• Shaky voice
• Muscle tension
• Confusion
• Palpitations
• Diarrhea
• Cold, clammy hands
• Difficulty making eye contact

Associated characteristics include:

• Low self-esteem
• Trouble being assertive
• Negative self-talk
• Hypersensitivity to criticism
• Poor social skills

Worrying about having symptoms

When you have social anxiety disorder, you realize that your anxiety or fear is out of proportion to the situation. Yet you’re so worried about developing social anxiety disorder symptoms that you avoid situations that may trigger them. And indeed, just worrying about having any symptoms can cause them or make them worse.

Causes

Like many other mental health conditions, social anxiety disorder likely arises from a complex interaction of environment and genes. Researchers continue to study possible causes, including:

• Genes. Researchers are seeking out specific genes that play a role in anxiety and fear. Social anxiety disorder seems to run in families. But it’s not clear whether that hereditary component is related to genetics or to anxious behavior you learn from other family members.
• Biochemistry. Researchers are exploring the idea that natural chemicals in your body may play a role in social anxiety disorder. For instance, an imbalance in the brain chemical serotonin (ser-oh-TOE-nin) could be a factor. Serotonin, a neurotransmitter, helps regulate mood and emotions, among other things. People with social anxiety disorder may be extra-sensitive to the effects of serotonin.
• Fear responses. Some research suggests that a structure in the brain called the amygdala (uh-MIG-duh-luh) may play a role in controlling the fear response. People who have an overactive amygdala may have a heightened fear response, causing increased anxiety in social situations.

Risk factors

Social anxiety disorder is one of the most common of all mental disorders. Up to 13 percent of people in Western countries experience social anxiety disorder at some point in their lives. Social anxiety disorder usually begins in the early to midteens, although it can sometimes begin earlier in childhood or in adulthood.

A number of factors can increase the risk of developing social anxiety disorder, including:

• Your sex. About twice as many women as men have social anxiety disorder.
• Family history. Some research indicates that you’re more likely to develop social anxiety disorder if your biological parents or siblings have the condition.
• Environment. Some experts theorize that social anxiety disorder is a learned behavior. That is, you may develop the condition after witnessing the anxious behavior of others. In addition, there may be an association between social anxiety disorder and parents who are more controlling or protective of their children.
• Negative experiences. Children who experience teasing, bullying, rejection, ridicule or humiliation may be more prone to social anxiety disorder. In addition, other negative events in life, such as family conflict or sexual abuse, may be associated with social anxiety disorder.
• Temperament. Children who are shy, timid, withdrawn or restrained when facing new situations or people may be at greater risk.
• New social or work demands. Meeting new people, giving a speech in public or making an important work presentation may trigger social anxiety disorder symptoms for the first time. These symptoms usually have their roots in adolescence, however.

When to seek medical advice

Feeling shy at parties or nervous about giving a speech doesn’t necessarily mean you have social anxiety disorder. If your fears or anxieties don’t really bother you, you may not need treatment. For instance, you may not like making speeches but you do so anyway without being overwhelmed by anxiety.

What sets social anxiety disorder apart from everyday nervousness is that its symptoms are much more severe and last much longer. Social anxiety disorder disrupts your life, causes you distress and affects your daily activities.

Common, everyday experiences that may be difficult to endure when you have social anxiety disorder include:

• Using a public restroom or telephone
• Returning items to a store
• Interacting with strangers
• Writing in front of others
• Making eye contact
• Entering a room in which people are already seated
• Ordering food in a restaurant
• Being introduced to strangers
• Initiating conversations

Social anxiety disorder symptoms can change over time. They may flare up if you’re facing a lot of stress or demands. Or if you completely avoid situations that would usually make you anxious, you may not have symptoms. Although avoidance may allow you to feel better in the short term, your anxiety is likely to persist over the long term if you don’t get treatment.

Screening and diagnosis

When you decide to seek treatment for symptoms of possible social anxiety disorder, you may have both a physical and psychological evaluation. The physical exam can determine if there may be any physical causes triggering your symptoms.

There’s no laboratory test to diagnose social anxiety disorder, however. Your doctor or mental health provider will ask you to describe your signs and symptoms, how often they occur and in what situations. He or she may review a list of situations to see if they make you anxious or have you fill out psychological questionnaires or self-assessments to help pinpoint a diagnosis.

To be diagnosed with social anxiety disorder, someone must meet criteria spelled out in the Diagnostic and Statistical Manual of Mental Disorders (DSM). This manual is published by the American Psychiatric Association and is used by mental health professionals to diagnose mental conditions and by insurance companies to reimburse for treatment.

Criteria for social anxiety disorder to be diagnosed include:

• A persistent fear of social situations in which you believe you may be scrutinized or act in a way that’s embarrassing or humiliating
• These social situations cause you a great deal of anxiety
• You recognize your anxiety level is excessive or out of proportion for the situation
• You avoid anxiety-producing social situations
• Your anxiety or distress interfere with your daily living

Complications

Left untreated, social anxiety disorder can be debilitating. Your anxieties may run your life. They can interfere with work, school, relationships or enjoyment of life. You may be considered an “underachiever,” when in reality it’s your fears holding you back from excelling. In severe cases, you may drop out of school, quit work or lose friendships.

Social anxiety disorder can also lead to other health problems, such as:

• Substance abuse
• Excessive drinking
• Depression
• Suicide

Treatment

Social anxiety disorder typically persists for life, often waxing and waning. But don’t lose hope. Treatment can help you control symptoms and become more confident and relaxed in social situations.

The two most effective types of treatment are medications and a form of psychotherapy called cognitive behavior therapy. For the greatest effectiveness, they’re often used in combination.

Psychotherapy
Cognitive behavior therapy is the only type of therapy that has been shown to be effective in treating social anxiety disorder. This type of therapy is based on the idea that your own thoughts — not other people or situations — determine how you behave or react. Even if an unwanted situation won’t change — you still have to give a presentation to management, for instance — you can change the way you think and behave in a positive way. In therapy, you learn how to recognize and change negative thoughts about yourself.

Cognitive behavior therapy may also include exposure therapy. In this type of therapy, you gradually work up to facing the situations you fear most. This allows you to become better skilled at coping with these anxiety-inducing situations and to develop the confidence to face them. You may also participate in skills training or role-playing to practice your social skills and gain comfort and confidence relating to others. You may also learn relaxation or stress management techniques.

First choices in medications
Several types of medications are used to treat social anxiety disorder. However, the Food and Drug Administration has specifically approved only three medications, all antidepressants, to treat social anxiety disorder.

Those antidepressants are:

• Paroxetine (Paxil, Paxil CR)
• Sertraline (Zoloft)
• Venlafaxine (Effexor)

Other medication options
Your doctor or mental health provider may also prescribe other medications that haven’t been specifically approved for social anxiety disorder. This is a common and legal practice called off-label use. These medications may include:

• Other antidepressants. You may have to try several different antidepressants to find which one is the most effective and has the fewest unpleasant side effects.
• Anti-anxiety medications. A type of anti-anxiety medication called benzodiazepines (ben-zo-di-AZ-uh-penes) may reduce your level of anxiety. Although they often work quickly, they can be habit-forming. Because of that, they’re often prescribed for only short-term use. They may also be sedating.
• Beta blockers. These medications work by blocking the stimulating effect of epinephrine (adrenaline). They may reduce heart rate, blood pressure, pounding of the heart, and shaking voice and limbs. Because of that, they may work best when used infrequently to control symptoms for a particular situation, such as giving a speech. They’re not recommended for general treatment of social anxiety disorder.

Stick with it
Don’t give up if treatment doesn’t work quickly. You can continue to make strides in therapy over several weeks or months. And remember that finding the right medication for your situation can take some trial and error.

For some people, the symptoms of social anxiety disorder may fade over time, and medication can be discontinued. Others may need to take medication for years to prevent a relapse.

Self-care

Although social anxiety disorder generally requires help from a medical expert or qualified psychotherapist, you can try some self-help techniques to handle situations likely to trigger social anxiety disorder symptoms.

First, assess your fears to identify what situations cause the most anxiety. Apply these techniques to those situations. Practicing these techniques regularly can help you manage or reduce your anxiety. You may need to begin with small steps in situations that aren’t overwhelming.

These techniques include:

• Eating with a close relative, friend or acquaintance in a public setting.
• Making eye contact and returning greetings from others, or being the first to say hello.
• Preparing for conversation. For instance, read the newspaper to identify an interesting story you can talk about.
• Giving someone a compliment.
• Focusing on personal qualities you like about yourself.
• Showing an interest in others. Ask about their homes, children, grandchildren, hobbies or travels, for instance.
• Asking a retail clerk to help you find an item.
• Getting directions from a stranger.

In addition, be sure to keep your medical or therapy appointments, take medications as directed, and talk to your doctor about any changes in your condition.

Coping skills

Coping with social anxiety disorder can be challenging. Having social anxiety disorder can make it difficult for you to go to work or school, to interact with other people, or even to visit the doctor. But maintaining connections and building relationships are key ways to help cope with any mental disorder.

Over time, treatment can help you feel more comfortable, relaxed and confident in the presence of others. In the meantime, don’t use alcohol or illicit drugs to try to get through an event or situation that makes you anxious.

Some positive coping methods include:

• Banishing negative thoughts about yourself
• Practicing relaxation exercises
• Adopting stress management techniques
• Reaching out to people you do feel comfortable around
• Joining a support group
• Engaging in pleasurable activities, such as exercise or hobbies, when you feel anxious
• Getting enough sleep
• Eating a well-balanced diet
• Setting realistic goals

As difficult or painful as it may seem initially, don’t avoid situations that trigger your symptoms. By regularly facing these kinds of situations, you’ll continue to build and reinforce your coping skills.

Over time, doing this can help control your symptoms and prevent a relapse of your condition. Remind yourself that you can get through anxious moments, that your anxiety is short-lived, and that the negative consequences you worry about so much rarely come to pass.

Arachnophobia is the scientific name for the fear of spiders. It is the most common example of an animal-based phobia and many people experience it mildly. For some people it has very intense effects. Different people suffer to different degrees and to those who do not suffer them phobias seem irrational, the afflicted person reacts intensely to the merest sign of the phobia causing animal. It is often difficult, if not impossible, for those of us not suffering to make any sense of what they are experiencing. Phobias can be stimulated by many animals but spiders are the most common source. Phobias do not infer a cowardly or otherwise weak mind, Bowers of the Antarctic, an intrepid explorer of the most inhospitable places on earth was apparently terrified of spiders. People who suffer badly can not even enter a room without having someone else check it for spiders first.

Fear of spiders has a long history, around the time of Christ’s birth parts of Abyssinia were abandoned by the whole population as a result of a ‘plague of spiders’. Amongst primitive peoples fear of spiders occurs irregularly, while many African peoples exhibit a general fear of large spiders most Amazonian Indians don’t. In fact the Piaroa Indians actually eat the larger spiders and consider them a delicacy.

They are not the only ones to do so, throughout European history there are scattered records of individual people who loved, and thus ate, and even delighted in eating, spiders. The French author Reaumur reports a certain young lady who ate all the spiders she could find. There is also written records suggesting that one Maria Schurrman was very fond of them, claiming her birth in the sun sign of Scorpio as justification for her habit. In addition to this the astronomer Lalande is also known to have enjoyed them. However it is mostly women who are recorded as having such epicurean tastes and W. S. Bristowe, author of The World of Spiders reports that although he had already tried eating cooked tarantulas he was surprised by a lady called Miss Jennifer Walker who assured him common British spiders were delicious eaten raw. She ate one after he had turned down the suggestion and he then followed suit. His report continues to tell us that during the after noon they sampled 5 different species.

So much for the love of spiders, it does effect some people, and my experience is that young people are more likely to accept spiders as just another fascinating animal if given the chance. I suspect a part of arachnophobia is a result of our adult alienation from the beauty of the world, and it is a fact that most serious sufferers are middle aged and older. It is also a fact that 9 out of ten recorded suffers are female. This of course may well reflect our social gender expectations in that men find it much harder to admit to being frightened of anything.

Paul Hillyard reports that when 18,000 children were questioned in the 1950s about the animal they liked least the spider came second with 10% of the vote (snakes won). In 1988 the Spider was still second but now the Rat had slipped into first place. In the USA in the 1980s the Cockroach was a clear winner and spiders were way down the list. Theodore Savory analysed the reasons why female school students in England disliked spiders and the 3 most important reasons were spider size, then the black colouration then 3rdly the length of the spiders legs. In the UK nearly 50% of woman and 10% of men admitted to some degree of arachnophobia when questioned. About 3% of people claimed an extreme fear, and the most people claimed some apprehension.

Scientists agree that there are 3 components to a phobia, 1) the experience of fear, 2) physiological responses (sweating, heart-rate etc.), 3) motor responses (immobilisation or flight). However there is little agreement as to where the phobias come from. There is some general agreement that many people seem to inherit at least a predisposition towards experiencing arachnophobia and that otherwise it can be conditioned into people, but apart from this there are a large number of unproven theories as to the causes.

The most accepted form of treatment is aversion or behaviour treatments. These tend to involve a mixture of education and experience, most arachnobobes (in fact most people) have little real knowledge of spiders, learning allows the sufferer to use their own mind to counteract the rising emotions. Familiarisation or experience has a similar effect, giving people the opportunity to gain perceptual evidence of spiders as being basically harmless, to desensitize them. Although the details of all treatments depend on the therapist as well as on the age and experience of the sufferer a large degree of moral support is essential.

WHAT IS DENTAL PHOBIA?

Dental phobia is the serious, often paralyzing fear of seeking dental care. It has been reliably reported that 50% of the American population does not seek regular dental care. An estimated 9-15% of all Americans avoid much needed care due to anxiety and fear surrounding the dental experience. This translates to some 30 - 40 million people so afraid of dental treatment that they avoid it altogether,

In terms of your dental health and overall well-being, this can have serious ramifications. Besides chronically infected gums and teeth which can affect your medical status, your ability to chew and digest can be seriously compromised. Without healthy gums and teeth, your speech can be affected as well. Your self confidence can be compromised if you are insecure about your breath and smile. This can lead to serious limitations in both your social and business environments.

WHY DO I FEAR THE DENTIST?

Dental phobias and anxiety stem from various sources. These can lead to a strongly conditioned fear response. The following are the most common origins of dental fear:

• Previously painful or negative experiences during visits to a dentist’s office. This can even include careless comments made by a dentist or hygienist during a past examination.
• A severe discomfort with feeling helpless and/or out of control in the
  dental situation.
• A sense of embarrassment of your dental neglect and fear of ridicule and/ or belittlement when you present to the dental office.
• Scary anecdotes of negative dental experiences learned vicariously from family and friends.
• Negative, menacing portrayals of dentists in movies, TV, newspapers and
  magazines.
• A sense of depersonalization in the dental process, intensified by today’s necessity for the use of barrier precautions, such as masks, latex gloves and shields.
• A general fear of the unknown.

WHAT CAN I DO ABOUT MY DENTAL FEAR?

The first thing you can do is to realize that your dental fear can be overcome. Fear is a learned behavior which, therefore, can be unlearned. Patient-centered behavior modification that treats you as a whole person, not as a set of teeth can help you overcome your fears. This will obviously take a team approach between you and your dentist and his/her staff. Communication is the key. You must feel comfortable expressing your fears and concerns and have a sense that you are being listened to. If you feel that the Dr. and/or staff is not genuinely concerned and listening, then absolutely feel comfortable with seeking out referrals to other offices. 

You should never compromise the level of communication that you feel is necessary to give you a sense of control over your situation in the dental office. Modern dentistry with a compassionate dental team can be truly painless. You can desensitize yourself to your fears if you take the first step and allow the right team to help you overcome your fears. (Look for a future article on “How to Choose the Right Dentist”)

1. A Sense of Control
   • Explanation and clarification of any and all procedures proposed is your right as a patient. If you have a question about a particular procedure, ask it! 
   • Empower yourself with the knowledge to alleviate fear of the unknown. You should have input into treatment decisions and choices. You should be honest with your dentist regarding how much treatment you think you can tolerate at first. As you build confidence in yourself and trust in the team that is caring for you, the length of your appointment and the amount of work accomplished will increase.
   • A Signaling System should be established allowing you to stop for any reason, whether it be because you need more anesthesia, want to rinse out, or simply need a two second break. The most common signal is raising your hand.
2. Never be Embarrassed
   • If you have been ridiculed in the past for your behavior or if you are embarrassed by your present dental condition caused by your neglect, please express yourself honestly and give your present dentist a chance to understand your concerns and show you that they care. You will be amazed at the wealth of treatment options that you might not have thought were possible. With modern dentistry, it’s never too late to recreate a new smile!
3. Relaxation Techniques
   • If you feel tense in the chair, the easiest way to relax is through forms of physical relaxation. A relaxed body promotes a clear and relaxed mind. The human body cannot be physically relaxed and mentally anxious at the same time! The brain won’t process these feelings simultaneously. Physical relaxation methods are easier to accomplish at first as compared to cognitive ones, so practice forms of physical relaxation first.
   • Examples of physical relaxation are Diaphragmatic Breathing, Progressive Muscle Relaxation, and various methods taught in yoga . There are numerous books and sources for these methods. If you induce relaxation in the presence of the stimuli that normally induces your fears (the dental environment), the fear response will be greatly diminished over multiple exposures and you will gradually desensitize yourself to these fears as you build confidence. The memories of traumatic visits will be replaced with more innocuous ones and this less threatening environment coupled with your relaxation methods will help you eliminate your fears.
4. Distraction
   • As you get more comfortable in the dental environment, you can engage in various distraction techniques that many offices have. The use of a Walkman or Discman is a common technique. Many offices now are equipped with Virtual Reality-like glasses that provide both visual and auditory distraction by allowing you to view videotapes through these glasses while having dental work done. We only suggest using distraction techniques once you have established some trust and confidence because your ability to communicate will be compromised, although it is easy to stop any of these devices if need be.
5. Predictable Pain Control
   • Modern dentistry has many new techniques with regards to the administration of local anesthetics to block any possibility of pain. There are many people who have anatomical or biologic variations that do require more individualized techniques in order to predictably achieve proper local anesthesia. This variation must be respected and communicated to your dentist. All injections should be given slowly. The needle itself is not the major cause of discomfort, but in fact, it is the pressure and volume of the fluids being injected that causes the discomfort. There are also great differences in the types of tissue in various locations, anatomically and from person to person, that must be considered when administering injections. There are even computer-controlled machines that are now available to standardize the injection process and make it more predictable than the conventional hand-held syringe.

COMMUNICATE, EMPOWER YOURSELF WITH KNOWLEDGE AND TAKE CONTROL OF YOUR FEARS!

Dental Anxiety Self-Test

Many people have a high level of anxiety and avoid visiting the dentist. This can cause future dental problems. Below are some questions that, if answered yes, may signify that you have some form of dental anxiety. It is important to note, however, that many new, wonderful products and procedures are available that can make the dental visit a pleasant experience.

• Do you feel slight uneasiness and tension the evening prior to your dental visit, which makes you cancel your dental appointment?
• While waiting in the reception area of the dental office, do you feel nervous about the visit?
• Have you had a prior dental experience that was unpleasant?
• While in the dental chair, do you feel uneasy and anxious?
• Does the thought of having a dental injection make you feel physically ill and tense?
• Does seeing the dentist or dental hygienist’s instruments make you anxious?
• Do you feel embarrassed that the dentist will say you have the worst mouth they have ever seen?
• Do objects placed in your mouth during the dental visit make you panic and feel like you cannot breath correctly?
• Do you feel that your dentist is unsympathetic only with you?

Fear In The Dentist’s Chair

What is the cause of dental phobia? According to a recent study in the British Dental Journal, dental phobia is initiated by a bad experience that unknowingly has become associated with dentistry. 

The study has found that despite the advancement of modern techniques and the use of very effective anesthetics, patients still seem to maintain the same level of anxiety as they did years ago. The proportion was shown to be the same today as it was in the 1930’s, 

Dr. Ruth Freeman of Queens University Dental School in Belfast, wrote the article and explains that if all dental phobia were related to painful experiences from a patient’s life, the condition should have gotten better over the years because of all the advanced techniques available today. This however is not the case and it suggests that dental phobia is brought on by outside experiences which are then related to dental experiences.

There are some techniques for relaxation that a dentist can put into practice for people with such trauma. Patients may be given sedation and be informed about pain control and they may be given the advantage of being able to control their own pain by stopping and starting treatment using hand signals.

A phobia is a form of anxiety disorder in which someone has an intense and irrational fear of certain objects or situations. Anyone suffering from high levels of anxiety is at risk of developing a phobia. One of the most common phobias is claustrophobia, or the fear of enclosed spaces. A person who has claustrophobia may panic when inside a lift, aeroplane, crowded room or other confined area.

Some other phobias, borne from anxiety, include social phobia – fear of embarrassing yourself in front of others – and agoraphobia, which is the fear of open spaces. The cause of anxiety disorders such as phobias is thought to be a combination of genetic vulnerability and life experience. With appropriate treatment, it is possible to overcome claustrophobia or any other phobia.

Symptoms of an anxiety attack
If a person suffering from claustrophobia suddenly finds themselves in an enclosed space, they may have an anxiety attack. Symptoms can include:

• Sweating
• Accelerated heart rate
• Hyperventilation, or ‘overbreathing’
• Shaking
• Light-headedness
• Nausea
• Fainting
• Fear of actual harm or illness.

Specific symptoms of claustrophobia
When in an enclosed space, the signs of claustrophobia may include:

• Inside a room – automatically checking for the exits, standing near the exits or feeling alarmed when all doors are closed.
• Inside a vehicle, such as a car – avoiding times when traffic is known to be heavy.
• Inside a building – preferring to take the stairs rather than the lift, and not because of health reasons.
• At a party – standing near the door in a crowded room, even if the room is large and spacious.
• In extreme cases – for a person with severe claustrophobia, a closed door will trigger feelings of panic.

The catch-22 of avoidance
Once a person has experienced a number of anxiety attacks, they become increasingly afraid of experiencing another. They start to avoid the objects or situations that bring on the attack. However, any coping technique that relies on avoidance can only make the phobia worse. It seems that anticipating the possibility of confinement within a small space intensifies the feelings of anxiety and fear.

The thought of treatment can be frightening
For someone with a disabling phobia, the realisation that this fear is irrational and that treatment is needed can cause further anxiety. Since most treatment options depend on confronting the feared situation or object, the person may feel reluctant.

Support and encouragement from family and friends is crucial. A person trying to overcome a phobia may find some treatment methods particularly challenging and will need the love and understanding of their support people. The therapist may even ask the family members or friends to attend certain sessions, in order to bolster the courage of the person seeking treatment.

Treatment
Treating phobias, including claustrophobia, relies on psychological methods. Depending on the person, some of these methods may include:

• Flooding – this is a form of exposure treatment, where the person is exposed to their phobic trigger until the anxiety attack passes. The realisation that they have encountered their most dreaded object or situation, and come to no actual harm, can be a powerful form of therapy.
• Counter-conditioning – if the person is far too fearful to attempt flooding, then counter-conditioning can be an option. The person is taught to use specific relaxation and visualisation techniques when experiencing phobia-related anxiety. The phobic trigger is slowly introduced, step-by-step, while the person concentrates on attaining physical and mental relaxation. Eventually, they can confront the source of their fear without feeling anxious. This is known as systematic desensitisation.
• Modelling – the person watches other people confront the phobic trigger without fear and is encouraged to imitate that confidence.
• Cognitive behaviour therapy (CBT) – the person is encouraged to confront and change the specific thoughts and attitudes that lead to feelings of fear.
• Medications – such as tranquillisers and antidepressants. Drugs known as beta blockers may be used to treat the physical symptoms of anxiety, such as a pounding heart.

Length of treatment
The person may be treated as an outpatient or, sometimes, as an inpatient if their phobia is particularly severe. Generally, treatment consists of around eight to 10 weeks of bi-weekly sessions.

Where to get help

• Sane Australia Helpline Tel. 1800 187 263
• Your doctor
• Psychologist
• Psychiatrist
• Trained therapist

Things to remember

• A phobia is an intense and irrational fear of certain objects or situations.
• A person who has claustrophobia may panic when inside an enclosed space, such as a lift, aeroplane or crowded room.
• With appropriate treatment, it is possible to overcome claustrophobia or any other phobia.

Phobias are very common – it is believed that at least one person in 10 is affected at some time in their life. And phobias about animals and birds are among the commonest of all. Pigeons, cats and dogs can be a particular problem, because there are so many of them around. A severe phobia about them can be as disabling as any anxiety disorder. Even fear of rats, frogs and snakes, which most people seldom encounter, can be the cause of much misery in certain circumstances. 

Some people become almost prisoners in their own homes for fear of common creatures like cats and dogs, pigeons and other birds.

Some people are convinced that they will have a panic attack and lose control if they even see film of the creature they fear on TV.
   

WHAT EXACTLY IS A PHOBIA?

Anxiety is a human trait and most individuals will have experience of it. Anxiety helps with vigilance, learning and general performance but in excess, it starts to work against us as extreme self-focus and apprehension reduces this attention and performance.  Anxiety at the minor symptom level is familiar to virtually all of us and from Anxiety Care’s experience, this often seems to weigh against an acute sufferer seeking help.  Embarrassment and shame at an ‘over reaction’, perhaps aggravated by the particular blending of emotions (such as anger, shame, guilt or sadness mixing with a dominating fear) that make up their ‘personal anxiety’ keeps the problem hidden and prevents this person from understanding that their response doesn’t mean they are weak, soft or immature.   It is often not understood that anxiety can follow a continuum from mild to acute that leaves some people with ‘liveable’ responses but others deeply disabled.  With animal phobias, the vast majority of people will be at, or close to, the mild end of the line where the problem is, at most, irritating, but in no way affects their everyday lives. This can work against the severe phobic as people experiencing a similar fear at a low level very easily come to believe that the acute sufferer is weak or ‘over reacting’.

Severe anxiety releases adrenaline and other chemicals into our blood, and these speed up our heart-beat, sharpen our senses and heighten our physical powers. These changes prepare us for what is called ‘flight or fight’- either to fight for our lives, or to run for them. A phobia is a disorder in which the body reacts in exactly the same way, and we experience the same feelings of anxiety and fear - but in situations where there is absolutely no need for  ‘flight or fight’.  The part of the mind that controls anxiety has, to all intents and purposes, lost all sense of proportion, and screams `danger!’ when the situation is not threatening in any rational way.    No matter how harmless the feared creature may be, for a severely phobic person the fear reaction is every bit as real as if the cause was a major threat. People with phobias usually realise all too well that their reaction is irrational, but this makes no difference to its effect.

WHAT ARE THE SYMPTOMS OF PHOBIA?

Animal and bird phobias can produce all the unpleasant symptoms of  ‘normal’ extreme anxiety:

 heart palpitations
 feeling sick
 chest pains
 difficulty breathing
 dizziness    
 ’jelly legs’
 feeling ‘unreal’
 intense sweating
 feeling faint   
 dry throat
 restricted or ‘fuzzy’ vision or hearing.

In severe cases, people may feel certain that they are about to die, go mad, or lose control of themselves and injure someone, or do some-thing disgusting and humiliating. Most of all they feel an overpowering urge to ‘escape’ from the situation they are in. They develop an acute fear of repeating these very unpleasant experiences, and this is what starts the phobia: the extreme reaction that is eased by escaping from the situation, which, in turn, proves to that part of the mind that controls anxiety (which has little real ‘sense’) that the extreme response was good and necessary. Of course, these are feelings, not reality. In practice, even the worst panic attacks do not cause any long-term ill-effects, and people simply do not die, go mad, or cause general mayhem in the course of them.

 As said, the level of symptoms that people with phobias experience varies a great deal, from mild anxiety to very severe panic and terror. While some people simply jump a little when they hear a pigeon’s wings fluttering, others can barely cope with the anxiety this brings. Some people who have full-scale panic attacks when a particular animal comes near them, refuse to go anywhere where they might encounter one. Others will not look at any book or magazine that might have photos of the feared creature in them.

In the early stages of an animal or bird phobia, people sometimes try to overcome their fears by brief encounters with the dreaded creature, usually retreating instantly. This avoidance brings a reduction of the tension, and rapidly becomes a habit, so that the next attempt becomes more difficult, and so on until they stop trying to face the problem altogether. Avoiding the situations that make us feel frightened ensures that we become more sensitive to those situations, and so ‘conditions’ us to fear them even more. This is why phobias can be such a big problem. Because we tend to avoid the things we fear, the fear can worsen very rapidly. To recover, we need to put that process into reverse.

The fear reaction is virtually automatic, and very difficult to control. In the early period of human development, it was a useful survival trait: as a soft bodied species surrounded by predators, we needed an instant response that would get us out of trouble, something that would not allow our inquisitive brains to let us linger, looking for the cause.  However, humans learn quickly and we can train ourselves to respond positively to threats, and not to react with terror to things which prove, with experience, to be harmless. Lion tamers, tight-rope walkers, scaffolders and fire-fighters have all learnt to handle potentially dangerous situations safely. If this were not true, we would still be cowering in the backs of caves.
   

WHAT CAUSES ANIMAL PHOBIAS?

It’s hard to be precise, though sometimes an unpleasant experience such as being badly scratched or bitten, or perhaps barked at by a large dog, may trigger it off. Animal bites can be painful, and some carry disease, so we all try to avoid being bitten, but most people can cope with having animals around them without becoming phobic. Few really dangerous wild creatures are found in Britain, and the vast majority of domestic animals are tame and friendly.

Some people no doubt learn their animal phobia from their parents. If father reacts nervously when a pigeon swoops past him, the children may well do so too.  But on the whole, most people find that their phobia develops gradually, or comes and goes over a long period, and that no particular cause or trigger is involved. In any event, it is seldom worth spending a lot of time and energy on ‘rooting out the cause’. The point is to learn to control the phobia.

HOW CAN I OVERCOME MY PHOBIA?

People with phobias have, as said, become ‘conditioned’ to produce the fear reaction in situations that aren’t really dangerous. The best way to counter this is by ‘de-conditioning’: training themselves to react correctly. This is done by gradual exposure to the things they fear, experiencing the fears without running away, and so ‘desensitising’ themselves to that lash of anxiety which insists that only flight is an option. This process needs commitment from the sufferer.  Sometimes anxiety is so high, the person is so sensitised to fear, that he or she cannot contemplate resisting it. Basically, so much energy is going in to avoiding what is seen as an insuperable problem that there is nothing left, or so the person perceives it, for trying to recover. In such a case a short course of anti-anxiety medication might be useful, perhaps a benzodiazepine. This won’t cure the phobia, but it may reduce the physical symptoms to a point where the person concerned feels that countering with desensitising techniques is, at least, feasible.

… we have to learn our irrational fears,  but we can also unlearn them …   

The idea of desensitisation is simple, and it does not necessarily require the help of professionals; but it does call for a fair amount of courage and determination. Family and friends can help make self-treatment much easier to manage, and this is also why many people prefer to join a self-help group where they can obtain support from people who have similar problems.

Anyone who decides to try desensitisation needs to draw up a personal ‘training programme’. This means working out where they are now, and deciding where they want to be at the end, and fitting as many gradual ‘exposure’ steps in between as they need. (Hierarchical steps as it is known in the trade).

1. Fear of dogs

Here is an example of how self-exposure steps for a serious fear of dogs could be  ‘graded’:

 Step 1:     Draw a small rough dog shape on a piece of paper.
 Step 2:     Work up to the biggest and most accurate version you can manage.
 Step 3:     Look at black and white photos of dogs.
 Step 4:     Look at colour photos.
 Step 5:     Look at videos.
 Step 6:     Look at dogs through a closed window.
 Step 7:     Then through a partly-opened window; then open more and more.
 Step 8:     Look at them from a doorway.
 Step 9:    Move further out from the    doorway; then further etc.
 Step 10:    Have a helper bring a dog into a nearby room (on a lead).
 Step 11:    Have the helper bring the dog into the same room, still on a
        lead.

Phobias vary of course so some people might start at steps 6 or 7, or include hard or soft toy dogs in the ‘ladder’, if this seems more appropriate.

It is important to work out what exactly is it about dogs that frightens you. Is it their look? Their sound? The feel of them? The way they move? The idea that they might attack you? Or something else or all of that?  (Dangerous dogs do exist, but they are a small minority. Most dogs are bred to be docile precisely because people want to keep them as pets. Dogs bark but that is part of being a dog and is rarely threatening to humans.)

If you don’t work out the precise nature of your fear, you may waste time trying to overcome something that isn’t a real problem, or delay recovery. This does not mean ‘getting down to the root cause in infancy’ (if there was one), but working out the combination of things about a dog that make you afraid.  For example, if it is noise, you could watch videos with the sound off first. If it is being bitten, make a muzzled dog part of your ‘exposure’ programme.  Working it out, you may then find that it only certain aspects of a dog that bother you and you can then work on that.  As another example: if is it noise and size, you could start with a very small yappy dog, or a large quiet one.  Here you are only approaching one fear at a time, which is often the best way to approach overcoming a phobia.

You should also bear in mind that although phobias tend to strike ‘across the board’ creating a fear of all dogs, or even of all furry or hairy animals, overcoming the fears can be a much more piecemeal process. This does not mean that you have to go through a desensitisation programme with every dog in the neighbourhood, but if you succeed with a soppy spaniel, don’t feel you have failed if you are still at a phobic level with the neighbour’s aggressive Alsatian. Just start again on the Alsatian, at whatever ’step level’ you need. The skill and confidence you built up on the first dog will help you tackle the second much more quickly.

2. Fear of cats

For a cat phobia, a very similar set of steps could be drawn up, just substituting ‘cat’ for ‘dog’ all the way through above. Cats can also be held on a lead, as in Steps 10 and 11, but it would probably be easier to restrain the animal in a cat basket.

As with dogs, you should try to work out what it is about cats that is frightening. Look, sound or feel? Or a combination of these? The way they move or jump? The claws?    And again as with dogs, don’t be downhearted if you learn to tolerate a pretty Siamese sitting on your lap, but are still at a phobic level with the tough-looking ginger tom from across the road. Once you have desensitised yourself to one cat, dealing with the next will be that much easier.
   
NOTE: Cats often seem to choose the person who dislikes them most to sit on. There may be because cats prefer people who sit still, and don’t look them in the eye; and a cat phobic is likely to be virtually rigid and speechless with their eyes fixed on anything but the cat!

3. Fear of mice and rats

It is almost a tradition for people - especially women - to scream at the sight (or the thought) of a mouse, and no doubt many children learn this reaction from their parents. This is strange, because mice are pretty harmless, although they may damage foodstuffs and are generally unhygienic. Like most animals, they are frightened of humans and generally try to keep out of our way.  Rats have a worse reputation, but both rats, mice and rodents like hamsters and gerbils are widely kept as pets because they are easily tamed and make friendly and, in the case of rats, quite intelligent companions.

Few people nowadays come across rats or mice in the wild, but here is an example of the exposure steps that someone with a severe phobia about mice might use:

 Step 1:     Draw a small rough mouse shape on a piece of paper.
 Step 2:     Work up to the biggest and most accurate version you can manage.
 Step 3:     Look at black and white photos of mice.
 Step 4:     Look at colour photos.
 Step 5:     Look at videos.
 Step 6:     Find somebody with a pet mouse (or visit a pet shop).
Get used to looking at caged mice from a distance.
 Step 7:     Get closer and closer over a period.
 Step 8:    Watch someone handling a mouse out of its cage,
first at a distance,  then closer and closer.
 Step 9:    Pick up the mouse in a small cage or box.

You can of course join this list at any point, break steps up into smaller ones; or make up your own. With gradual steps and plenty of practice, you should be able to work right up to actually touching the mouse - and if it is rats or hamsters that you fear, you can draw up a very similar set of steps. As with all phobias, as mentioned, it pays to work out what exactly you fear about mice or rats. It may be the appearance, or perhaps the feel of them. Perhaps it is the darting movements, the twitching noses, the fear of being bitten, or of catching a disease, or of droppings contaminating food in the kitchen. Whatever you work out, those are the aspects of the animal that you should concentrate on in your exposure work.

As said already, phobias tend to strike across the board, so someone who fears mice will probably also feel the same way about rats and other small furry animals. However, recovery is a more piecemeal business as mentioned above, and you may find that you have become perfectly relaxed about pet mice but are still strongly phobic about hamsters, or ‘wild’ mice. If so, don’t be downhearted, but go through the same process with the other animals: it will be much easier second time around.

4. Fear of frogs and toads

The frogs, toads, newts and lizards found in Britain are completely harmless to humans. They are not poisonous, and indeed do not even have teeth, though they do a very good job in the garden, eating slugs and insect pests in large numbers.    As with all such phobias, it is useful to begin by working out what precisely frightens you about these creatures. Is it the appearance? Or the feel? (Frogs are usually cold, smooth and wet to the touch; toads are rough-skinned and cold but dry.) Or the unpredictable way they sometimes jump? Whatever it is, if you are not clear about it you run the risk of spending time and energy trying to overcome something that is not really a problem for you; or as discussed earlier, trying to overcome two phobias at once (for example, touching and jumping) which will make the job harder.

Exposure steps can be very similar to the one we have already suggested for dogs, cats, mice and rats; though this time you may need to find a place where there is a pond and get used to being near it.

5. Fear of snakes

Snake phobia is very common and there is a case for thinking that it may be an instinctive fear that is part of our natural make-up. There are also many myths and legends in which snakes are shown as evil and dangerous,  and this probably influences us as well.    However, the reality is that snakes are now quite rare in Britain,  and few people will ever see one in the wild. We have one native snake which is poisonous, the adder, which lives in dry heath-land areas, but adders are extremely shy, and usually hide when they hear someone coming. Only four people have been killed by adders in this country since the War. In tropical countries it is a different matter: there are many poisonous snakes and they are definitely a threat to life. Snakes, incidentally, are not ’slimy’ as most people imagine, but dry and solid to the touch.

An exposure programme for someone with a severe phobia about snakes should start with thinking about what exactly makes them feel frightened. The steps themselves can then be much the same as for other animal phobias:

 Step 1:     Draw a small rough snake shape on a piece of paper.
 Step 2:     Work up to the biggest and most accurate version you can manage.
 Step 3:     Look at black and white photos of snakes.
 Step 4:     Look at colour photos.
 Step 5:     Look at videos.
 Step 6:     Go to a zoo and look at snakes in their secure glass compartments.
        Start at a distance, then get closer and closer. They can’t get
         you through the glass!
 Step 7:     (You may not feel the need to go on to handle a snake, but            specialist pet shops and some private zoos are the place for
those who do.)

6. Fear of birds

Birds, especially pigeons, are a common object of phobic fears. This is a big problem for those who are affected, because birds are highly mobile, and although they seldom if ever enter a building except by accident, they can appear almost anywhere outdoors at any time. People with severe phobias about birds may find themselves confined to their homes, scarcely daring to open a window or a door in case a bird should swoop down.

As with other phobias, it is important to establish what exactly triggers the feelings of fear. With birds it may be the fluttering wings, the way they move, the way pigeons in particular walk fearlessly towards people, hoping for food. It may be the texture of feathers, or the fear of disease, or indeed any combination of these.

Once this is clear in your mind, you need to work out what you are capable of bearing now, and what you would like to be able to do in the future. A gradual series of self-exposure steps can then be put together, like this one for someone with severe pigeon phobia:

 Step 1:     Draw a small rough pigeon shape on a piece of paper.
 Step 2:     Work up to the biggest and most accurate version you can manage.
 Step 3:     Look at black and white photos of pigeons.
 Step 4:     Look at colour photos.
 Step 5:     Look at videos.
 Step 6:     Look at pigeons through a closed window (if they do not come to your garden, or if you do not have a garden,  get someone to drive you to a place where they congregate).
 Step 7:     Then partly open the window and watch them. Open more and
more,  etc.
 Step 8:    Look at them through an open doorway.    
 Step 9:    Move further out from the door, then further, etc.
       

SOME HINTS FOR SELF-EXPOSURE WORK

The first step in the programme can be very simple - perhaps staying in a situation that can just be managed now, but for a little longer than before.

The steps can be as large or as small as necessary, and big steps can be broken down into smaller ones. But each step should challenge the anxiety a little more than the last.

Don’t be overwhelmed by the size of the task. As a rule, the steps become steadily easier as you work through them.

Don’t expect to be completely free from anxiety before you leave each step and go onto the next - it will go completely in its own time as you progress.

Make sure you work out what exactly about the animal is frightening. Is it the feel of it? Or the noise it makes? Or the way it moves? Is it the fear of being bitten? Or of disease? If you don’t work out the real focus of your fears, you could be wasting time trying to overcome the wrong problem, or be making the work more difficult than it need be.

Reading about animals,  and birds,  including reptiles,  can help.

Do the exercises as often as you can. You are trying to build up positive memories to replace all the bad ones of being beaten by the phobia, and too long a gap between efforts makes this more difficult.

An hour or so at a time and repeating this every day is best. Waiting until you feel ’strong’ or until you cannot avoid it any longer is not a positive approach.
   
Do enough at each step to raise your anxiety. You are trying to get used to a level of physical symptoms that you can manage, and where you are in control.
   
Keep a ’self-exposure diary’ detailing the exposure work you have undertaken and noting down the way you felt about it.

If it is possible to find someone to work with, who can talk to you calmly and positively while you are doing the steps (and not over-sympathising or endlessly asking how bad you are feeling)  this can help.

PANIC

Many people with phobic conditions are terrified of having a panic attack if they should find themselves near the thing they fear (dog, pigeon, frog etc.) and be unable to ‘escape’ quickly enough.

Panic is an very unpleasant experience, and while it is happening it is very hard to think rationally. Typically, people who are panicking feel that they are about to have a heart attack, or go mad, or lose control of their bowels, or run amok and injure themselves and others. The urge to prevent this happening produces a powerful desire to escape from the situation immediately. In reality, the imagined horrors simply do not occur. Anxiety Care has never come across a single instance of someone having a heart attack, stroke, or brain haemorrhage,  or going mad as a result of a panic attack. People don’t collapse or have ‘fits’ during panic either.

The worst that can happen is that they feel faint or dizzy and have to sit down. ‘Losing control’ is very rare. People do not shout and scream, or foam at the mouth, murder children or mow down passers-by during a panic. Even in the few cases where someone has claimed to have lost control, the reality is a little different. One person described to Anxiety Care how she ‘rushed screaming out of the house’ - but it turned out that she had taken the time to close the doors and windows first. Another ‘kicked insanely at the car window to get out’, but thoughtfully removed her shoes first to avoid doing any damage.

Panic is basically an internal event. It may feel as though the mind and body are breaking up, but the truth is that other people seldom even notice when someone is having an attack, especially in a busy place. They are too busy thinking about their own affairs, and even if they see someone run out of the park, they are likely to assume there is a ’sensible’ reason - like being late for a bus. In any event, they will have forgotten all about it in a minute or two.

The boring truth about panic is that although it feels dreadful at the time, and although the overdose of adrenaline and other chemicals can leave a person feeling drained and shaken:

 panic does not cause any permanent harm

 it does not drive people insane

 panic attacks only last a short time,  and then they subside

 they subside irrespective of whether you stay in the `panic situation’ or ‘escape’.

Final notes
If you enlist the help of a friend or family member in the work of overcoming your phobia, read the booklet ‘Self-treatment for Phobias’, available on this website and make sure they read it too. Ensure that the helper has no preconceived ideas about overcoming fears.  Too many people favour the ‘in the deep end’ approach and you do not need to have the object of your terror suddenly waved in your face in the guise of helping.  If your partner is not sympathetic to your plight, don’t choose him or her to help.  Some animal phobics coming to Anxiety Care have detailed partners and family members who have used their phobic fear against them as a means of controlling their behaviour, or simply controlling their lives.  If in doubt about this it is always safer to believe your eyes than your ears.  That is, don’t listen to what a person says he or she is doing; turn off the volume and watch what they are actually doing.

Finally, there are no extra points for getting better the most painful or difficult way.  Choose appropriate steps; small amounts of anxiety are just as effective as large amounts in retraining that part of the brain that controls anxiety reactions.  Never be afraid of breaking up steps into smaller steps if there is a sticking point.  And never, ever use a sticking point as a reason to give up.  The only failure is not trying.

Introduction

Water normally flows into and out of your ears without causing any problems. You can nearly always shower, bathe, swim, and walk in the rain without a problem — which is remarkable, considering how large and deep an opening your ear provides. You’re protected by your ear’s shape, which tips fluid out, and by its lining, which has acidic properties that protect against bacteria and fungi.

When your ear is exposed to excess moisture, however, water can remain trapped in your ear canal. The skin inside becomes soggy, diluting the acidity that normally prevents infection. A cut in the lining of the ear canal also can allow bacteria to penetrate your skin. When this happens, bacteria and fungi from contaminated water or from objects placed in your ear can grow and cause a condition called swimmer’s ear (acute otitis externa, or external otitis).

Swimmer’s ear is an infection of your outer ear and ear canal. It can be associated with a middle ear infection (otitis media) if the eardrum ruptures.

Usually, self-care steps can relieve the symptoms of swimmer’s ear. However, a severe case of swimmer’s ear will require a trip to your doctor.

Signs and symptoms

Signs and symptoms of swimmer’s ear usually appear within a few days of exposure to contaminated water, and may include:

• Severe pain on moving your outer ear (pinna, or auricle) or pushing on the little “bump” (tragus) in front of your ear.
• Pain or discomfort in or around your ear. Usually only one ear is involved.
• Itching of