The following two case studies of phobias illustrate their onset, development, and the various treatment approaches typically used. These studies are fictionalized composites of the experiences of actual clients.
Ellen P. entered an anxiety disorders clinic requesting large amounts of tranquilizers. She revealed that she wanted them to enable her to fly on airplanes; if she could not fly, she would probably lose her job as a sales representative. Ellen described an eight-year history of a fear of flying, during which she had simply avoided all airplane flights and had driven or taken a train to distant sales appointments. She would sometimes drive through the night, keep her appointments during the day, then again drive through the night back to the home office. As these trips occurred more often, she became increasingly exhausted, and her work performance began to decline noticeably.
A review of major childhood and adolescent experiences revealed only that Ellen was a chronic worrier. She also reported flying comfortably on many occasions prior to the onset of her phobia but remembered her last flight in vivid detail. She was flying to meet her husband for a honeymoon cruise, but the plane was far behind schedule because of poor weather. She began to worry that she would miss the boat and that her honeymoon, and possibly her marriage, would be ruined. The plane then encountered some minor turbulence, and brief images of a crash raced through Ellen's mind. She rapidly became increasingly anxious, tense, and uncomfortable. She grasped her seat cushion; her heart seemed to be pounding in her throat; she felt dizzy and was beginning to perspire. Hoping no one would notice her distress, she closed her eyes, pretending to sleep for the remainder of the flight. After returning from the cruise, she convinced her husband to cancel their plane reservations and thus began her eight years of avoiding flying.
Ellen's psychologist began exposure therapy for her phobia. First she was trained to relax deeply. Then she was gradually exposed to her feared stimuli, progressing from visiting an airport to sitting on a taxiing plane to weekly flights of increasing length in a small plane. After ten weeks of therapy and practice at home and the airport, Ellen was able to fly on a commercial airliner. Two years after the conclusion of therapy, Ellen met her psychologist by chance and informed her that she now had her own pilot's license.
In the second case, Steve R. was a high school junior who was referred by his father because of his refusal to attend school. Steve was described as a loner who avoided other people and suffered fears of storms, cats, and now, apparently, school. He was of above-average intelligence and was pressured by his father to excel academically and attend a prestigious college. Steve's mother was described as being shy, like Steve. Steve was her only child, and she doted on him, claiming she knew what it felt like to be in his situation.
When interviewed, Steve sat rigidly in his chair, spoke in clipped sentences, and offered answers only to direct questions. Questioning revealed that Steve's refusal to attend school was based on a fear of ridicule by his classmates. He would not eat or do any written work in front of them for fear he was being watched and would do something clumsy, thus embarrassing himself. He never volunteered answers to teachers' questions, but in one class, the teacher had begun to call on Steve regularly for the correct answer whenever other students had missed the question. Steve would sit in a near-panic state, fearing he would be called on. After two weeks of this, he refused to return to school.
Steve was diagnosed as having a severe social phobia. His therapy included a contract with his teachers in which it was agreed that he would not be called upon in class until therapy had made it possible for him to answer with only moderate anxiety. In return, he was expected to attend all his classes. To help make this transition, a psychiatrist prescribed an antianxiety drug to help reduce the panic symptoms. A psychologist began relaxation training for use in exposure therapy, which would include Steve volunteering answers in class and seeking social interactions with his peers. Steve finished high school, though he left the state university at the end of his first semester because of a worsening of his phobias. His therapy was resumed, and he graduated from a local community college, though his phobias continued to recur during stressful periods in his life.
These cases illustrate many of the concepts related to the study of phobias. In both cases, it is possible that a high emotional reactivity predisposed the person to a phobia. In Ellen's case, the onset of the phobia was sudden and appeared to be the result of Pavlovian conditioning, whereas in Steve's case, the phobia likely developed over time and involved social learning: modeling of his mother's behavior. Steve's phobia may also have been inadvertently reinforced by his mother's attention; thus, instrumental conditioning may have been involved as well. Ellen's phobia could be seen to involve a sense of lack of control, combined with a possibly inherited predisposition to fear enclosed spaces. Steve's phobia illustrated both a spreading of the phobia and recurrence of the phobia under stress.
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