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Phobia: Fear is exclusively triggered by harmless situations/objects.

• The mere thought of the situation/object can generate anticipatory anxiety.
• In severe cases, the phobic fear can be panic-like when panic attacks occur.
• The phobic situation/object is avoided.

Specific Phobia: The fear relates to situations/objects that are located "outside" the person. Examples of specific phobia:

• Fear of public toilets.
• Fear of blood or injuries.
• Fear of thunder.
• Fear of darkness.
• Fear of blushing (Erythrophobia).
• Fear of exams.
• Fear of enclosed spaces (Claustrophobia).
• Fear of riding elevators.
• Fear of heights.
• Fear of infection.
• Fear of injections.
• Fear of hospitals.
• Fear of animals.
• Fear of urinating or defecating.
• Fear of poisoning.
• Fear of consuming certain foods.

Hypochondriacal Anxiety: The fear relates to situations/objects that are supposed to be inside the person. Examples of Hypochondriacal Anxiety:

• Nosophobia/Illness phobia: Fear of having a disease.
• Dysmorphophobia: Fear of physical disfigurement/abnormality.

Agoraphobia: Fear of leaving one's own house, of open spaces, crowds, public places and transportation, traveling, having no escape route.

• Agoraphobia can become chronic.
• Agoraphobia can be accompanied by a panic disorder.

Social Phobia: These fears occur in social situations, in public, participation in small groups.

Panic Disorder: Panic attacks occur recurrently without another phobia.

Generalized Anxiety Disorder: The anxiety is not limited to specific situations/objects. There are many worries. Generalized anxiety disorder tends to become chronic. Therefore, psychotherapy is very important.

Behavioral therapy for panic in Hamburg Altona Ottensen & Psychotherapy Hohwacht Plön Holstein A panic attack (anxiety attack) has all of the following characteristics:

• It is a single episode of intense fear of present or assumed danger
• It begins abruptly
• It reaches a maximum within a few minutes and lasts at least several minutes

The following symptoms may be present:

• Fear of loss of control
• Fear of dying
• Fear of going crazy
• Breathing difficulties
• Feeling of tightness
• Dizziness
• Chest pain
• Dizziness
• Increased heart rate
• Feeling that objects are unreal (Derealization)
• Feeling that one is not really here (Depersonalization)
• Numbness
• Heart palpitations
• Hot flashes
• Cold shivers
• Tingling sensations
• Dry mouth
• Nausea
• Palpitations
• Weakness
• Sweating
• Tremor
• Restless feeling in stomach or chest
• Insecurity

Features:

• Automatic reactions to panic fear are flight, fight or freeze.
• A panic attack is usually followed by constant fear of another anxiety attack.
• Panic attacks can trigger fear of being alone or of public places.
• Rarely, panic attacks occur in post-traumatic stress disorders, triggered by sudden remembering and intense re-experiencing of the trauma.
• Waking from sleep with a panic attack is known with memory in nightmares and without memory in Pavor Nocturnus.
• Generalized anxiety disorders and phobias such as agoraphobia or claustrophobia can appear accompanied by panic attacks, especially when left untreated.

Panic disorder is defined when:

• The anxiety attacks (panic attacks) are recurrently severe
• The anxiety attacks (panic attacks) are not limited to a specific situation or special circumstances or a specific object, often occur spontaneously, they are not predictable, they are not associated with particular exertion, dangerous or life-threatening situations.

People who suffer from a panic disorder have first experienced an "inexplicable" panic attack.

A panic disorder develops due to a feedback process (vicious cycle):

1. After occurrence of a stressor such as:
   • Accelerated breathing (Hyperventilation)
   • Accelerated pulse
   • Drugs
   • Exhaustion
   • Medications
   • Stress
   • Other physical illnesses
2. The mental association of symptoms with danger: an anxious, catastrophic misinterpretation of physical reactions
3. This triggers an increase in arousal.
4. This intensifies the symptoms.
5. This intensifies the fear.
6. This fear intensifies the physical reaction.
7. Flight and avoidance behavior momentarily lead to anxiety reduction, which reinforces the avoidance behavior.

Typical misinterpretations of physical reactions in panic:

• I'm gradually going crazy because my thoughts are racing and I can no longer control them!
• I have a tumor because I feel weak and am shaking!
• I'm going to faint because I feel chest pain!
• I could have a heart attack because my heart is racing!
• I could suffocate because I feel a lump in my throat!

Methods from behavioral therapy expand coping alternatives, whereby the fear/the panic can be confronted and managed. See:

• Anxiety management
• Relaxation techniques.
• Cognitive restructuring
• Self-verbalizations.
• Guided discovery
• Stress inoculation training according to Meichenbaum
• Thought stopping Description:
• First of all, one should calm down, reduce stress.
• It is important to regularly practice a relaxation technique (Autogenic Training, Progressive Muscle Relaxation, Meditation). Learn to connect the relaxation state with a signal (e.g. pressing fingers) that can trigger the relaxation state. Learn to breathe slowly with the abdomen.
• With the help of "Guided Discovery" (through well-thought-out questions. Not instruction!) and "Cognitive Restructuring", the conviction in the above misinterpretations and thinking errors can be reduced in behavioral therapy and replaced with alternative medical explanations. One can discover with relief that one is in fact not suffering from a physical/mental illness!
• With the help of (also suggestive) self-verbalizations one can:
  • calm oneself
  • interpret the situation positively and assess it as safe
  • direct attention: outward/to positive things/to active occupations
• Through behavioral experiments such as sauna, running, spinning, thought stopping, behavioral therapyconfronts the above misinterpretations (and the fear of fear), tests them and supports the discovery of alternative medical explanations.
• Through self-reinforcement training, the effort against anxiety is supported and maintained in behavioral therapy. Setbacks receive an alternative meaning: they are no longer final. New anxiety attacks in everyday life are methodically attended to according to the above connections and discussed in therapy.

Some of the methods and goals applied by behavioral therapy expand the coping alternatives of anxiety management, whereby anxiety / panic / stress can be confronted and managed:

• Relaxation techniques.
• Guided discovery and cognitive restructuring
• Self-verbalizations
• Behavioral experiments
• Self-reinforcement training
• Gradual confrontation of anxiety
• Resource structuring
• Stress inoculation training according to Meichenbaum
• Thought stopping, need perception and fulfillment.
• Assertiveness training for learning to say no and set boundaries.
• Sleep, movement (including sports) and nutrition hygiene.
• Resource structuring

Relaxation techniques:

• First of all, one should calm down, reduce stress: vacation, break, stop!
• It is important to regularly practice a relaxation technique:
  • Autogenic Training
  • Progressive Muscle Relaxation
  • Meditation
• Learn to connect the relaxation state with a signal that can trigger the relaxation state:
  • physical movement or posture
  • mental construct
  • verbalizations
• Learn to breathe slowly with the abdomen.
• Guided Discovery and Cognitive Restructuring
  • With the help of "Guided Discovery" (through well-thought-out questions. Not instruction!) and "Cognitive Restructuring" according to Albert Ellis or Aaron Beck, behavioral therapy can:
  • Reduce the conviction in the above misinterpretations and thinking errors and replace them with alternative medical explanations. One can discover with relief that one is in fact not suffering from a physical/mental illness!
  • Likewise, these methods of behavioral therapy are applied against dysfunctional thinking errors (such as perfectionist, blame-assigning...) that are at the source of self-burdening emotions.
• Self-verbalizations:
  • With the help of (also suggestive –see also hypnosis here–) self-verbalizations (instructions in internal dialogue) one can:
  • Calm and strengthen oneself
  • Interpret the situation positively and assess it as safe
  • Direct attention: outward/to positive things/to active occupations
• Behavioral experiments: Through behavioral experiments such as sauna, running, spinning, thought stopping, role plays, behavioral therapy confronts the above misinterpretations (and the fear of fear), tests them and supports the discovery of alternative medical explanations.
• Self-reinforcement training:
  • Through self-reinforcement training, the effort against anxiety is supported and maintained in behavioral therapy. Setbacks receive an alternative meaning: they are no longer final. New anxiety attacks in everyday life are methodically attended to according to the above connections and discussed in therapy.
• Gradual confrontation of anxiety (also mentally according to Joseph Wolpe) under favorable circumstances enables systematic desensitization of anxiety:
  • Creation of an individual anxiety hierarchy
  • Teaching an anxiety-antagonistic procedure. Learning a relaxation technique.
  • Slow, gradual presentation of mildly anxiety-inducing situations in imagination (also in hypnotic trance with the help of substitute figures), which should evoke a tolerable degree of anxiety. Through the antagonistic effect of simultaneous relaxation, the anxiety is gradually reduced (reciprocal inhibition)
• Resource structuring: Resource structuring: Among other things, with the help of strategies such as problem-solving training according to Goldfried & Zurilla, one structures:
  • Time management
  • Planning
  • Structuring activities
  • Establishing recovery phases
  • Defining realistic goals
  • Setting priorities
  • Delegating tasks.

Do you suffer from a Generalized Anxiety Disorder (GAD)?

Main features of Generalized Anxiety Disorder are:

• Worries
• Anxiety
• Do you believe that something threatening could happen to you?
• Do you focus your attention on danger?
• Do you have excessive, frequent, strong worries/concerns about minor everyday matters?
• Do these worries impair you?
• Is it difficult for you to control your worries?
• Do you feel persistent, diffuse anxiety (anticipatory anxiety)?

Typical accompanying physical symptoms of these worries in Generalized Anxiety Disorder:

• Breathing difficulties
• Feeling of tightness
• Dizziness
• Heart palpitations
• Hot flashes
• Cold shivers
• Lump in throat
• Tingling in stomach
• Dry mouth
• Muscle tension
• Nausea
• Difficulty swallowing
• Pain
• Sweating
• Inability to relax

Typical accompanying feelings/affects/emotions of these worries in Generalized Anxiety Disorder:

• Fear of going crazy
• Fear of loss of control
• Fear of dying
• Tension
• Being startled
• Feeling of dizziness
• Feelings of being keyed up
• Numbness
• Nervousness
• Irritability
• Restlessness
• Weakness
• Insecurity

Typical accompanying thoughts of these worries in Generalized Anxiety Disorder:

• Depersonalization Derealization
• Difficulty falling asleep because of worry
• Concentration difficulties
• Empty feeling in head because of worries

Characteristics of a self-insecure personality:

• persistent and pervasive feelings of tension and worry.
• conviction of being socially awkward, unattractive or inferior compared to others.
• exaggerated worry about being criticized or rejected in social situations
• personal contacts only when there is certainty of being liked
• restricted lifestyle because of the need for physical security
• avoidance of professional or social activities that require intensive interpersonal contact, out of fear of criticism, disapproval or rejection. Topic: inferiority feelings, inferiority complex

Social phobia / social anxiety can manifest as:

• Fear of failure and fear of criticism:
  • Do you not make decisions quickly and confidently?
  • Can you not express criticism easily and openly?
  • Do you almost always try to hide your feelings?
  • Do you not rely on your own judgment?
  • In discussions, do the right arguments only occur to you afterwards?
  • Are you often afraid of appearing ridiculous?
  • Do you always have the feeling of bothering other people when you ask them for information?
  • Do you often have to fight against your shyness?
  • Are you constantly afraid that you might say or do something wrong?
  • When someone criticizes your work, can you no longer accomplish anything?
  • Do you let your decisions easily be overturned by other people?
  • Are you not indifferent to what other people think about you?
  • Do you avoid taking responsibility as much as possible?
  • Is it extremely unpleasant for you to be inappropriately dressed at a social gathering?
  • Do you lack self-confidence?
  • Are you very embarrassed when you are the center of attention?
  • Is it extremely embarrassing for you to arrive late to an event?
  • In the presence of authority figures, are you always confused?
• Contact anxiety:
  • Do you find it difficult to start a conversation with a stranger?
  • Do you find it difficult to tell someone that you like them?
  • When you are invited to a stranger's house, do you feel inhibited the whole time?
  • In the presence of the opposite sex, are you shy?
• Unable to assert oneself:
  • When someone interrupts you, do you not ask them to let you finish speaking?
  • Can you not assert your demands?
  • Do you tend to apologize for everything?
  • Can you not demand appropriate payment for your work?
  • Are you too polite to complain about bad food in a restaurant?
  • Do you hardly dare to express your own wishes?
  • Is it unpleasant for you to take up a saleswoman's time for long?
  • When you are ridiculed, can you no longer respond at all?
  • Is it almost impossible for you to demand a raise?
  • Do you find it difficult to complain about incorrect bills?
  • When your supervisor unjustly reprimands you, can you not defend yourself?
• Unable to say no:
  • Do you always swallow your anger?
  • Is it impossible for you to argue with people who are close to you?
  • Do you refrain from everything that could provoke contradiction?
  • In disagreements, are you always the first to give in?
  • Do you not immediately express your anger when a friend unjustly criticizes you?
  • Do you tend to give in rather than start an argument?
  • Do you never dare to openly say what you don't like about others?
  • Do you avoid unpleasant confrontations as much as possible, even when they would be necessary?

Social Phobia: Diagnostic Criteria: A) Either 1. or 2.:

1. Marked fear of being the center of attention or of behaving in an embarrassing or humiliating way;
2. marked avoidance of being the center of attention or of situations in which there is fear of behaving in an embarrassing or humiliating way. These fears occur in social situations such as eating or speaking in public, meeting acquaintances in public, joining or participating in small groups, such as at parties, conferences or in classrooms.

B) At least once since the onset of the disorder, at least two anxiety symptoms from the list below (one of the symptoms must be one of items 1. to 4.) must have been present together at some point in the feared situations:

1. Palpitations, heart pounding or increased heart rate
2. Sweating
3. Fine or coarse tremor
4. Dry mouth
5. Breathing difficulties
6. Feeling of tightness
7. Chest pain or discomfort
8. Nausea or abdominal discomfort (e.g., feeling of restlessness in the stomach)
9. Feeling of dizziness, insecurity, weakness or lightheadedness
10. Feeling that objects are unreal (derealization) or that one is far away or "not really here" (depersonalization)
11. Fear of loss of control, going crazy or "flipping out"
12. Fear of dying
13. Hot flashes or cold shivers
14. Numbness or tingling sensations

plus at least one of the following symptoms:

• Blushing or trembling,
• Fear of vomiting,
• Urge to urinate or defecate or fear of it.

C) Marked emotional distress due to the anxiety symptoms or avoidance behavior. Insight that the symptoms or avoidance behavior are exaggerated and unreasonable. D) The symptoms are restricted exclusively or primarily to the feared situations or to thoughts about them. E) The symptoms of criterion A. are not caused by delusions, hallucinations or other symptoms of the disorder groups organic mental disorders, schizophrenia and related disorders, affective disorders or obsessive-compulsive disorder, nor are they the result of a culturally accepted view.

Dipl.-Psych. Egon Molineus, Psychological Psychotherapist offers: in Hamburg-Altona-Ottensen & Hohwacht-Ostsee-Holstein a Social Competence Training/Assertiveness Training using Behavioral Therapy Groups.

Dipl.-Psych. Egon Molineus, Psychological Psychotherapist / Behavioral Therapy treats illness anxiety and hypochondria in Psychotherapy Hamburg Altona Ottensen & Psychotherapy Hohwacht Plön Holstein Here follows some information about these psychological burdens and about their treatment within behavioral therapy.

Hypochondria exists when all of the following 3 criteria are met:

• Persistent conviction (for over 6 months) of already suffering from a serious physical illness.
• The constant worry about this conviction causes persistent suffering / disruption of daily life and prompts patients to seek medical treatments / examinations / help from healers.
• Despite medical determination that there is no sufficient physical cause for the physical symptoms, the conviction persists: Acceptance of the doctor's communication at most for a short time.

The persistent fear of being able to contract a serious illness is the main feature of an illness phobia (illness anxiety).

• Reassurance seeking must be stopped.
• Avoidance must be stopped. The illness-phobic vigilance leads to SOMATOSENSORY AMPLIFICATION: the physical sensations are intensified. And thereby the illness anxiety grows.
• BEHAVIORAL EXPERIMENTS should be undertaken within behavioral therapy. During these, it can be observed how the illness-phobic focus on physical sensations leads to their intensification. It should be discovered here that the "threatening symptoms" have an alternative explanation.
• The patient is also encouraged through targeted questions or examples to generate new information themselves. This technique is called Guided Discovery. SELF-OBSERVATION PROTOCOLS: In anxiety-triggering situations, self-observation of dysfunctional thoughts, feelings, actions and physical sensations should be systematically and written down. See above: "Thinking behavior in hypochondria" and "Behavioral actions in hypochondria and illness anxiety".
• These dysfunctional thoughts and actions should be recorded. These contribute to the generation and intensification of discomfort and illness-phobic alarm reactions. In situations that trigger stress-inducing reactions, the physical stress reactions are dysfunctionally interpreted as signs of illness. This reinforces the illness anxiety, the physical stress reactions and the discomfort. A vicious cycle occurs here. All these components should be recorded in writing.
• Training in directing perception toward things that do not signify danger. The illness-phobic directing of attention to body perception intensifies body perception and discomfort: Somatosensory Intensification
• The safety-seeking behavior, the compulsive-phobic health-checking need should be reduced.
• Stress leads to alarm-reactive, physical reactions throughout the entire body. Stressors should be reduced.
• In cases of insufficient information, illness phobia should be replaced by functional reality testing, functional research and specialist medical examination.
• Dysfunctional, illness-phobic compulsive rumination should be replaced by defined behavioral therapy exposures.