As the phobia becomes worse, even thinking about being in a situation to which one has a phobic reaction can engender panic. As a result, women with agoraphobia often begin to restrict their range of activities and locations. In extreme cases, they may only venture out when accompanied by a trusted friend or relative. Some agoraphobias are even afraid to be alone in their own homes unless a companion remains with them. Luckily, agoraphobia is an easily treated condition if the appropriate therapy is under-taken. A combination of medication, counseling, and stress management training will produce good results in as many as 90 percent of all people suffering from this condition.

Another common type of phobia is social phobia. This occurs when there is fear of performing in front of other people or being scrutinized by other people. The most common social phobia involves public speaking. This is a major issue for many people, including students giving speeches in class, women who must give a formal presentation at work or at social or charitable func-tions, and even professional actors and other performers. Other common social phobias include fear of eating in public, fear of being watched or looked at while at social gatherings, fear of signing documents in front of other people, fear of being photo-graphed in a crowded room, or even fear of blushing in public. These phobias may begin in childhood and can persist throughout adult life (although in many women, social phobias decrease in severity with age). They often develop in children who are more shy and self-conscious.

Many people employ a variety of self help techniques to deal with social phobias, some of which are remarkably effective. For example, professional and amateur speaking groups and organi-zations give people the chance to speak in front of a supportive peer group; this often helps decrease anxiety related to public speaking. Classes on self-image and self-esteem utilize a variety of imaging and assertiveness techniques; these classes tend to be very popular and well-attended. Some women find that they can effectively dispel social phobias when engaged in one-on-one counseling.

A third type of phobia, called simple phobia, involves fear of a particular situation or object. Common examples of simple phobias include fear of animals like dogs or snakes, airplanes (for fear the airplane will crash), heights, or even having blood drawn for a medical test. Many simple phobias originate in childhood and persist into adult life (even though the adult may recognize that they are irrational). They may also originate in a traumatic event, such as being stuck in an elevator or experiencing a near accident during plane travel. A traumatic event may condition a person to fear repeated exposure to a similar situation (e.g., plane travel or using an elevator). Simple phobias are easiest to treat, because the fear response can usually be handled by gradual exposure to the phobia-inducing situation or object as well as the practice of a variety of stress-reducing techniques such as visual-izations and affirmations. These are discussed in the self help section of this book.

Risk Factors for Anxiety Disorders
A variety of factors can predispose a woman to develop anxiety disorders. These include physiological imbalances, genetic factors (familial predisposition), family programming, major long- and short-term life stresses, and personal belief systems.

Physiological Imbalances
Research suggests that women with generalized anxiety disorder may have an imbalance of gamma amino butyric acid (GABA) in their brain. GABA is a neurotransmitter, a substance that transmits messages from one part of the brain to another. When people are given GABA or placed on drugs that increase the activity of GABA, their anxiety is diminished. While the exact mechanism triggering generalized anxiety is not known, it is possible that a GABA deficiency or extreme sensitivity on the part of the body to the available GABA levels may play a role in its etiology. Similarly, panic disorders have been identified as occurring in animals when there is a dysfunction in a specific system in the brain called the noradrenergic system. This system is very sensitive to another neurotransmitter called norepinephrine. When there is a dysfun. tion in the way the noradrenergic system functions, panic attack are triggered.

Genetic Factors (Familial Predisposition)
Genetic factors seem to have some relevance as risk factors for developing anxiety disorders. For example, in studies of identical twins, the likelihood of both twins having an anxiety disorder if one is afflicted is statistically significant (greater than 30 percent) Fraternal twins, who do not have the same genetic makeup, are also at higher risk of developing an anxiety disorder if their sibling is affected, although they do not have nearly the risk of identical twins. Agoraphobia, the most common anxiety disorder also seems to show a familial predisposition. While 5 percent of the entire population suffers from this condition, the rate of agoraphobia in people with one parent who had this diagnosis if 15 to 25 percent.

Family Programming
Certain types of family environments seem to predispose children to develop anxiety disorders, producing insecurity, fear, and dependency in susceptible children. One such setting is created ~ parents who are critical perfectionists, constantly demanding that a child perform at peak levels. In this family, any departure from peak performance is punished or criticized. A child in this situa-tion may grow up with a poor sense of self-esteem, anxious and afraid to take risks for fear of failing.

Parents who themselves have phobias or are overly anxious may also raise children who suffer from anxiety. These parents tend to teach their children that the world is a fearful place, full c danger and risks. This type of family may raise a child who is timid and anxious about meeting new life challenges.

Parents who are overly controlling and suppress a child's self-assertiveness by punishment may engender anxiety in their children. In this environment, children are punished for speaking out and expressing their feelings. Such children may grow up afraid to take initiative or show their true convictions.

Not all children raised in stressful family environments develop anxiety disorders. Many children grow up in very difficult family environments without ever suffering excessive anxiety. The likeli-hood of developing an anxiety disorder when raised in a high-stress family is probably greater in children born with more sensitive and reactive personalities. These are children whose fight-or-flight response is easily triggered by upsetting circumstances.

Major Life Stresses
Women who have suffered from major life stresses over a long period of time, such as marriage to an abusive husband, death, chronic illness in several family members, or constant financial worries, may find their ability to handle stress with equanimity and calm hampered. Unremitting major life stresses are likely to cause wear and tear on the nervous system and, over time, cause a woman to be excessively anxious or tense.

In addition, a major stress occurring in a short period of time can also engender anxiety. This is particularly true when the stres-sor-such as death of a spouse or loss of a long-term job-causes significant life change or dislocation. Even positive experiences such as getting married or having a baby cause anxiety, because they throw people into entirely new situations for which they may have no preparation.

Personal Belief Systems
Many women have belief systems that reinforce the anxiety disor-ders and engender behavior that maintains the anxiety state. These include poor self-image and a low estimate of one's abili-ties. Many women with anxiety disorders are very insecure and feel ill-equipped to make the life changes necessary to confront and change anxiety-related issues.

Women with anxiety disorders often hold a negative view of the world. They see life situations and places as dangerous and threatening, whereas women without anxiety disorders may see the same circumstances as harmless and benign. These negative belief systems about the outside world, if too ingrained, may make it difficult to change.

In addition, women with anxiety disorders often reinforce their own upset through their internal dialogue. A woman who engages in constant fearful and anxious self-talk may anticipate certain sit-uations and people as threatening and dangerous, thus reinforcing her feelings of anxiety. Because we are all constantly dialoguing with ourselves throughout much of the day, negative self-talk can be a big factor in perpetuating anxiety disorders.

In summary, anxiety disorders can take a variety of forms, including generalized anxiety disorder, panic disorder, and pho-bias. Many circumstances can increase the risk of developing an anxiety disorder, such as physiological imbalances, genetic factors, family upbringing, major long- and short-term life stress, and the person's own personal beliefs and negative self-talk, which can keep an anxiety disorder going once it has become an established process. Anxiety disorders can be treated through counseling, stress management techniques and breathing exercises, nutritional therapies, and regular exercise. These are discussed in depth in the self help chapters of this book.

Anxiety Due to Endocrine Imbalances
Many endocrine-related health problems have anxiety and mood swings as major symptoms. These health conditions are discussed in this section.

Premenstrual Syndrome
Anxiety and mood swings are the hallmark of premenstrual syndrome (PMS), one of the most common problems affecting women during their reproductive years (from the teens to the early fifties). In my practice, more than 90 percent of women with PMS complain of heightened anxiety and irritability that increases in intensity the week or two prior to menstruation. Many PMS patients describe severe personality changes-much like Dr. Jekyll and Mr. Hyde. They say they are irritable, witchy, and mean, that they yell at their children, pick fights with their spouses, and snap at friends and co-workers. Some spend the rest of the month repairing the emotional damage done to their relationships during this time.

Because PMS affects one-third to one-half of American women between the ages of 20 and 50 (as many as 10 to 14 million women), it is a common cause of anxiety as well as of other emotional symptoms like depression and fatigue.

In addition to the emotional symptoms, PMS has numerous physical symptoms involving almost every system in the body. More than 150 symptoms have been documented, including headaches, bloating, breast tenderness, weight gain, sugar crav-ing, and acne. However, for many women, the emotional symp-toms and fatigue are the most severe, adversely affecting their family relationships and their ability to work. In addition, it is not unusual for women to have as many as 10 or 12 of the symptoms.

There is no single cause of PMS; medical researchers now believe that various hormonal and chemical imbalances can trigger PMS symptoms. Though it is not entirely known what causes the anxiety symptoms, research suggests that several types of imbalances are likely culprits. One possible cause is an imbalance in the body's estrogen and progesterone levels. Both estrogen and progesterone increase during the second half of the menstrual cycle. Their chemical actions affect the function of almost every organ system in the body. When properly balanced, estrogen and progesterone promote healthy and balanced emo-tions. However, PMS mood symptoms may occur if the balance between these hormones is abnormal, because they have an opposing effect on the chemistry of the brain. Estrogen acts as a stimulant and progesterone has a sedative effect on the nervous system, so if estrogen predominates, women tend to feel anxious and if progesterone predominates, women tend to feel depresses Other examples of the opposing effects of estrogen and proges-terone include the following: estrogen lowers blood sugar, proge sterone elevates it; estrogen promotes synthesis of fats in the tissues, progesterone breaks them down. Thus, when estrogen al progesterone are appropriately balanced, women are more likely to have normal mood and behavioral patterns.