Fear resulting from psychological trauma can be extremely deep-seated. The distress, feelings of helplessness and constant flashback of traumatic events can turn one’s world upside down, causing major problems with daily activities and quality of life. It may be easy for someone to say, “Well, why can’t you just get over it?” But in reality, we need to recognise that it is much easier said than done. In order to help people move past their traumatic experiences, researchers and psychologists have worked tirelessly, creating various therapeutic methods and tweaking them to achieve the optimal recovery outcome. In regards to the treatment of post-traumatic stress disorder (PTSD), you may be familiar with an approach known as Dialectical Behavioural Therapy. In this article, we’ll be introducing you to an alternative psychotherapy technique, also known as Eye Movement Desensitisation and Reprocessing (EMDR).
Developed by Francine Shapiro in 1987, EMDR therapy is an empirically validated treatment for trauma and other negative life experiences. While it is also increasingly applied for the treatment of other mental health conditions such as depression, anxiety or panic attacks, researchers have not found EMDR to be as effective as with trauma-related conditions. As its name suggests, EMDR isn’t all about talk therapy or medications. In a different vein from cognitive behavioural therapy, EMDR doesn’t focus on altering a client’s thought patterns or behaviours. Instead, it relies on one’s own rapid, rhythmic eye movements, allowing the brain to process memories and resume its natural healing process.
What is the Basis of EMDR Therapy?
EMDR is fundamentally based on the Adaptive Information Processing (AIP) Model. A key tenet of this model is that the symptoms of PTSD are manifested due to memories that are dysfunctionally stored or not fully processed. Memories of disturbing experiences often string along negative emotions, thoughts, beliefs and even physical sensations that were associated with them at the time of occurrence. This can bring about a multitude of unpleasant symptoms that can be exceptionally detrimental to one’s mental health.
When one is exposed to stress or trauma, the body’s automatic response would be to activate its Sympathetic Nervous System (SNS). As an adaptive system, it controls our natural fight, flight or freeze instincts, which is critical in ensuring our survival. When the SNS is activated, the individual will undergo physical alterations such as increased heart and breathing rates, decreased blood flow to the digestive system and constricted blood vessels. In addition, hormone levels including those of adrenaline and cortisol will increase dramatically, causing hypervigilance. However, for someone who is under constant stress from traumatic flashbacks, the over-stimulation of the SNS will be greatly damaging to this person’s physical health. As such, EMDR therapy aims to process memories such that the experience is remembered, but the fight, flight or freeze response is eased.
At this juncture, you may be wondering how clinician-directed eye movements could possibly alleviate trauma-induced stress. EMDR therapy involves guiding the client towards reliving triggering experiences in short phases while the clinician directs his eye movements. During the process, the client will be tasked to focus on trauma-related imagery and the relevant sensations. The clinician will then simultaneously move their finger across the client’s field of view, with each phase lasting approximately 20 to 30 seconds. This will then be repeated a couple of times. At some point, other forms of rhythmic left-right stimulation (for example, listening to tones that go back and forth between the left and right sides of your head) will also be incorporated into the therapeutic process. As distressing as it sounds, the process in fact allows for the vividness and emotional triggers of the memory to be reduced over time. When the client’s attention is diverted as they recall the traumatic event, this makes the exposure to negative thoughts and memories less upsetting, hence limiting a strong psychological response. After attending several EMDR therapy sessions (depending on the individual), the impact of the traumatic event is believed to be significantly reduced.
How is EMDR Structured?
Generally speaking, EMDR takes on an eight-phase approach.
Stage 1: History Taking and Treatment Planning
For a start, the clinician will work hand-in-hand with the client to identify the traumatic experiences which require attention. Should the client have a problematic childhood, the initial stage of EMDR may focus on resolving childhood traumas before moving on to resolve adult onset stressors. Identifying targets for EMDR treatment is also crucial – this means looking further into the client’s past memories, their current emotional triggers, as well as what they hope to achieve by the end of the treatment phase.
Stage 2: Preparation
In this phase, the clinician introduces the client to a few emotion-coping strategies to ensure that the client is well able to manage their emotional distress whenever a trigger is brought up. It is important that the client is able to deal with overwhelming emotions even between EMDR sessions in daily life. The clinician may also familiarise the client with the eye movements or bilateral stimulations.
Stage 3: Assessment
The clinician will then identify and assess the specific traumatic memories that need to be tackled. This also involves analysing the associated emotions and sensations triggered by the memories.
Stages 4 to 7: Treatment Process
These intermediate stages focus on the process of desensitisation, installation, a body scan, and seeking closure. The client is asked to concentrate on the trauma-related imagery and memory while engaged in the directed eye movements or other bilateral stimulation. After each set of stimulation, the client will be asked to clear their mind and report what they feel, think, and the sensations they experience. Depending on the individual, the clinician may have the client refocus on the same memory, or move on to another. This process is repeated until the client reports no distress.
Installation is where the clinician works with the client to increase the strength of positive cognition. This means focusing on the preferred positive beliefs, rather than negative ones. For example, an individual dealing with trauma arising from childhood domestic abuse may start off with a negative belief of “I am weak and powerless”. Installation aims to change that belief into one of “I am now in control.” Of course, EMDR does not force one to believe in something that is inappropriate or unsuitable for the situation. In the example brought up, allowing the client to realise that positive belief could mean encouraging them to take on self-defence training, or other skills that can provide them with a greater sense of security and control.
A body scan is used in order to check for any residual somatic response that is linked to event-related tension or stress. Should any undesirable bodily sensations be present, the clinician will then target them specifically in subsequent sets.
Stage 8: Evaluation
The next EMDR session begins with this phase. This stage is mainly for the re-evaluation of the client’s plight. More importantly, this step is to ensure that the necessary progress is made and to review the client’s psychological state. Further review will be carried out, and the relevant changes will be made to provide the optimal treatment effect.
Although EMDR may be a relatively new technique as compared to other forms of therapy, it is nonetheless an extensively researched method proven to alleviate the stress symptoms of trauma survivors and other individuals who have had distressing life experiences. If you think that EMDR therapy is right for you, do seek help from a mental health professional.
So you are going to see a psychologist for the first time – now what should we expect? The thought of having to step into a psychologist’s room for the first time can be nerve-racking, and understandably so. Oftentimes, individuals may be apprehensive and would wonder if talking to a complete stranger is really going to help, or if opening up your innermost thoughts to a stranger was too much of a risk to take. However, rest be assured that these mental health professionals are well-versed in psychotherapy methods to help you manage your issues as best as possible, and will work closely with you at a comfortable pace. Just like in the treatment of physical illnesses by physicians, patient privacy and confidentiality are also primary obligations for psychologists. In this article, we hope to give you a clearer idea of what you can expect from your visit to a psychologist, especially if it is your first session.
First things first, it is important to understand that psychotherapy isn’t merely a one-off session. While the duration of treatment may vary from one person to another, the American Psychological Association (APA) reports that “recent research indicates that on average 15 to 20 sessions are required for 50 percent of patients to recover as indicated by self-reported symptom measures.” The type and duration of treatment also heavily depend on the nature and severity of each client’s conditions, and it would simply be unfair to make an overgeneralised statement. Regardless, it would be beneficial to go in with an open mind, and to have an honest conversation with your psychologist. It really helps to trust that the process works, while acknowledging that it takes time.
Meeting the psychologist
At the beginning, the first few sessions would aim to help one identify the most pertinent issue that needs to be dealt with. The psychologist will talk through with you gathering some information on your life history, your family’s mental health history, the problems you are dealing with, and analyse those details – no matter how insignificant they may seem at first – that could have possibly led to emotional distress or coping difficulties. For the psychologist, being able to get a good grasp of the situation and seeing the big picture is vital for formulating the treatment plan and treatment process, as it will help to determine the type of psychotherapy that is best suited for you. The psychologist is trained to listen and analyse your conditions in order to help you with your recovery. As such, it is equally important that you don’t hold yourself back from being fully honest with your psychologist. To a large extent, the patient’s participation in the therapy is an important determinant of the success of the outcome.
While we fully understand that it can be unnerving, these mental health professionals are trained to help you work through the challenges you face, and the therapy room is very much a safe, non-judgemental space. Goal-setting is one of the key aspects of psychotherapy, and it is exceptionally important to set goals from the start that you can use to track your progress. You may start by identifying personally meaningful broad motives, hopes and dreams – having a clear direction in mind will better steer future sessions towards alleviating symptoms of distress and tackling the root cause of one’s concerns. Don’t worry if you feel the need to change your goals or take a different approach halfway through the treatment process. Psychotherapy is a dynamic process after all, and increased self-discovery along the way can certainly give you a better sense of what needs to be changed.
Different approaches to psychotherapy
There are several approaches to psychotherapy that can be implemented in the following sessions. Not strictly limited to one or the other, psychologists may make use of psychoanalysis and psychodynamic therapies, cognitive-behavioural, interpersonal, and other types of talk therapy. They can help you focus on changing problematic behaviours, feelings, and thoughts to build on healthy habits, or teach you emotion-coping strategies to cope with your symptoms. Forms of treatment like cognitive-behavioural therapy also aim to help individuals recognise negative thought and behaviour patterns, thereby working towards a positive change. Each session is essentially a problem-solving session. By allowing yourself to talk to your psychologist about your most difficult moments, your feelings and the change you want to observe, the psychologist is then able to make use of his/her expertise to assist you. Many mental health professionals don’t limit their treatment to any one approach. Instead, they blend elements from different approaches and tailor their treatment according to each patient’s needs.
To make the most of the treatment process, “homework” may sometimes be assigned as between-session tasks to clients as part of your treatment. A variety of homework assignments exist – sometimes in the form of practising new skills, habits, and other coping mechanisms, or someone who is dealing with complicated emotions could be asked to record your negative thoughts in nightly journal entries. When you return for your next session, the psychologist would then check in on your progress, and address any issues that may have arisen while you were completing your tasks. For some clients the benefits of therapy can be achieved in a few sessions, while for other clients they might need more to improve. Empirical evidence supports the benefits of homework in promoting positive symptom change and increasing patient functioning, that is, the quality of a client’s participation in therapy through active application of what they learn will lead to improvements in their conditions.
Was the psychologist right for you?
Often during the conversation with the psychotherapist, or after the session, you may feel a sense of relief, elation, or anxiety and exhaustion. However you feel, it is important to take note of those feelings. Did the psychologist put you at ease? Did he/she listen to you carefully and demonstrate compassion? Did he/she develop a plan to guide you with your goals and show expertise and confidence in working with issues that you have? For the treatment to be effective, you need to be able to ‘click’ with the psychologist, that is you are able to build trust and a strong connection with your psychologist.
To end off, the first session with a psychologist is understandably a bit intimidating and overwhelming, but the first step in the journey to recovery is a critical step to regain your mental wellbeing.
Caregivers with a family member affected by addiction problems are often exhausted, drained dry of their empathy and compassionate capacities.
They recount countless cycles of suspended hope followed by just as many broken promises as they watch the affected person return time and again to their compulsive addiction despite a seemingly obvious trail of destruction behind them.
Caregivers learn to cope with the endless demands on their energies by blending the words uttered by the affected persons as a cocktail of lies, manipulation and attention-seeking antics to get what they want.In time, the cries for help from the affected person turn into cries for help by the boy who cried wolf and eventually fading into indistinguishable white noise.
Professor Lisa Firestone of the Glendon Association observes that there is a natural tendency for caregivers to minimise any suicide expressions in general.Responses such as, “Well, his past attempts weren’t serious.” or “He is just manipulating to get something.” are commonly observed.There is also a general tendency to not want the expressions to be true.In the case of addicts, words such as “I want to die” or “I am going to end my life” no longer convey the same meaning or gravity of their sense of desperation.
Why should we want to pay attention to an addict’s cry for help?
In Singapore, we lose 1.1 lives every day to suicide.It is still the leading cause of death for youths aged 10 to 29.While direct correlation evidence is still being researched on, studies in America have shown that more than 90% of people who kill themselves suffer from depression have a substance abuse disorder or both. Suicidality and addiction share a high concordance relationship.
When we overlay the statistics with a physiological lens, we note that both groups of persons have been observed in studies to have a dysfunctional hypothalamic-pituitary-adrenal (HPA) axis which essentially controls our body’s response to stress.
In a person with a normal functioning HPA axis, on the reception of a stressor, the hypothalamus in our brain instructs the secretion of the corticotropin-releasing factor (CRF) and vasopressin to stimulate our pituitary glands to produce the adrenocorticotropic hormone (ACTH).The ACTH, in turn, stimulates glucocorticoid synthesis and release (commonly referred to as cortisol) from the adrenal glands.This chain reaction provides a person the increased energy to handle the stress event and to do so without suffering from the pain and fatigue.When the stress event is gone, the body produces a negative feedback loop which then brings the body system back to homeostasis.
In a person exposed to a persistent or extreme level of stress, or in a person who frequently activates the HPA axis through substance use, the body starts to blunt the sensitivity of the HPA axis and blunt cell receptivity to cortisol in its efforts to return to and maintain homeostasis.This alteration to the sensitivity of the HPA axis affects our ability to tolerate physical and mental stresses and creates a need for a much bigger stimulus to activate the HPA axis (which may mean higher dosage of substance use); and when the HPA axis does react, produces a much bigger and exaggerated response (which may translate to more aggressive behaviours).
What Does This Mean In Practical Terms?
Many suicidal persons described having a voice in their head which is constantly there; telling them how much they need to seek fulfilment and comfort by reaching for the desired stimulus, whether it be a substance or a behaviour, of which one is killing themselves.Their mind starts to command them to constantly plan, to seek out and to take actions to soothe the unbearable lack that they are feeling.Eventually, the voice in the head goes from coaxing and persuading to being more intensive and aggressive towards the self to take immediate drastic actions.
The relief of death, a final refuge, becomes alluring and pleasurable and the fear of dying eventually transforms into the fear of not dying and becoming the loser, disappointment, and burden that they already believe themselves to be to their caregivers.This dual push towards drastic action and the need for an ever-increasing amount of substance in addicts leads to an increase in the risk level of suicidality.
What Can We Look Out For?
How then does the caregiver separate the wheat from the chaff amid the chaos that addiction has already wrought onto the family system to detect the risks of suicidality?
Below are some, though not exclusive, common markers to look out for. It is particularly useful to note changes in the content of the affected person’s expressions and any escalation or sudden extinction of intensity.
Intense Emotional Outbursts
Extreme Isolation or Withdrawal
The feeling of Being a Misfit in Every Way
Researching or Procuring Means of Suicide.
Self-Harm, Including Risky Substance Use or Behaviours.
Planning of Affairs.
Presence of Trigger Events
Loss of Primary Relationship.
Physical or Mental Health Conditions That Debilitate.
Abuse or Trauma Events.
What Can Caregivers Do On Observing The Signs?
Ask the Suicide Questions:
In the past few weeks, have you ever wished that you were dead?
In the past few weeks, have you felt that you or your family would be better off if you were dead?
In the past week, have you made plans about killing yourself?
Have you tried to kill yourself?
If the answers are yes to any or to all the questions, caregivers are encouraged to take the following first steps:
Be empathetic towards the suicidal wish.
The objective is not to agree with the act of suicide but to understand what has happened to lead the affected person to the conclusion that suicide is the only solution.
Find a genuine connection with the affected person.
However difficult that person might have been in your life, express what this person means to you personally and how the loss of this person would affect you.
Make a safety plan.
Ask the affected person to agree to not take or delay any action to harm themselves until they get to or you get them to professional help.
Professor Lisa Firestone observes that suicidal persons are generally ambivalent: a part of them wants to die but a part of them wants to live as well.There is often a process of the dividing up of the self within the person, between an aspect which is life affirming and engaging with the outer world; and the anti-self, which is self-critical, self-hating and ultimately suicidal.The key to recovery is to connect with and help strengthen that part of them that wants to keep on living.
6 Dazzi, T., Gribble, R., Wessely, S., & Fear, N. (2014). Does asking about suicide and related behaviours induce suicidal ideation? What is the evidence? Psychological Medicine, 44(16), 3361-3363. doi:10.1017/S0033291714001299
Stress is something we can never escape from, be it good (eustress) or bad (distress). From the small, tedious daily hassles to long-term occurrences that weigh on your mind, stress can impact us in different ways, and the experience varies for everyone. Just as how different individuals have differing levels of pain tolerance, the same applies for stress.
Stress comes in many forms, but they can be largely categorised under ‘environmental’ (e.g noise), ‘social’ (e.g family demands, friendship conflicts), ‘physiological’ (e.g sleep disturbance) and ‘cognitive’ stressors (e.g low self-esteem, high expectations of oneself). While a certain level of stress may be necessary to provide motivation and encourage positive growth, excessive and unhealthy levels of stress especially in the long-term may cause undesirable mental and physical health consequences:
Disrupted sleep patterns / insomnia
Undue anxiety or fear
Difficulty concentrating / forgetfulness
High blood pressure
Nervous behaviours such as teeth grinding or nail biting
Increased frustration and irritability
A racing mind / constant worrying
Poor eating / digestive upsets
Poor decision-making processes
Increased heart rate / rapid breathing
Sweating / sweaty palms
Sense of helplessness
Restlessness / fatigue
When stress becomes chronic, physical health consequences can definitely worsen, and an individual may also develop depression or anxiety disorders. As such, while there is no one-size-fits-all, this article aims to provide useful tips and suggestions on how you can better manage your stress levels, and to avoid being overwhelmed and giving in to chronic stress.
To guide us along, there are two main types of stress-coping mechanisms – ‘Problem-focused’ and ‘Emotion-focused’ coping. These are possibly the most basic approaches to healthy stress-coping, and aim to reduce or eliminate the causes of stress, apart from merely alleviating its symptoms.
Problem-focused coping is where action is taken to clarify and resolve the stressor directly, and hence addresses the demands of a given situation. An example of this method of coping is when a student who is worried over an upcoming examination copes by attending more review sessions and reading up on her course materials diligently. This serves to reduce her anxiety and increase her confidence to excel in her examination. A problem-focused mechanism is primarily used when one appraises a stressor to be within his capacity to change, and hence makes the appropriate adjustments and alterations to cope with the impending demands. As such, it is also important to learn how to identify the root cause of the direct stressor before responding to it accordingly.
Emotion-focused coping may be a concept that you find familiar. Unlike problem-focused coping, emotion-focused coping involves making efforts to regulate your emotional response to a stressor. This means identifying your feelings, focusing and working through them. According to Folkman and Lazarus (1980), such a mechanism can be extremely helpful especially when you need to work through your emotions before you can think clearly enough to act rationally. Emotion-focused coping can be done in various forms such as:
Venting or talking to a friend / close oneWhenever you feel stressed or overwhelmed, bottling up may not be the best way around. Talking to others about what’s bothering you could bring great relief, and perhaps they could also provide you with the constructive feedback or encouragement that you need. Physical affection, such as hand-holding and hugs can help combat stress too. Just as how others may come to you whenever they need support, don’t be afraid to lean into your social circle and find comfort in your friends. Of course, do also remember to be mindful of your friends’ emotions and needs while you’re busy venting!
Journaling In this digital age, perhaps Journaling may come across as a rather old-fashioned way of coping with your emotions. Many a time, people would rather distract themselves and destress by playing mobile games or browsing through social media as and when they are feeling stressed. Although those can be a possible methods of destressing, the beauty of journaling shines through when you give yourself some time to reflect and balance yourself by creating your very own safe space. Writing in a journal can help you clear your mind by releasing any pent-up feelings, to let go of negative thoughts, as well as to enhance your self-awareness as you write about your progress.
Meditation Practising mindful meditation is an effective strategy to combat stress, for it can help you eliminate the stream of jumbled thoughts that are contributing to your heightened stress levels. Studies have shown that training in mindfulness can potentially increase your awareness of your thoughts, emotions, and maladaptive ways of responding to stress, therefore allowing one to cope with stress in a healthier and more effective way (Bishop et al, 2004, in Shapiro et al, 2005). With guided meditations that can easily be found online, all you need to do is to set aside some time for some mental self-care.
Reframing the situation and finding meaning in it When we are stressed, we often only focus on the bad and how much we dread a particular situation. However, it can be helpful to look on the bright side and to find the benefit and meaning in a stressful event. By doing so, we can make these experiences a little more tolerable, as well as to grow and build resilience as we go along.
Other Means of Coping with Stress
Last but not least, pay more attention to your diet and nutrition intake. For some of you, caffeine is a must-have on a daily basis, with some people having four to five cups of coffee per day. However, when you combine stress with the artificial boost in stress hormones from caffeine, this creates a significantly compounded effect. While caffeine can be particularly effective in providing you with the short-term energy boost and increased alertness, it can potentially heighten stress levels in the long-term. As such, it is always good to consume it in moderation and to be mindful of your caffeine intake. In addition, you may want to consume foods rich in vitamin B, which can help to reduce stress responses in your body.
As previously mentioned, everyone experiences life events in their own unique way, and a strategy that works for you may not for others. With that said, we hope this article has helped you to understand the various ways to combat stress better, and that you find the strategy best suited for you. However, if you ever find yourself struggling to cope with stressful life events, do reach out to one of our psychotherapists or counsellors for help.
Zimbardo, P. G., Johnson, R. L., & McCann, V. (2017). Psychology: Core Concepts (8th ed.). Pearson. (Accessed 25/11/2020)
Shapiro, S.L., Astin, J.A., Bishop, S.R., & Cordova, M. (2005). Mindfulness-based stress reduction for health care professionals: results from a randomised trial. International Journal of Stress Management, 12 (2), 164-176. (Accessed 25/11/2020)
We are no strangers to feelings of anxiety – at certain stages of our lives or in particular situations, we would have experienced anxiousness and worry with relation to our careers, studies, relationships and even our environment. However, anxiety levels may go beyond the healthy norm for some people, and may instead develop into anxiety disorders that may have a debilitating effect on their lives. According to the American Psychology Association (APA), an individual who suffers from an anxiety disorder is described to have “recurring intrusive thoughts or concerns”, where the duration and severity in which the individual experiences anxiety could be blown out of proportion to the original stressor, resulting in undesirable tension and other physical alterations. In this article, we will be exploring a few types of anxiety disorders as well as how they can manifest within us.
Generalised Anxiety Disorder (GAD)
Generalised Anxiety Disorder is a psychological issue characterised by persistent and pervasive feelings of anxiety without any known external cause. People who are diagnosed with GAD tend to feel anxious on most days for at least six months, and could be plagued by worry over several factors such as social interactions, personal health and wellbeing, and their everyday routine tasks. For example, an individual with GAD may find himself experiencing headaches, cold sweats, increased irritability and frequent feelings of “free-floating” anxiety. Others may also experience muscle tension, sleep disruptions or having difficulty concentrating. Often, the sense of anxiety may seemingly come from nowhere and last for long periods of time, therefore interfering with daily activities and various life circumstances.
In contrast, Panic Disorders are characterised by the random occurrence of panic attacks that have no obvious connection with events that are co-occurring in the person’s present experience. This means that panic attacks could occur at any time, even when someone is casually enjoying a meal. Of course, panic attacks could also be brought on by a particular trigger in the environment, such as a much-feared object or situation. Some individuals have reported that panic attacks feel frighteningly similar to a heart attack, especially with the rapid increase in heart palpitations, and the accompanying shortness of breath. Other symptoms also include trembling, sweating, and feelings of being out of control. With these panic attacks bringing on sudden periods of intense fear and anxiety, it can be exceptionally terrifying when these attacks reach their peak within mere minutes. However, a notable difference between a panic disorder and GAD is that an individual diagnosed with panic disorder is usually free of anxiety in between panic attacks.
Obsessive-Compulsive Disorder is a disorder marked by patterns of persistent and unwanted thoughts and behaviours. Obsessions are recurrent thoughts, urges or mental images that cause anxiety. On the other hand, compulsions are the repetitive behaviours that a person feels the urge to do in response to an obsessive thought or image. One common example often exhibited in films is where an individual has an obsessive fear of germs. This person may avoid shaking hands with strangers, avoid using public restrooms or feel the urge to wash their hands way too frequently. However, OCD isn’t purely limited to feelings of anxiety due to germs. OCD can manifest in other ways as well, such as wanting things to be symmetrical or in perfect order, repeatedly checking on things (“Did I leave my stove on?”), or the compulsive counting of objects or possessions. While everyone double-checks their things and has their own habits, people with OCD generally cannot control their thoughts and behaviours, even if they are recognised to be rather excessive. They can spend at least 1 hour a day on these thoughts and behaviours, and will only feel the much-needed brief sense of relief from their anxiety when they perform their rituals. As such, OCD can be exceptionally debilitating to one’s mental health.
Social Anxiety Disorder
Persons with Social Anxiety Disorder, or SAD, experience high levels of anxiety and fear under particular or all social situations, depending on the severity of their condition. They are often afraid of being subjected to judgement, humiliation or rejection in public, causing them to feel embarrassed. As such, individuals with SAD may feel extra self-conscious and stressed out, and try to avoid social situations where they might be placed at the centre of attention.
A phobia involves a pathological fear of a specific object or a situation. This means that one may experience intense anxiety upon encountering their fears and will take active steps to avoid the feared object. Phobias may centre on heights(acrophobia), birds (ornithophobia), crowds and open spaces(agoraphobia), and many others. People with agoraphobia, in particular, may struggle to be themselves in public spaces, for they think that it would be difficult to leave in the event they have panic-like reactions or other embarrassing symptoms. In severe cases, agoraphobia can cause one to be housebound.