PHOBIAS – AN EXAMPLE OF AN ANXIETY DISORDER. What is fear? What is anxiety? Fear - unpleasant...

PHOBIAS – AN EXAMPLE OF AN ANXIETY DISORDER

What is fear? What is anxiety? Fear - unpleasant feeling of anxiety or

apprehension caused by the presence or anticipation of danger

Anxiety -- feeling of worry: nervousness or

agitation, often about something that is going to happen

- PSYCHIATRY extreme apprehension: a medical condition marked by intense apprehension or fear of real or imagined danger

When does anxiety become a problem?

All people experience anxiety at some time.

It is a normal element of human existence.

However, anxiety can become a major problem with disturbing consequences.

What axis in DSM-IV-TR do anxiety disorders come under? (see textbook if you have forgotten)

Anxiety disorders

Come under Axis 1 and are characterised by extreme apprehension, fear, stress and unease.

5 main types of anxiety disorder

1. Generalised

anxiety disorder

2. Post-traumatic

stress

3. Panic disorder

4.Obsessive-

compulsive disorder

5. Phobic disorder

OUR FOCU

S

What is a phobia?

A phobia is a persistent, irrational and intense fear of a particular object or event.

persistent - existing for an unpleasantly long

irrational - lacking in reason or logic intense - extreme in a way that can be felt

What cause simple phobias? After many years of extensive research into

the origin and maintenance of simple phobias, scientists came to an important conclusion - there is no simple explanation

Main factors are:- Biological- Genetic tendencies- Brain chemistry- Psychological- Sociocultural- Environmental

Subcategories of phobias•Fe

ar of other people

•Fear of social situation

Social Phobia

•Fear of leaving a familiar place

Agoraphobia

•One specific object/event

•e.g. – fear of heights

Simple phobia or Specific phobia Click here for the four main

types of simple phobias

Four main types of simple phobia:

Animal Natural

Environment

Situation Phobias

Blood - injection-injury phobia

Simple Phobias

Symptoms of phobic anxiety elevated heart rate & blood pressure tremor (shaking in hands) palpitations (abnormally fast heartbeats

that a person is aware of) diarrhoea sweating shortness of breath dizziness

Fear of clowns- symptoms

Watch the following You Tube video that explains the symptoms by someone suffering from a simple phobia.

http://www.youtube.com/watch?v=W2nK_qmvJ7A&feature=related




At what age to phobias start? Age of onset of simple phobias:- Animal 7 years- Blood 9 years- Dental 12 years- Claustrophobia 20 years- Social Before 20 years- Agoraphobia Late adolescence

early adulthoodMost simple phobias first appear at anytime, but particularly during

adolescence.

PANIC ATTACKS

A panic attack is the unexpected onset of intense anxiety that can last for a few minutes or up to an hour or so.

Sufferers experience: Great discomfort Shortness of breath or tight in the chest Become disorientated Often fear the panic attack will happen again

and lead to total loss of control or even death

PANIC ATTACKS

Not classified as a separate disorder in the DSM-IV-TR.

Panic attacks are a symptom in a number of anxiety disorders described in the DSMe.g. Panic disorder, specific phobia, social phobia, PTSD (post traumatic stress disorder)

DSM diagnoses panic attacks when 4 or more symptoms develop suddenly and reach a peak within 10 minutes.

Symptoms such as: sweating, trembling, chest pain, feeling of choking, dizziness, feeling lightheaded or faint, depersonalisation (detached from oneself), fear of dying, chills or hot flushes, fear of losing control or going “crazy”, nausea, abdominal distress etc.

Biological factors & phobiasStress Response

• flight –or-flight response will occur when a person is frightened or highly stressed

GABA- found in 40% of all synaptic junctions.

•Low levels of the neurotransmitter GABA leads to higher levels of anxiety• Anti-anxiety drugs that mimic GABA’s inhibitory effects can help manage anxiety

Genetic predisposition and inherited vulnerabilities

• genetic vulnerability is expressed in a person’s personality; people who are nervous and apprehensive about objects and events are more likely to develop simple phobias and anxiety disorders

BIOLOGICAL CONTRIBUTING FACTORS TO SPECIFIC PHOBIAS

Research suggests we may inherit a predisposition or “tendency” to develop an anxiety disorder.

Genetic research on identical twins – if one has an anxiety disorder, the other is more likely to have an anxiety disorder.

This is not the case though with non-identical twins or other siblings.

Other biological factors that can contribute to specific phobias and phobic reactions is the role of the stress response and the brain’s neurochemistry (specifically the neurotransmitter called GABA).

ROLE OF STRESS RESPONSE

Psychological component of anxiety – apprehension, worry, uneasiness

Physiological component underlies psychological component of anxiety – like the physiological response to stress – the fight-flight response is activated.

Heartrate up, heartbeat faster to speed up blood flow and direct blood from where it is not needed to where it is needed.

Adrenal hormones surge into bloodstream Speed and depth of breathing increase


The symptom of feeling dizzy or even fainting are thought to be due to initial increase in ANS arousal followed by a sudden drop in blood pressure and heart rate.

Phobic anxiety becomes problematic when the stress response is triggered in the absence of any real threat or danger (e.g. Objects or events that have very little potential for actual harm).


A person with a specific phobia has their stress response triggered by the perception of threat or danger.

Because their perception of threat is unreasonable, the level of anxiety tends to be excessive.

The stress response they experience is often very severe and can persist at this high level for at least as long as the exposure or anticipated exposure to the phobic stimulus.

The role of Gamma-amino-butyric acid…….GABA

Not enough Yo gaba gaba makes me anxious!

GABA

Gamma-amino butyric acid is the primary inhibitory neurotransmitter in the CNS.

Inhibits postsynaptic neurons from firing – stops them passing on the neural impulse

Gets in the synapse to block transmission One of it’s role is it helps fine tune brain

activity, keeps neural transmission maintained at an optimal or “best possible” level.

Without GABA, activation of postsynaptic neurons might get out of control and spread throughout the brain, causing seizures similar to those of epilepsy.

Glutamate

2nd most common neurotransmitter in the brain Excitatory neurotransmitter in the CNS Makes postsynaptic neurons more likely to

pass on the neural impulse (to “fire”) Gets the post synaptic neuron excited so it

requires less stimulation to make it fire

Also plays a role in aiding learning and memory by strengthening synaptic connections

GABA

Stop the message!

GLUTAMATE

Get the message going!

GABA and Glutamate

The inhibitory effect of GABA counterbalances the excitatory effect of glutamate and vice versa.

Therefore, they both have important roles in regulating CNS arousal.

GABA is believed to play a role in anxiety.

GABA and anxiety

Lack of the neurotransmitter GABA might lead to over stimulation, and thus heightened anxiety

Role of a group of drugs known as benzodiazepines in the management of phobic anxiety provide evidence for the role of GABA in anxiety.

Benzodiazepines – a class of drugs that ‘calm down’ neural activity. Valiam, Xanax, Rohypnol, Serepax etc. commonly referred to as “minor tranquillisers”

Benzodiazepines reduce physiological arousal and promote relaxation, but induce drowsiness and are highly addictive.

All drugs are either Agonists – mimic the activity of a neurotransmitter

Or Antagonists – inhibit the activity of a neurotransmitter

a substance that stops or slows a chemical reactionMicrosoft® Encarta® 2008. © 1993-2007 Microsoft Corporation. All rights reserved.

Inhibitory or agonist - a substance that stops or slows a chemical reaction.Benzodiazepines are GABA agonists.They imitate GABA and stimulate activity at the site of a postsynaptic neuron where GABA is received from a presynaptic neuron.By doing this, benzodiazepines have inhibitory effects on postsynaptic neurons and reduce symptoms of anxiety by imitating GABA’s inhibitory effects.


Ethyl alcohol (type people drink) has similar effects on GABA receptors which is why alcohol is typically experienced as relaxing.


Antagonists inhibit a neurotransmitter’s activity.

Agonist is the opposite to antagonist.

They reduce GABA function and therefore produce anxiety symptoms.


The GABA/Anxiety connection has led researchers to hypothesise some people develop anxiety because they have a dysfunctional GABA system – the result of failure to produce, release or receive the correct amount of GABA that’s needed to regulate neuronal transmission in the brain.


Level of GABA in a person’s brain may be affected by a wide range of factors:•Genetic inheritance•Socio-cultural factors• exposure to prolonged stress• exposure to environmental toxins•Nutritional deficiencies (vitamin B6 and citric acid, and high caffeine intake)


Proposals that GABA levels can be increased “naturally” by:• Drinking green tea• Eating foods “high in GABA” (e.g. Beans, dairy foods, eggs,

seafoods and wholegrains)• GABA supplements from health food stores (although there is no significant research evidence that shows GABA supplements can penetrate the “blood-brain barrier”.


The Blood-Brain Barrier is a physiological mechanism that protects the brain (and spinal cord) from undesirable toxins and poisons in the blood that may cause harm.

It consists of blood vessels that are semi-permeable.

It allows some blood-borne chemicals to pass through but not others.


Many drugs such as heroin and cocaine can cross the blood-brain barrier and affect neurotransmitter functioning.

The GABA supplements may/may not cross the blood-brain barrier and so their effectiveness in managing anxiety is unclear.

Caffeine induced anxiety disorder

Caffeine – the most widely consumed drug in the world (coffee, tea, Coca Cola)

Low doses believed to improve sporting performance, increase alertness and reduce fatigue, potentially lift mood.

Contains some anti-oxidants which have positive effects on heart health.

Can also be useful for some types of headaches (e.g. migraines) – in some cases reduced by caffeine.


Some researchers though are increasingly concerned with caffeine’s role in panic and other anxiety disorders.

Caffeine induced anxiety disorder has been added to the DSM-IV-TR.

One study found caffeine doses of 4 to 5 cups given to people with panic disorder, nearly half of participants experienced a reaction just like their panic attacks.

Symptoms can include appearing “wired”, overly talkative, irritable, tachycardia (rapid heart rate), restlessness, complaining about not being able to sleep well and having energy “to burn”.


Symptoms are believed to develop as caffeine inhibits GABA release.

Too much caffeine is a direct consequence of having high glutamate production without enough GABA to counterbalance it in the brain.

Some people with anxiety symptoms are therefore advised to avoid caffeine.

Theoretical approaches to explaining psychological contributing factors

Psychodynamic model

Behavioural model: classical conditioning and operant conditioning

Cognitive model

Psychodynamic model –

Is based on the work of Freud (late 1800s)

States that the development of all mental disorders including phobias is due to unresolved psychological conflicts that occur in the unconscious part of the mind, beneath ordinary conscious awareness. that arise during the phallic stage of a child’s development.

The conflicts originate in early childhood experiences during which our instinctive impulses (“urges”) and society’s view of what is “acceptable” behaviour often clash.

If a person is unable to deal with this conflict, their anxiety is displaced to a situation or object that is less relevant – e.g. in the case of Hans a fear of horses.


Freud – the unconscious is a storage place for all information about ourselves that is not acceptable to the conscious mind. (It is NOT our memory though).

Freud – unconscious contains all memories of experiences that may be a source of anxiety and thus very difficult to bring into our conscious minds.

Freud believed that the unconscious thoughts and feelings have a considerable influence over our conscious thoughts and behaviour.


Following birth we each progress through a series of 5 different psychosexual stages:

Oral stage (0-2 years) Anal stage (2-3 years) Phallic stage (4-5

years) Latency stage (6 –

puberty) Genital stage (puberty

– early adulthood)

“Sex” in Freud’s context meant something “physically pleasurable”, not specifically sexual activity.

At each stage different parts of the body become the focus of our attention and pleasure.

Each stage has a crucial developmental conflict that must be satisfactorily resolved in order to move to the next stage.

•Phallic stage - in psychoanalytic theory, relating to a stage of psychosexual development during which a young child's sexual feelings are concentrated on the genitals.•Oedipal & Electra complexes


An unresolved conflict can be a source of anxiety.

Freud described anxiety as an uncomfortable or unpleasant psychological feeling that often arises from the fear that our instincts will make us do something we will be punished for.

We protect ourselves by using defence mechanisms.

“

Defence mechanisms

Defence mechanisms are the conscious part of our mind, called the “ego” defending or protecting itself against anxiety arising from unresolved internal conflicts.

Defence mechanisms reduce anxiety by denying, falsifying or distorting reality at an unconscious level and so we have no need to feel anxious.

We are usually not aware that we are using defence mechanisms.

OEDIPAL COMPLEX

According to Freud a specific phobia he called anxiety hysteria develops as a consequence of an unresolved Oedipal complex.

The Oedipal Complex is a developmental conflict that emerges during the phallic (third) stage of psychosexual development (4-5 years).

It describes the unconscious, powerful, passionate love and desire the male child has developed toward his mother.

OEDIPAL COMPLEX

The term is now broadly used to apply to the desire of either a male or female child to “possess” the opposite-sex parent and “eliminate” the same-sex parent

The desire is unconscious so the child is not aware of it.

Soon after developing the desire the boy begins to fear the father who is bigger and more powerful will become aware of this and punish him by castration.

As a consequence the boy develops castration anxiety (a fear he will be emasculated).

OEDIPAL COMPLEX

To successfully resolve the Oedipal Complex, the male child uses the defence mechanism called repression to prevent the socially unacceptable desire and it’s accompanying anxiety from entering conscious awareness.

It results in the boy identifying with his father. The male child comes to act, think and feel as if he were his father. He thinks if he is similar to his father, then his father won’t punish him.

OEDIPAL COMPLEX

When repression doesn’t work, another type of defence mechanism is attempted known as displacement.

Displacement involves directing feelings away from the object or person that causes them to a substitute object or person that is less threatening.

In this way the anxiety is redirected onto a seemingly unimportant, irrelevant object or situation which becomes the phobic stimulus.

The child can then deal with the unresolved conflict and the anxiety by avoiding the phobic stimulus.

OEDIPAL COMPLEX

The phobic stimulus is related to and “symbolises” the male child’s unconscious desire for his mother.

Thus, any feared object or situation associated with specific phobia symbolises the source of an unresolved Oedipal complex and triggers anxiety.

Read the case of “Little Hans” on pages 644 and 645.

Behavioural Model: Classical and Operant Conditioning

Behavioural model – phobias are learned through experience and may be acquired, maintained or modified by environmental consequences such as rewards and punishment.

Classical conditioning processes play a role in the acquisition (or development) of a simple phobia, and operant conditioning processes play a role in the persistence (or maintenance) of a simple phobia.

Behavioural Model: Classical and Operant Conditioning

Focuses on observable behaviours and downplays cognition

Behaviours are learned through classical conditioning and maintained through operant conditioning.

Operant conditioning can contribute to the acquisition of a phobia by rewarding when comforting distress caused by a phobia.

e.g. development of dentist phobia

Think about ‘Little Albert’ – draw a similar diagram to explain how his phobia developed & was maintained.

Read examples on pages 646 and 647

Dentist PhobiaClassical Conditioning – phobia develops

Before Conditioning

NS No ResponseUCS UCRpain from injection fear: due to pain from injection

During Conditioning

NS + UCS UCRdentist pain fear: due to pain from injection

After Conditioning

CS CRvisit to dentist fear: due to visit to dentist

Operant conditioning – phobia maintained

The avoidance of the unpleasant injection acts as a negative reinforcer the strengthens the likely hood of that behaviour being repeated.

Arachnophobia

UCS– spider in sandpit UCR– fear NS– spiders CS– spiders CR – fear

Avoidance of spiders or spider related places, images etc is negatively reinforcing, avoiding the bad stimulus.

This strengthens further avoidance behaviours

Cognitive Model

Emphasises the influences of thought processes

is used to examine the distorted thinking process involved in the development

Argues that anxious individuals are more likely to exaggerate perceived threats, making then more likely to interpret some situations, objects or activities as more dangerous than the average person would

Cognitive Bias (“Cognitive Distortion”)

Key assumption – people with phobias have a cognitive bias – a tendency to think in a way that involves errors and bad judgement and faulty decision making

Cognitive biases can be habitual ways of thinking and therefore make someone more prone to experiencing fear and anxiety in response to a phobic stimulus.

TYPES OF COGNITIVE BIAS

There are several different types of cognitive bias:

1. Attentional bias2. Memory bias3. Interpretive bias4. Catastrophic thinking

ATTENTIONAL BIAS

Attentional bias is the tendency to selectively attend to threat-related stimuli rather than to neutral stimuli.

The person tends to pay more attention to “signs of danger” (threatening information) in their environment while ignoring “signs of safety” (non-threatening information).

E.g. A person with a fear of spiders may be the first or only person in the room to notice a spider web.

They are hypervigilant always alert and constantly looking around for something relevant to their phobia. It is not helpful and maintains their symptoms.

MEMORY BIAS

Memory bias occurs when recall or recognition is better for negative or threatening information than for positive or neutral information.

E.G. A person with a phobia of horses may remember the time they were chased by a horse but not the other times when horses did not react to their presence.

INTERPRETIVE BIAS

Interpretive bias (judgmental bias) is the tendency to interpret or judge ambiguous stimuli and situations in a threatening manner.

E.g. The fluff on the carpet as a spider

CATASTROPHIC THINKING

Catastrophic thinking is a type of negative thinking in which the object or event is perceived as being far more threatening, dangerous or insufferable than it really is and will result in the worst possible outcome.

e.g. A dog phobia may cause a person with catastrophic thinking to think the dog they encounter will attack them and leave them with permanent facial disfigurement.

The person experiences heightened feelings of helplessness and grossly underestimates their ability to cope with the situation.

Socio-cultural contributing factors 3 most common contributing factors:

Specific environmental triggers(developing a phobia after a direct negative experience with an object or situation)

Parental modelling(observing and reproducing a parent’s fear of an object or situation)

Transmission of threat information(exposure to negative or frightening information about an object or situation).

Specific Environmental Triggers Often an initial fear response to a specific

environmental trigger becomes a conditioned fear response through classical conditioning processes and is produced whenever the specific stimulus (or a generalised version) is subsequently encountered.

Research indicates the more severe the initial trauma the more likely a phobia will develop.

One encounter alone may be enough to produce and maintain the fear response.

People are usually able to identify the particular traumatic event that has caused the phobia.

Specific Environmental Triggers A single traumatic experience does not

explain the fact that not all people who share the same traumatic experience develop a phobia.

One reason given is each individual’s prior experience.

Parental Modelling

Observational learning, or modelling, can lead to development of phobias by observing another’s fearful behaviour towards a particular object or situation.

Children most vulnerable to this as they do not have knowledge or experience to know whether their parents’ behaviour is appropriate or rational.

Not as common a pathway to phobias though as direct experience.

Transmission of threat information Transmission of threat information

refers to the delivery of information from parents, other family members, peers, teachers, the media and other secondary sources about the potential threat or actual danger of a particular object or situation.

Sociocultural factors & phobias Social and cultural factors can contribute to the

type and incidence (the rate of occurrence) of simple phobia.

e.g. A child whose parents suffer a phobia of moths is more likely to develop the same or similar phobia.

Some phobias are culturally specific. e.g. taijin kyofusho, a social phobia that appears

almost exclusively in Japan. This is a fear of offending or harming others in social situations. It is different from a traditional social phobia, in which the sufferer is afraid of being personally embarrassed on humiliated.

Sociocultural factors & phobias: cont

Parental modelling can lead to the transmission of threat information which is incorporated into a child’s LTM and phobia can develop

i.e. children who are exposed to parents with phobic responses are more likely to develop comparable fears to similar stimuli

Treatments for simple phobias1. Cognitive behaviour therapy (CBT):

- uses a combination of verbal and behaviour modification to help people change their thinking

- focuses on the person to change negative thoughts (flies can kill me) to more positive ones (flies are unpleasant but they won’t hurt me if I am careful).

- person is encouraged to recognise that the likelihood of their perceived events happening in real life is very small.

- often combined with relaxation to treat a wide range of phobias.

Treatments for simple phobias

1. Cognitive behaviour therapy (CBT): 1. Cognitive therapy deals with maladaptive thoughts

and beliefs, and behavioural therapy deals directly with maladaptive behaviours such as avoidance and reduced activity levels that can worsen or maintain a person’s psychological problems.

2. In behaviour therapy, the habitual or reflexive ways of responding that are maladaptive become extinguished and new, more adaptive habits and reflexes are conditioned.

3. The emphasis on the cognitive or behavioural parts can vary, depending upon the disorder and the person’s symptoms.


1. Cognitive behaviour therapy (CBT): - CBT tends to be relatively short term, structured and

focused on the “here and now” type therapy. Functioning more effectively in the present and the future is the focus.

- Step 1- Person identifies their fear and anxiety related thoughts, as

well as any cognitive biases.- This can be done by asking questions of the person or may

be more direct and bluntly approached.

- Step 2- Person is encouraged to look for evidence that supports

their fear cognitions and evidence that does not support them. Once these thoughts are recognised as hypotheses not facts, they are open to questioning and challenging.


1. Cognitive behaviour therapy (CBT): - Step 3- Sometimes a person’s cognitive distortions result

from a lack of information or from inaccurate information.

- So the client is encouraged to gather accurate information about their phobic stimulus.

- Once new evidence is evaluated, they are more able to counter them with alternative more objective and useful thoughts.

- This new way of thinking will then lead to changes in their feelings and behaviour, especially by reducing fear, anxiety and avoidance.


1. Cognitive behaviour therapy (CBT): - Step 4- The behavioural component of CBT can include

engagement in behavioural experiments (planned “hands on” activities the client engages in between CBT sessions. They are designed to “test out” the accuracy of the cognitive distortions.

- Steps involved in setting up a behavioural experiment are:- Make a prediction- Review existing evidence for and against the prediction- Devise a specific experiment to test the validity of the prediction- Note the results- Draw conclusionsRead example on p. 661

Behavioural component of CBT The behavioural component of CBT may

also include the use of: Systematic desensitisation Flooding

Treatments for simple phobias2. Systematic desensitisation

- based on the idea that most anxiety responses are initially required through classical conditioning, therefore getting rid of a phobia can be achieved through counter conditioning (‘unlearning” the association between anxiety and the phobic stimulus)

Steps involvedStep 1Teach the client a relaxation strategy to use when confronted with phobic stimuluse.g. Progressive muscle relaxation, visual imagery, slow breathing technique (SBT)

Systematic desensitisation

Steps involvedStep 2Therapist helps the client create a fear hierarchy (or “anxiety hierarchy”) – a list of feared objects or situations ranked from least to most anxiety producing. (approx. 10-15 situations rated and ranked on a 100 point scale).

Step 3 Systematic graduated pairing of items in the hierarchy with

relaxation by working upward through the hierarchy one step at a time.

This can be either “in vivo” (real life) or “visual imagery” (imagined).

No advancement occurs until relaxation is achieved at each step.

Systematic desensitisation

Click me to view a video

about systematic

desensitisation.

CBT – behavioural componentSystematic desensitisation

Attempts to replace fear response with relaxation

patient taught relaxation techniques

gradually introduced to fear inducing stimulus while practicing relaxation.

Fear hierarchy

Treatment of phobias

3. Flooding- Based on the idea that phobias are learnt through

classical conditioning.- Occurs when the client is exposed to feared

stimulus all at once for long periods of time until anxiety subsides

- Helps the client to replace feelings of anxiety/fear with feelings of relaxation

- Can be done “in vivo” or with visual imagery using a virtual reality device.

- Although effective, is not suitable for everyone and can increase rather than decrease their phobia.

- http://www.youtube.com/watch?v=DkaeVrs7-ZA&feature=relmfu

http://www.youtube.com/watch?v=DkaeVrs7-ZA&feature=relmfu

http://www.youtube.com/watch?v=DkaeVrs7-ZA&feature=relmfu

CBT – behavioural component

Flooding

Expose the patient to their fear straight away

They will panic at first

Soon realise that nothing bad has happened

Biopsychosocial Approach

Health professionals take a holistic approach to treating simple phobias and consider the following factors- genetic vulnerability- physiological processes- psychological determinants- family history of anxiety and simple phobia- environmental influences- symptoms and whether the person can function

effectively at work, home and socially.

Example of factors considered

Biological – has the person been born with

an easily startled

personality

Sociocultural – has the

person learnt to fear

something by observing other family

members

Psychological – has the

person overestimat

ed the perceived level of danger

Combining all the factors

Biological, psychological and social-environmental factors must be considered when treating simple phobias

Step 1 - Full understanding of all the elements needed

Step 2- determine which therapy or combination of therapies is suitable (e.g. CBT, Systematic desensitisation or flooding)

Step 3 – determine if anti-anxiety medication is also needed

Lutraphobia- Fear of otters

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