Phobias Revision (Diagnosis, Causes, Treatments)

• Phobia = a persistent fear leading to great anxiety that is excessive, unreasonable and irrational.

• Usually occurs when a person's fear has a specific focus, e.g. animal / situation / object.

Types of Phobia

•  
  • Simple/Specific Phobia = presence of specific object or situation causes fear.
  • Social Phobia = fear of being scrutinised by / exposed to unfamiliar people.
  • Agoraphobia = anxiety of situations which person believes are dangerous/uncomfortable - e.g. crowdedness or vast openness. 

• Person knows fear is irrational but can't do anything about it.

• Phobia can be kept under control if feared stimulus avoided --> will do anything to avoid

• Avoidance can lead to difficult and long-term problems by reinforcing phobia.

• Phobias are extremely common. 

• Experienced by a lot more women than men.

• deGraaf et al (2002) - women at least 2x more likely to develop phobia

• High comorbidity - if someone has one specific phobia its likely they will also have another.

• Are women just more likely to share phobias/report symptoms?

• Phobias present in all cultures but differ greatly due to different attitudes --> different DSM criteria.

• Genetics
  • Hettema et al (2003) - 20-40% heritability from twin studies.
  • Kendler et al (2001) - family member with phobia = increased chance of developing phobia.
• Fear Circuit
  • Malizia (2003) set of brain structures tend to be activated when people are feeling anxious or fearful.
  • Amygdala - critical for conditioning fear in animals - sends signals to hypothalamus,thalamus, hippocampus etc.
  • Medial Frontal Cortex -Shin et al (2003) - people who meet criteria for anxiety disorders show less activity.
  • Deficits in MFC may disrupt functioning of amygdala = increased emotional responses.
  • Nervous System (Sympathetic) - overactive in some individuals? - primed and ready for action in response to minor fear?
• Neurotransmitters
  • Serotonin - poor functioning in anxiety disorder sufferers (Chang et al, 2003)
  • NA - high levels linked to anxiety disorders (Chang et al, 2003)
  • GABA - dysfunction in neurons producing GABA = less GABA  anxiety.

Classical Conditioning (Cause)

• A neutral event is paired with a traumatic event resulting in fear.
• Leads to the neutral event causing fear on its own.
• E.g. Little Albert and the white rats.
• Classical conditioning causes/initiates a phobia.
• A single event may be enough to produce fear 
• Yule et al (2010) - surviving sinking ship = fear of water and boats.

Operant Conditioning (Maintenance)

• Once learnt the feared neutral stimulus is avoided.
• Avoidance reinforced by a reduction in anxiety.
• Phobias are maintained by this constant reinforcement from avoidance.
• Avoidance gives short-term relief but long-term can lead to  increase in physical symptoms and use of safety behaviours.

• Not everyone with phobia can recall a traumatic event.
• Not everyone that experiences a traumatic event develops a phobia.(Rachman, 1977; Marks, 1977).

Modelling (Bandura, 1966)

• Observe someone being fearful or hear negative feedback about something = more likely to be fearful yourself. 

Childrearing

• Overprotective parents make child think the world is dangerous = anxious child.
• Muris (1996) - mothers responses influence childhren. 

• Davey et al (1993) - claimed it is people's reactions after an event which are important e.g. negative reaction after seeing a spider = more likely to instill fear in observers.

• BUT! - behavioural/learning view suggests all things equally likely to be phobic.
• why are certain objects/situations more likely to be reported as phobias than others?

• Seligman (1971) - born with innate predisposition to learn fear to some things more than others as they were real threats to ancestors.

• Poulton & Menzies (2002) - we are born wary of certain stimuli.

BUT! 

• LoBue et al (2011) claim fear is learnt in first years of life, not innate. 
• Babies don't show fear but are more attentive to stimuli accompanied by a fearful voice.

Females:

• Raikson (2009) - female infants learn to associate negative face expressions to spider. 
• Evolutionary sense for females to be more wary/fearful to protect selves and offspring?

• People develop phobias because think about/perceive world in different way. 

• Phobias are caused by cognitive biases/maladaptive thinking.

• Phobics attend to threat-relevant material more than non-phobics.

• Williams et al (1996) - arachnophobics take longer to process spider related words.

• BUT! - as yet no evidence for cause and effect. 

• Cognitive biases <===?===> phobias

• Freud --> phobia is the expression/projection of repressed unconscious conflicts.

• Case Study --> Little Hans' fear of horses caused by oedipus complex/fear of father.

• Phobias are a defence against the anxiety produced by repressed id drives.

• Ego uses defence mechanisms (displacement/projection) to transfer phobia to other object/event so it is easier to deal with/avoid. 

• Behaviour is a product of learning, what can be learnt can be unlearned. 
• Aim of treatment is to break the avoidance cycle.
• Clients must approach NOT avoid feared stimuli. 
• If avoidance is prevented, person will realise situation is not dagerous.

1) Systematic Desensitisation - Joseph Wolpe (1958)

• Goal = to weaken association between neutral object and anxiety. 
• Reconditioning takes place so neutral object associated with relaxation.
  • 1) build anxiety hierarchy (lowest to highest fear)
  • 2) Trained in deep muscle relaxation
  • 3) Work through hierarchy until can face top (biggest fear) without anxiety.

2) Implosion Therapy and Flooding

• Expose client at outset to most fearful situation. 
• Fear exhaustion takes place.
• Impossible to avoid thus avoidance is no longer rewarding. 
• Implosion = takes place in client's mind.
• Flooding = takes place in real life situation.

Systematic Desensitisation

• Works better than insight therapies for treating phobias. 
• Good for those who can learn relaxation.
• Best for people with a good imagination.
• BUT!
• Difficulty transferring to real life from imagination?
• Cost of facing phobias in real life e.g. fear of flying?

Implosion and Flooding

• Marks (1981) - 80% effective.
• Ost (1996) - can be effective after just 3 hours. 
• Ost (1996) - 70-90% still show improvement after one year.
• BUT!
• Less than 15% want flooding.
• 25% drop out
• Ethics and cost?

Virtual Flooding - 83% improvement (Garcia-Palacios, 2002) but not accessible to all therapists.

• watch filmed or live models dealing calmly with a phobic situation.

• Client feels less anxiety when faced with the same stimulus

• Bandura & Menlove (1968)

• Important to note that behaviour and learning therapies are effective at altering overt behaviour but don't root out the underlying cause!

• Anti-anxiety drugs (minor tranquilisers)

•  
  • reduce anxiety, tension, nervousness etc.
  • very common but can lead to dependency and side effects.
  • Side effects include addiction, lethargy and rebound anxiety. 

• Cortisol treatment
  • hormone makes people forget what they are scared of, can't retrieve memory. 
  • Helps form new memories and overwrite old ones. 

Efficacy

• Lydiard et al (1996)
• Temporary effects, the effects wear off if the medication/treatment stops.
• How long will the drugs have to be taken? - for rest of life?
• Drugs may cause addiction and dependency as use must be continued for benefits to be seen.

Psychotherapy

• Phobias are caused by underlying conflicts.
• Conflicts must be brought to the surface in order to be dealt with in light of adult reality.
• Dream Analysis and Free Association used. 
• BUT! - these methods have less evidence of success with phobias. 

Cognitive Therapy

• Little point changing thoughts as person knows fear is irrational. 
• Can try to alter beliefs/cognitive biases if faulty or present. 
• Help individual reappraise the situation and realise there is no danger
• Help realise that feeling of danger is due to faulty thoughts. 

INTEGRATION OF THERAPIES IS NEEDED FOR MAXIMUM EFFECTIVENESS! - E.G. COMBINE DRUG TREATMENTS WITH ANY OTHER THERAPIES WHICH WORK

• Not all therapies will work for everyone, is a case of finding which is most effective.