A NXIETY D ISORDER : P HOBIA Aaaaaaahhhhhhhhhh peaches!

ANXIETY DISORDER: PHOBIAAaaaaaahhhhhhhhhh peaches!

ANXIETY Anxiety is a normal response to an

anticipated threat in the environment. It serves a vital function in preparing the individual to respond to the threat and is the precursor to the fight-or-flight response. That is, anxiety is a preparatory response to a real threat.

Example: We feel anxious when we walk down a dark street in an unfamiliar neighbourhood. This is then replaced with a fear response when an armed mugger confronts us.

ANXIETY

Anxiety consists of three sets of responses – physiological, cognitive and psychological – that occur simultaneously and are seen as one general response. The general anxiety response merges with the stress response as the threat, or the perception of the threat, materialises.

Physiological: Increased heart rate, sweating, flushing/blushing/feeling faint, increased breathing/feeling short of breath, lump in the throat/choking sensation, dry mouth, butterflies in stomach, nausea, diarrhoea, need to urinate, pins and needles, dizziness, tremor/shaking

ANXIETY

Cognitive: Fear of impending doom, death, embarrassment, losing control, being trapped

Psychological: Feeling tense/restless, sense of unreality, time moving slowly, hypervigilant, difficulty concentrating

ANXIETY AS A DISORDER Although anxiety is a normal and expected response it can

occur in people in unwanted or unexpected times or with a severity far in excess of the threat. When this happens it can be a marker of an anxiety disorder.

The ICD-10 and DSM-IV-TR list a number of anxiety disorders where the anxiety response is too great, inappropriate or overly persistent, causing distress and impairment to the person with the disorder.

Examples of anxiety disorders are: Post traumatic stress disorder (PTSD) Agoraphobia Obsessive-compulsive disorder Social phobia They are relatively common throughout the world.

ANXIETY AS A DISORDER

Girl with OCD

TYPES OF PHOBIAS

There are three characters of phobia indentified in ICD-10:

Specific Agoraphobia Social

SPECIFIC PHOBIA

A phobia is an intense, irrational, persistent fear of a stimulus that is out of proportion to the actual threat and may impact a person’s functionality.

Common examples of stimuli for phobia are: Animals such as spiders, snakes, dogs, sharks Injections/blood The natural environment such as heights, the dark,

storms Common situations such as being in a lift Flying in an aeroplane Medical or dental procedures

DSM PHOBIA CATEGORIES

1. Animals

2. Situations

3. Blood / injections

4. Natural environments

5. Other (choking, dying, illness, falling etc)

SPECIFIC PHOBIA

Ophidiophobia

HOW MANY PHOBIAS?

Traditional phobia names use a Greek prefix Most specific phobias are not listed in the

DSM as there are literally too many to list Simply classified as ‘specific phobias’

ICD -10 uses the term ‘specific’ interchangeably with ‘isolated’

Some phobias are less specific eg. Agoraphobia

These are referred to as ‘complex phobias’

ANGLOPHOBIA- FEAR OF ENGLAND OR ENGLISH CULTURE

SPECIFIC PHOBIA

While many of these evoke anxiety in people to an extent, for it to be a phobia, a person must:

Experience or anticipate the experience of the object or situation as extremely anxiety-provoking if not terrifying

Must seek to avoid or minimise exposure to the object or situation

Be impaired in their social and occupational functioning as a consequence

The person may adapt their lifestyle to take into account their phobia. For example, they may never fly, or may never go into an area where they might see a snake. But for many people with phobias, encountering their phobia may be unavoidable as in the case of spiders, blood/injections or heights.

SPECIFIC PHOBIA

Ablutophobia

SPECIFIC PHOBIA Specific phobias are common with

up to one in eight people reporting a specific phobia over their lifetime.

Women are more than twice as likely to be affected as men regarding most phobias except blood/injection phobias, which are approximately equal.

Specific phobias also tend to start early, with animal and blood/injection phobias beginning early in childhood, and situational phobias usually by the early twenties.

Needle Phobia

PHOBIAS

TYRANNOPHOBIA- FEAR OF TYRANTS

APPLICATION OF THE BIOPSCHYOSOCIAL FRAMEWORK TO PHOBIAS

Looking at - Biological Factors Psychological Factors and Social/Environmental Factorsthat may influence onset of phobias and that may be used to help overcome phobic reactions.

About Specific Phobias

BIOLOGICAL FACTORS THAT MAY INFLUENCE SUSCEPTIBILITY TO PHOBIAS

Genetic inheritance

Neurotransmitter imbalance

BIOLOGICAL FACTORS THAT MAY INFLUENCE SUSCEPTIBILITY TO PHOBIAS

Genetic Factors It seems that specific phobias are more

common in close relatives of people with a specific phobia and most likely if your twin has a phobia. This suggests that genetic factors contribute to the transmission of the disorder, however, even if your twin has a specific phobia, there is an 80% chance that you won’t develop it, indicating that environmental and non-genetic factors are much more important.

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 – stops them passing on the neural impulse

Gets in the synapse to block transmission Helps fine tune brain activity, keeps neural

transmission from getting out of control

Without GABA neural activation could spread like fire throughout the brain causing seizures

GLUTAMATE

2nd most common neurotransmitter in the brain

Excitatory neurotransmitter Makes postsynaptic neurons more likely to

pass on the neural impulse Gets the post synaptic neuron excited so it

requires less stimulation to make it fire

Also plays a role in learning and memory, strengthening synaptic connections

GABA

Stop the message!

GLUTAMATE

Get the message going!

GABA AND ANXIETY

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

Benzodiazepines – a class of drugs that ‘calm down’ neural activity. Valiam, Xzanax, Rohypnol, Serepax etc.

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

Or Antagonists – inhibit the activity of a neurotransmitter

BENZODIAZEPINES - AGONISTS TO CONTROL PHOBIC REACTIONS

Mimic the activity of GABA in inhibiting post synaptic neural activity

Effective in the management of anxiety disorders

So anxiety disorders might be the result of a dysfunctional GABA system, not making enough neurotransmitter

One study showed that anxiety disorder sufferers have 22% less GABA than healthy individuals

Conversely studies show that antagonists can increase anxiety

GABA SUPPLEMENTS?

GABA like substances found in many foods, supplements also available from health food retailers

Unlike drugs that are specifically manufactured for the purpose, there is no evidence that supplements can penetrate the blood brain barrier

The blood brain barrier is a kind of filtration system that only allows certain substances into the brain

PSYCHOLOGICAL FACTORS THAT MAY IMPACT SUSCEPTIBILITY TO PHOBIAS

There are a number of psychological theories concerned with why people form phobias. These include: Freud’s Psychodynamic Theory Behaviouralist Theories Cognitive Theories

PSYCHOLOGICAL FACTORS – FREUD’S PSYCHODYNAMIC MODEL

Mental disorders are caused by unresolved conflicts that occur in the subconscious

‘Skeletons in the closet’ Memories that are too distressing are pushed

out of conscious awareness

As we grow up we progress through different psychosexual stages

• Oral 0 – 2• Anal 2 -3• Phalic 4 -5• Latency 6 – Puberty

FREUD’S PSYCHODYNAMIC MODEL

As we progress through these stages different parts of the body become the focus of attention and pleasure

Each stage has a critical developmental conflict that must be resolved to move onto the next stage

Unresolved conflicts cause anxiety

Freud’s anxiety refers to unpleasant feelings when our instincts make us do something that we will be punished for

FREUD’S PSYCHODYNAMIC MODEL

We use defence mechanisms to protect ourselves from this anxiety

The ego (conscious part of the mind) distorts, denies or falsifies reality unconsciously

We can then ‘believe’ that there is no reason to be anxious

We lie to ourselves to be happy

FREUD’S PSYCHODYNAMIC MODEL – OEDIPAL COMPLEX AND ELECTRA COMPLEX Child develops sexual attraction to his opposite-sex

parent Below conscious awareness Boys then fear their father who is bigger and

stronger, believes punishment will involve castration Tries to use Repression as a defence mechanism Child identifies with father – being like dad will mean

dad will be less inclined to punish me If this doesn’t work, Displacement can be used Anxiety directed onto another irrelevant object, then

the child can avoid this stimulus and thus solve the initial conflict but now we have a fear of the displacement object.

FREUD’S PSYCHODYNAMIC MODEL – PSEUDO SCIENCE?

Based on very small (unhealthy) samples Very subjective Can easily shift the facts to fit the theory Some useful ideas

Not used in its original form today by the majority of practicing psychologists but many psychologists still use the concept of an ‘underlying problem’ when trying to explain mental health problems.

Oedipal Complex

PSYCHODYNAMIC MODEL

PAPAPHOBIA- FEAR OF THE POPE

PSYCHOLOGICAL FACTORS: BEHAVIOURAL MODEL Behavioural theories (also known as conditioning or

learning theories) of specific phobia suggest that phobias are acquired through experience, an initial negative experience of an object or situation (neutral stimulus) is learnt or associated with anxiety and fear. This learning may then be negatively reinforced by the person’s avoidance of the stimulus as this behaviour ‘takes away the feelings of anxiety’.

Behavioural theorists are therefore suggesting that classical conditioning plays a role in the ‘acquisition’ of the phobia, and operant conditioning plays a role in the maintenance of the phobic behaviour.

PSYCHOLOGICAL FACTORS: BEHAVIOURAL MODEL

Phobias are learned

Learned through classical conditioning or observational learning (and possibly through operant conditioning)

Maintained through operant conditioning

BEHAVIOURAL MODEL – WATSON AND LITTLE ALBERT

BEHAVIOURAL MODEL

How might cynophobia, fear of dogs, be acquired through classical conditioning and then maintained through operant conditioning?

BEHAVIOURAL MODEL

Acquisition of a Cynophobia through Classical Conditioning

Neutral stimulus – Dog Unconditioned stimulus – Being bitten by

dog/Dog barking at a toddler Unconditioned response – Fear of the dog Conditioned Stimulus – Dog Conditioned Response – Fear of dog Generalised Conditioned Stimulus – All Dogs Generalised Conditioned Response – Fear of

all Dogs

BEHAVIOURAL MODEL Maintenance of Cynophobia

through Operant Conditioning Antecedent – Dogs, situation where a

dog could be present Behaviour – Avoidance of dogs at all

costs Consequence – Reduction/removal of

anxiety Type of Learning – Behaviour

maintained through negative reinforcement

BEHAVIOURAL MODEL

Behaviour theorists also suggest it is possible to acquire a phobia through operant conditioning. This could occur if the fear response exhibited to an antecedent stimulus is followed by a positive reinforcer.

How might cynophobia be acquired through operant conditioning?

BEHAVIOURAL MODEL Acquisition of Cynophobia through

Operant Conditioning Antecedent – Child sees a fierce dog Behaviour – Child screams and shows

a fear reaction Consequence – Mother cuddles child Type of Learning – Behaviour increased

through positive reinforcement – next time child sees a dog they scream because they want attention from the mother but this now strengthens the fear response pathway.

PSYCHOLOGICAL FACTORS: COGNITIVE MODEL

Focus is on thinking How do people process information? How do they think about the phobic

stimulus?

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

COGNITIVE MODEL – ATTENTIONAL BIAS

Seek out and notice threatening stimuli over normal stimuli

Eg. Arachnophobias might notice a spider web in the corner while everyone else is looking at the painting on the wall

Tend to be hyper vigilant – always looking out for the phobic stimulus

COGNITIVE MODEL – MEMORY BIAS

Remember the bad things more readily Eg. Only remember being dumped by a big

wave, not the hundreds of small waves that were enjoyable to jump over

Memories reconstructed to be worse than the actual event

COGNITIVE MODEL – INTERPRETIVE BIAS

Neutral situations or stimuli interpreted as threatening

Eg. Fluff on the carpet is a spider, a dog running over happily is going to attack

COGNITIVE MODEL – CATASTROPHIC THINKING

Negative thinking in which things are percieved in the ‘worst possible’ light

What can go wrong will go wrong, and in a big way

Often underestimate their ability to cope with the situation

SOCIO-CULTURAL FACTORS THAT MAY IMPACT SUSCEPTIBILITY TO PHOBIAS

There are a number of socio-cultural factors that may impact a person’s development of a specific phobia. These include: Specific Environmental Triggers Parental Modelling Transmission of Threat Information

SOCIO-CULTURAL FACTORS –SPECIFIC ENVIRONMENTAL TRIGGERS

Traumatic event involving the phobic stimulus Fear learned through classical conditioning Fear persists through operant conditioning

Research shows that the more severe the trauma the more likely it is that a phobia will develop

If the trauma is severe enough only one experience is necessary (unlike normal CC where repeated pairings are needed)

Not a complete explanation, some people do not develop phobias despite severe trauma

SOCIO-CULTURAL FACTORS – PARENTAL MODELLING

Child who observes an extreme fear reaction from a parent may imitate the same reaction

Modelling bravery can help children cope with fears

SOCIO-CULTURAL FACTORS – TRANSMISSION OF THREAT INFORMATION

Delivery of information from others about potential threat

Children might develop a phobia if constantly warned about the dangers of going outside alone

Research suggests that fears develop largely due to negative information about a specific event, object or situation being communicated often enough

SOCIO-CULTURAL FACTORS

Transmission of threat from parents, peers, teachers or the media about potential threats may lead to acute fear of the stimulus. For example, some movies such as ‘Jaws’ and ‘Anaconda’ led to people developing fears of sharks and snakes.

LUTRAPHOBIA- FEAR OF OTTERS

PSYCHOTHERAPEUTIC TREATMENT OF PHOBIAS

Psychoanalytic psychotherapy aims to uncover the unconscious ‘real object’ of anxiety that has been displaced onto the stated phobic object or situation. As this displacement from ‘real object’ to phobic object occurred early in childhood it is thought that as the person becomes older and more mature this realisation will be relatively less confronting and therefore resolved.

The realisation takes place in therapy sessions and could possibly involve hypnosis.



BEHAVIOURAL APPROACH TO TREATING PHOBIAS

Behavioural or conditioning theories propose a combined approach to the treatment of specific phobias.

The first is teaching the person relaxation strategies that allow them to control their anxiety response, such as control breathing and heart rate.

Once the person has mastered this they are subjected to an exposure therapy that may be graded – systematic desensitisation, or total – flooding.


Systematic desensitisation is an exposure therapy that uses a graded approach. After learning a relaxation technique, the phobic person is first exposed to a mild or trivial example of the feared stimulus, and allowed to relax in its presence. As they become less fearful, the intensity of the stimulus is gradually increased.

At each stage the person is allowed to acclimatise to the stimulus using the relaxation strategies before exposure to the next stage.

Although this may be a prolonged therapy, in the case of severe phobias, it is very effective.


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


How would we treat our cynophobic person using systematic densensitisation?


Flooding is similar to systematic desensitisation except that the final stage or the worst case scenario is the only one used. In flooding the worst possible situation is physically and continually presented. The situation is repeated until the person overcomes their fear and is able to tolerate the exposure.

Although flooding is a quick form of therapy, it may be extremely distressing (which leads to ethical problems) and does not appear to provide better results than systematic desensitisation.

CBT – BEHAVIOURAL COMPONENT

Flooding

Expose the patient to their fear straight away

They will panic at first

Soon realise that nothing bad has happened!


Overcoming a fear of balloons


How would we treat our cynophobic person using flooding?

COGNITIVE APPROACH TO TREATING PHOBIAS

A cognitive approach is often added to behavioural therapy, cognitive behavioural therapy or CBT.

This type of therapy aims to cognitively reconstruct the person’s thoughts and beliefs about the feared stimulus.

It does this by identifying and correcting negative and irrational thoughts and maladaptive beliefs. By providing alternative adaptive or corrective thoughts when the person is undergoing exposure therapy, it aims to facilitate the decrease in fear.


Three kinds of thoughts are targeted: The irrational or unfounded fear of the object The fear of fear, which prompts avoidance

behaviour The fear of being embarrassed in front of

others

COGNITIVE BEHAVIOURAL THERAPY

CBT is focused in the present Recognition that past events shaped now However the focus of CBT is changing the

current trend in thinking and behaving

Client taught to identify unhelpful thoughts and to shift thinking to more balanced helpful thoughts

Makes the client responsible for their thoughts rather than being a victim of them

CBT AND PHOBIAS

Tries to develop a new understanding of the phobic stimulus

Identify anxiety related thoughts and cognitive biases

Look at evidence that supports/rejects these biases

Switch from unhelpful irrational thoughts to evidence based rational thoughts


How would we treat our cynophobic person using cognitive behaviour therapy?

SOCIO-CULTURAL SUPPORT IN THE TREATMENT OF PHOBIAS

Like other mental health problems, an important factor in ensuring successful treatment is to have a good support network.

Good friends! Parents and peers need to be supportive –

showing an understanding of the condition and helping during therapy. It is especially important to not ridicule the individual as this may decrease the likelihood of the individual facing the phobic situation for fear of embarrassing themselves.

Parents and teachers need to ensure that the bias presented in the media is not seen to be the only information available.

SOME STRANGE PHOBIAS

Weird Phobias 1

Weird Phobias 2

Weird Phobias 3

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A NXIETY D ISORDER : P HOBIA Aaaaaaahhhhhhhhhh peaches!