Phobic Disorders

The clinical characteristics of phobias include:

• Panic attacks (e.g. crying, difficulty breathing, pounding heart or stomach upset)
• An immediate anxiety response follows exposure
• Recognising that the fear is irrational (this may be absent in children)
• Avoidance of the phobic stimulus/situation interferes with daily life

Reliability refers to the consistency of a measuring instrument e.g. questionnaire or scale of fear perception. Inter-rater reliability asks one or more clinicians to judge/assess a scale etc. and if there is a general consensus, reliability is high. Test-retest reliability measures consistency over time: a test is repeated by the same participant, but over a period, and if results are similar, reliability is high.

Validity is whether a test is measuring what it set out to. Comorbidity suggests that if more than one disorder occurs side by side, then diagnostic categories may not be useful as deciding what disorder to treat is a problem. Concurrent validity establishes validity by comparing the results of one measure with another similar, established measure. Construct validity is attempting to assess validity if it is really measuring the theoretical concept it is meant to be.

Reliability issues refer to the consistency of a measuring instrument e.g. a questionnaire

• Inter-rater reliability: Skyre et al 1991 assessed this for diagnosing social phobia by asking 3 clinicians to assess 54 patient interviews obtained with the SCID-I. High inter-rater agreement (+0.72)
• Test-retest reliability: SCID takes 1-2 hours to complete; the alternative is the shorter, self administered MDC. Hiller et al 1990 reported satisfactory/excellent diagnostic agreement

Validity refers to the extent that a diagnosis represents something that is real/distinct from other disorders; if it is measuring what is intended to be measured. Validity and reliability are inextricably linked

• Comorbidity is the extent that two (or more) conditions co-occur. Kendler et al has found high levels of comorbidity between social phobias, animal phobias, generalised anxiety disorder and depression. So maybe conditions are not separate entities and therefore diagnostic category is not useful (when diagnosing)
• Concurrent validity is establishing the value of a new measure against an original one. Herbert et al 1991 established the concurrent validity of SPAI by giving the test to 23 social phobics; correlated well with other measures
• Construct validity is the extent that a test for phobic disorders really does measure a target construct (symptom) of phobias
  

• Family studies: having a proband increases the risk an individual develops a similar disorder. Fyer et al 1995 found probands had 3 times as many relatives who also experienced a similar phobia than the normal controls. Solyom et al 1974 found 45% of phobic patients had at least one relative with the disorder compared to 17%. Ost 1989 found 64% of blood phobics had a relative with the same
• Twin studies: comparisons can be made between identical (MZ) and non-identical (DZ) twins. A closer concordance rate between MZs and DZs is evidence for a genetic basis. Torgerson 1983 compared 85 MZ and same sex DZ twins where one had an anxiety disorder. Disorders were five times more frequent in MZ twin pairs.
• People could inherit an oversensitive fear response e.g. panic attacks. Once an individual has experienced one this creates further anxiety one will happen in the future. Explained in terms on the ANS, this leads to increased levels of adrenaline (adrenergic theory). OR dopamine pathways in the brain predispose people to be more readily conditioned to acquire phobias

EVALUATION: Kendler et al 1992: variable heritability rates between disorders. Torgerson only found 31% concordance for MZ twins; less for DZ. Problems with twin/family studies is that the environments are not controlled.

Diathesis stress model combines genetics and the environment (inherited predisposition is triggered environmentally)

Tiihonen et al 1997 found lower numbers of dopamine re-uptake sites in social phobia sufferers. Drug therapies have been effective. There are cause and effect issues, however.

• Ancient fears, modern minds: some stimuli e.g. heights, darkness, storms and strangers presented a threat to our ancestors, so modern day phobias are an exaggeration of this (Marks and Nesse). Other stimuli e.g. leaves and shallow water did not pose a threat so are less likely to be feared. At the same time, recent dangers e.g. cars and electricity have not been around long enough to be feared.
• Prepotency is something with power prior to the event: our ancestors who could respond to potential ancient threats appropriately were more likely to survive and pass on genes. Natural selection then shaped our nervous system so we attend to some cues e.g. loud noises more than others.
• Preparedness is the innate readiness to learn about dangerous situations rather than inheriting rigid behavioural responses. Biological preparedness (Seligman 1970) argued animals are prepared to learn an association between life threatening stimuli and fear, which is then difficult to extinguish. For example, Marks 1987 said when an infant sees a stranger, it looks at the mother to gauge a response; if it is fearful, the infant will show a similar reaction. However it is not a reaction to all stimuli: Mineka et al 1984 found rhesus monkeys rapidly developed snake phobias if they saw another monkey acting the same, but they did not acquire the same fear towards flowers.

• Freud proposed that phobias were the conscious expression of repressed conflicts between the ego, id and superego in the unconscious mind. The ego repressed these conflicts as a defense mechanism, but continue to show themselves in various ways e.g. dreams or displacement (where the conflict is displaced onto a neutral stimulus/situation)
• Little Hans (1909) was a 5 year old who had a phobia of horses. He heard cautionary tales of horses; he asked his mother to touch his penis (whereby he became afraid of her leaving him); he saw a horse and cart fall down and thought it was dead. Freud suggested Hans projected his source of anxiety (his mother leaving) onto the horse that would "bite him". Then, he symbolised his father as a horse that "died" and his mother as a cart that "gave birth" when it collapsed. These three things filled him with anxiety.

EVALUATION: Little Hans has several issues e.g. subjective evidence from the father, possible unreliable accounts, interpretations are subjective, case studies cannot be generalised and Hans' phobia could easily be interpreted by classical conditioning.

Has been supported by Bowlby 1973 who found agoraphobics had early experiences of family conflict and developed separation anxiety. Whiting et al 1966 found occurence of phobias was higher in structured child rearing societies, leading children to repress desires. Psychodynamic approach targets underlying causes; this is possibly where other explanations fail.

• Classical Conditioning in terms of Watson and Rayner's Little Albert case study (1920): UCS was a loud noise and the UCR was fear. Fluffy white objects e.g. a rat, a bunny and cotton wool were paired with the UCS. Over time, the fluffy objects became a CS, producing a CR. Little Albert had learned to associate the fluffy objects with the loud noise.
• Mowrer 1947 suggested learning was a two-process theory, introducing operant conditioning into the process. The first stage is classical, but the second is operant e.g. the avoidance of the phobic stimulus/situation reduces fear and therefore negatively reinforces the individual. Then, avoiding them entirely means no anxiety is experienced, positively reinforcing them.
• Social Learning Theory suggests extreme fears are acquired thorugh observation and modelling e.g. seeing a parent react fearfully to a spider may lead a child to imitate because the behaviour appears rewarding e.g. by gaining attention.

EVALUATION: Sue et al says people often recall a specific incident when their phobia appeared e.g. a dog bite. However Ost 1987 says not everyone recalls such an incident, or have since been forgotten. DiNardo uses the diathesis-stress model to suggest why not everyone who was bitten by a dog develops a fear. Bandura and Rosenthal 1966 did an experiment where a model 'experienced pain' when a buzzer sounded; later on, observing participants has an emotional reaction to the buzzer.

• Aaron Beck 1985 suggests that phobias are developed by irrational thinking e.g. 'if I get trapped in a lift I will suffocate'; so fears arise because people become afraid of situations where fears occur; therefore these situations are avoided. Beck also argued that phobics tend to overestimate their fears, increasing the likelihood of phobias occuring

EVALUATION: Gournay 1989 said phobics were more likely to overestimate risks which means they may generally be more fearful and results in an increased phobia predisposition. Also, Cognitive Behavioural Therapy or CBT has had success as a treatment because it changes the dysfunctional assumptions, suggesting they were the cause in the first place

However all of the psychological explanations are reductionist by condensing complex human behaviour to a simple set of principles like irrational thoughts. It is more likely that a combination of factors work together.

• Chemotherapy consists of anti anxiety drugs e.g. Benzodiazepines (Xanax) that increase the natural GABA (gamma-amino-butyric-acid) which has a 'quietening' effectby reacting with GABA receptors and releasing chloride ions that make it harder for a neurone to be stimulated; beta-blockers reduce the activity of adrenaline/noradrenaline (part of the sympathomedullary pathway) by binding to heart cell receptors and making them more difficult to stimulate, this reduces blood pressure and heart rate; anti-depressants (including SSRIs or Selective Serotonin Re-uptake Inhibitors e.g. Zoloft which increase serotonin that regulates mood, and MAOIs which inhibit monoamine oxidase - an enzyme responsible for breaking down monamine neurotransmitters like serotonin and dopamine). 
• Psychosurgery is often a last resort when a pathological cause cannot be found. Capsulotomy and cingulotomy (part of the limbic system - to do with emotions) sever the connections between the organs. Deep brain stimulation involves placing wires in target areas of the brain and when the current is on, target circuits are interrupted and reduce symptoms.

EVALUATION: Kahn et al 1986 found BZs more effective than placebos; Hildago et al said they were more effective than anti-depressants. Turner et al 1994 found no difference between beta-blocker and placebo group. Liebowitz et al found MAOIs more effective than placebos and beta-blockers; Katzelnick et al 1995 found improved levels of self-rated anxiety with SSRIs. However drugs only treat symptoms, not the cause. Addiction can be a problem (to BZs); also, reliance on the drugs. Side effects of BZs include aggression and memory impairment (this could be beneficial however). Ruck et al studied 26 patients with non-obsessive anxiety disorders who had a capsulotomy; the mean pre-op anxiety score was lowered from 22.0 on the Brief Scale for Anxiety to 4.6 a year later. However the negative symptoms were great e.g. 7 people trying to commit suicide and 2 epileptic seizures. Szasz (1978) criticised psychosurgery, saying a person's psychological self is not physical so it is illogical to operate upon.

Behavioural Therapy: Systematic Desensitisation (SD) Wolpe (1950): Counterconditioning: relaxation techniques are learnt to teach the patient a new association by acquiring a new stimulus-response link: 'reciprocal inhibition' because relaxation inhibits anxiety. Desensitisation hierarchy is worked out between therapist and patient and proceeds through gradual steps from least fear inducing to most. Can be in vivo (where patients confront their fear directly) or in vitro (or covert, the therapist asks to imagine the feared stimuli).

Cognitive Therapy: Rational Emotive Behaviour Therapy (REBT) Ellis (1950): ABC model: Activating event leads to a Belief (either rational or irrational) which results in a Consequence (a rational or irrational behaviour). By disputing these irrational thoughts either logically (does this make sense?), empirically (where is the proof?) or pragmatically (is this useful?), patients move from catastrophising to having rational interpretations that help them feel better.

EVALUATION: McGrath et al 1990 reported 75% success with SD. Menzies and Clarke 1993 said in vivo techniques better than covert ones. Ohman et al 1975 suggests SD may not be as effective in treating phobias with an underlying evolutionary component e.g. darkness or heights. However SD is fast and require less effort on the patient's part than REBT. SD can be self-administered which has proved successful with social phobia (Humphrey 1973). SD may cause symptom substitution. SD more to do with exposure than relaxing; Klein et al said the 'active ingredient' was the hopeful expectancy that the phobia can be overcome. Engels et al said REBT successful with a number of disorders including social phobia. Ellis 1957 claimed a 90% success rate but not all people put principles in place; some people just want a therapise to discuss worries with, without cognitive effort. Alloy and Abrahmson said irrational beliefs may be counterproductive but realistic e.g. depressed people gave more accurate estimates of disasters than normal controls.