Psychology - Phobias

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Classification and diagnosis of phobic disorders

Clinical characteristics of specific phobic disorders

  • an individual shows marked/persistent fear that is excessive or unreasonable
  • fear is cued by presence/anticipation of a specific object/situation
  • exposure to the phobic stimulus provokes immediate anxiety response such as a panic attack
  • in children, anxiety may be expressed as crying, tantrums, freezing or clinging
  • key characteristic is that the person recognises that their fear is excessive/unreasonable
  • characteristic distinguihses between a phobia and a delusional mental illness
  • individual is not aware of the unreasonabeleness of their behaviour 
  • avoidance or distress in the feared situation interferes significantly with the person's normal routine, occuptation, social activities or relationships
  • there is marked distress about having the phobia
  • distinguishes phobia from everyday fears that do not interfere with normal day-to-day living
  • panic attacks are a common symptom associated with phobias, especially agoraphobia
  • panic attack involves physical symptoms such as pounding hert, difficulty breathing, dizziness
  • in individuals under age of 18, duration is at least 6 months
  • anxiety, panic attacks or phobic avoidance should not be better accounted for by another mental disorder, such as OCD or post-trauamatic stress disorder
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Classification and diagnosis of phobic disorders

Issues of reliability and validity

Reliabilty

  • reliability refers to the consistency of a measuring instrument such as questionnaire or scale to assess how fearful a person is about certain objects/experiences
  • reliability of such questionnaires or scales can be measured in terms of 2 independent assessors give similar scores (inter-rater reliability) or whether the test items are consistent (test-retest reliability)
  • Inter-rater reliability - Skyre et al (1991)
  • assessed inter rater reliability for diagnosing social phobia
  • asked 3 clinicians to assess 54 patient interviews obtained using the Structured Clinical Interview (SCID-I)
  • there was high inter-rater agreement (+.72)
  • shows that diagnosis of phobia is reliable
  • Test-retest reliability - scales such as SCID take 1-2 hours to complete
  • alternative is to use shorter, structured, self-administered scales
  • are popular for specific phbias e.g Munich Diagnostic Checklist (MDC)
  • Hiller (1990) reported satisfactory to excellent diagnostic agreement in a test-retest study using the MDC
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Classification and diagnosis of phobic disorders

Issues of reliability and validity

Validity 

Comorbidity

  • comorbidity is an important issue for validity of diagnosis
  • refers to extent that 2 or more conditions co-occur
  • research has found high levels of comorbidity between social phobias, animal phobias, generalised anxiety disorder and depression (Kendler et al 1993)
  • Such comorbidity suggests that these conditions are not separate entities and therefore the diagnostic category is not very useful 

Concurrent validity

  • questionnaires and interviews are used in the diagnosis of phobic disorers
  • one way to demonstrate they are measuring what they intend to measure is to use concurrent validity
  • this establishes the value of a new measure of phobic symptoms by correlating it with an existing one
  • Herbert et al (199( established concurrent validity of Social Phobia Anxiety Inventory by giving the test to various other standard measures to 23 social phobics
  • SPAI correlated well with the other measures
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Classification and diagnosis of phobic disorders

Issues of reliability and validity 

Validity

Construct validity 

  • also used to assess diagnostic questionnaires and interviews
  • measures the extent that a test for phobic disorders really does measure a target construct (symptom) of phobias
  • clinicians identify possible target behaviours we would expect in someone with a phobic disorder
  • see if people who score high on the test for phobic disorders also exhibit the target behaviour
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Classification and diagnosis of phobic disorders

Evaluation

Reliability

Research evidence

  • SCID is a semi-structured interview requiring extensive training to administer
  • may explain the high reliability 
  • reliability has not always been found to be high 
  • Kendler et al (1999) used face to face and telephone interviews to assess individuals with phobias
  • over a one month interval (test-retest) found a mean agreement of +.46
  • reliability over the long term (8 years) was even lower at +0.30
  • on other hand, Picon et al (2005) found good test-retest reliability (better than +.80)
  • indicates that reliability can be good at least in the short term 
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Classification and diagnosis of phobic disorders

Evaluation

Reliability

Reasons for low reliability

  • Kendler et al (1999) suggest that the low reliability found in their study might be due to several factors
  • test-retest reliability might be due to the poor recall by participants of their fears
  • low inter-rater reliability might be due to the different decisions made by interviewers when deciding if the severity of a symptom does or does not exceed the clinical threshold for a symptom 
  • one clinician might conclude that a symptom is clinically significant whereas another could conlude severity does not exceed the clinical threshold
  • therefore, diagnosis is not made

Validity 

Comorbidity

  • findings on comorbidity have been supported in many other studies
  • Eysenck (1997) reported that up to 66% of patients with one anxiety disorder are also diagnosed with another anxiety disorder
  • implication is that a diagnosis should simply be 'anxiety disorder' rather than phobia or OCD
  • further support: Vasey and Dadds (2001)
  • reported that treatment success of anxiety disorders was unrelated to the original diagnosis of social phobia
  • same treatments worked equally well which means there's no benefit in making a specific diagnosis of one kind of anxiety disorder


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Classification and diagnosis of phobic disorders

Evaluation

Validity

Support for concurrent validity

  • Mattick and Clarke (1998) showed that their Social Phobia Scale (SPS) correlates well with behavioural measures of social phobia

Implications of low reliability and/or validity

  • in order to conduct research on the effectiveness of treatments for phobic disorders, researchers require a reliable and valid means of assessing the disorders in the first place
  • diagnosis and classification is critical, therefore
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Biological explanations of phobic disorders

Genetic factors

Family studies

  • research shows that having a family member with a phobic disorder increases the risk that an individual develops a similar disorder
  • Fryer et al (1995) found that probands had 3 times as many relatives who also experienced phobias as normal controls
  • Solyom et al (1974) found that 45% of phobic patients had at least one relative with the disorder, compared to 17% of non-phobic controls
  • relatives usually have the same disorder as the proband
  • Ost (1989) found that 64% of blood phobics had at least one relative with the same disorder

Twin studies

  • comparisons can be made between identical (monozygotic, MZ) twins and non-identical (dizygotic, DZ) twins
  • as MZ twins are genetically identical, a closer concordance rate between MZ twins and DZ twins is evidence for a genetic basis for phobic disorders
  • Torgersen (1983) compared MZ and same sex DZ twin pairs where one twin had an anxiety order with panic attacks
  • such disorders were 5 times more frequent in MZ twin pairs
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Biological explanations of phobic disorders

What is inherited?

  • oversensitive fear response can be explained in terms of the functions of the autonomic nervous system (ANS)
  • in some individuals there may be abnormally high levels of arousal in the ANS 
  • leads to increased amounts of adrenaline
  • additional theories concern dopamine pathways in the brain that predispose some people to be more readily conditioned to acquire phobias easily
  • abnormally high serotonin activity has been suggested as a cause of over sensitive fear response
  • affects those areas of the brain involved in the fear response, such as the amygdala
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Biological explanations of phobic disorders

Evolutionary approach

Ancient fears and modern minds

  • some stimuli are more likely to be feared than others, such as snakes, heights, storms, darkness, separation and leaving the home range
  • might be referred so as ancient fears
  • most modern day phobias are exaggerations of these ancient fears (Marks and Nesse 1994)
  • many other stimuli such as stones, leaves, shallow water were also part of our ancestors environment
  • because they posed no significant danger, are rarely feared

Propotency

  • Experiencing anxiety after than event has happened would not be an adaptive response
  • therefore, animals have evolved to respond to potential threats
  • those ancestors who were able to respond to ancient threats were more likely to survive and pass on their genes to subsequent generations
  • natural selection has shaped our nervous system so we attend more to certain cues than others
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Biological explanations of phobic disorders

Evolutionary approach

Preparedness

  • in addition to idea of prepotency, is a more flexible arrangement to have an innate readiness to learn about dangerous situations rather than inheriting rigid behavioural responses to specific situations
  • concept of biological preparedness (Seligman 1970) accounts for this
  • Seligman argued that animals, including humans, are biologically prepared to rapidly learn an association between particular stimuli and fear
  • once learned, association is difficult to extinguish 
  • what is inherited is therefore the predisposition to form certain associations rather than others, instead of inheriting a fixed fear of certain things
  • Rhesus monkeys rapidly develop a fear of snakes if they see another rhesus monkey showing fear towards a snake
  • however, same rapid association is not made if another rhesus monkey shows fear towards a flower (Mineka et al 1984)
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Biological explanations of phobic disorders

Evaluation

Genetic factors

Family and twin studies

  • provide modest support for the genetic basis of phobic disorders
  • there is considerable variability between disorders
  • Kendler et al (1992) estimated a 67% heritability rate for agoraphobia, 59% for blood/injury, 51% for social phobias and 47% for animal phobias
  • other studies have found even less support for genetic explanations
  • Torgerson found only 31% concordance for MZ twins in terms of anxiety disorders
  • found almost no concordance for DZ twins

Diathesis stress model

  • even at the highest rates, it is clear that phobic disorders are not solely genetic and have some considerable experimental component
  • combination can be explained by the diathesis stress model
  • genetic factors predispose an individual to develop phobias but life experiences play an important role in triggering such responses
  • important to remember that comorbidity between phobias and depression 
  • means genetic factors may predispose individuals to a range of different mental disorders
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Biological explanations of phobic disorders

Evaluation

Evolutionary approach

Prepotency

  • Ohman and Soares (1994) provided supporting evidence for prepotency effects
  • 'Masked' pictures were constructed of feared objects in such a way that animals in the pictures were not immediately recognisable
  • participants who were fearful of snakes or spiders showed greater GSR (indicates arousal of the ANS) when briefly shown masked pictures, compared to viewing neutral pictures or when compared to non-phobic participants
  • shows important components of phobic responses are set in motion before the phobic stimulus is represented in awareness

Preparedness

  • two important predictions arising from concept of prepareness are that we learn certain fears more readily and that such fears are harder to unlearn
  • McNally concluded that although there was firm evidence for enhanced resistance to extinction of fear responses conditioned by 'prepared' stimuli', evidence for rapid acquisition was equivocal
  • Davey (1995) proposed a simpler explanation - expectancy biases
  • expectancy bias is an expectation is an expectation that fear relevant stimuli will produce negative consequences in the future
  • therefore, no need to invoke past evolutionary history
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Biological explanations of phobic disorders

Evaluation

An evolutionary approach

Clinical phobias

  • Merckelbach et al (1988) found that most of the clinical phobias in their sample were rates as non-prepared rather than prepared
  • research has found that clinical phobias do not display the suddenness of onset and resistance to treatment predicted by preparedness (de Silva et al 1977)
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Psychological explanations of phobic disorders

Psychodynamic

  • Sigmund Freud was the first to offer a psychological explanation forn the origins of phobias
  • proposed that a phobia was the conscious expression of depressed conlifcts
  • ego deals with conflict by protecting itself and repressing emotions into the unconscious mind
  • Freud believed that such repressed conflicts continued to create anxiety which the mind deals with in various ways
  • include expressing repressed thoughts in dreams, displacing repressed anxieties onto a neutral object/situation
  • illustrated this explanation with the study of Little Hans
  • Hans recovered from his phobia once has was able understand and accept his real anxieties about his mother, father and sister
  • according to Freud, this demonstrated that the source of the phobia was the repressed anxiety
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Psychological explanations of phobic disorders

Behavioural

Classical conditioning

  • fears are acquired when an individual associates a neutral stimulus such as a bunny with a fear response
  • can be demonstrated in cases such as Little Albert
  • in this case the original unconditioned stimulus is a loud noise, and the unconditioned response is fear
  • by pairing the loud noise with the fluffy object, the fluffy object now become a conditioned stimulus
  • has acquired the same properties
  • next time Albert saw a fluffy object he cried, presumably because he was scared

Operant conditioning

  • Mowrer (1947) proposed that learning phobias involves more than classical conditioning
  • described the acquisition of phobias in his two-process theory
  • first stage is classical conditioning, in the second operant conditioning occurs
  • avoidance of the phobic stimulus reduces fear and is thus reinforcing
  • person avoids anxiety created by avoiding them entirely
  • fact no anxiety is experienced from this avoidance behaviour is positively reinforcing
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Psychological explanations of phobic disorders

Social learning

  • extreme fears (phobias) may be acquired through modelling the behaviour of others
  • e.g seeing a parent responding to a spider with extreme fear may lead a child to acquire a siilar behaviour because the behaviour appears rewarding i.e the fearful person gets attention

Cognitive

  • phobias may develop as a consequence of irrational thinking
  • thoughts create extreme anxiety and may trigger a phobia
  • Aaron Beck (Beck et al 1985) proposed that phobias arise when people become afraid of situations where fears may occur
  • suggested that a social phobias may develop because 'a person develops the dysfunctional belief that no one likes them'
  • this belief develops into a fear of social rejection ad individual avoids situations which are likely to produce fear
  • Beck also argued that social phobics tend to over-estimate their fears, therefore increasing the likelihood of phobias
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Psychological explanations of phobic disorders

Evaluation

Psychodynamic

Little Hans

  • Freud only provided one piece of evidence to support his explanation of phobias
  • this was the case study of Little Hans
  • there are 2 main problems of this
  • Hans' phobia could easily be explained in terms of classical conditioning
  • Case study concerns one unique individual and therefore can't be generalised to the wider population
  • Hans study has ben further criticised because of lack of objectivity 
  • Both Hans' father and Freud interpreted the evidence according to their expectations about the origins of phobias

Research support

  • Bowlby (1973) found that agoraphobics often ad early experiences of family conflict
  • suggested that such conflicts lead a young children to feel very anxious when separated from their parents (separation anxiety)
  • such fears are suppressed but later emerge as agoraphobia 
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Biological explanations of phobic disorders

Evaluation

Behavioural

Conditioning

  • people with phobias often recall a specific incident when their phobia apepared
  • e.g being bitten by a dog/experiencing a panic attack in a social situation (Sue et al 1994)
  • supports the behavioural explanation of phobias
  • not everyone who has a phobia can recall such an incident
  • possible that such traumatic incidents did happen, but have since been forgotten (Ost 1987)
  • not everyone who has been bitten by a dog develops a phobia of dogs (Di Nardo et al 1988)
  • could be explained by the diathesis stress model
  • only those with a genetic vulnerability for developing anxiety disorders would become phobic after such an event

Biological preparedness

  • fact that phobias do not always develop after a traumatic experience could be explained by biological preparedness
  • Bregman (1934) failed to condition a fear response in infants aged 8-16 months by pairing a loud bell with wooden blocks
  • may be that fear responses are only learned with living animals, a link with ancient fears

Social learning

  • experiment by Bandura and Rosenthal (1966) supported the social learning explanation 
  • in the experiment, model apparently experienced pain every time a buzzer sounded
  • later on, participants who observed this showed an emotional reation to the buzzer, demonstrating an acquired 'fear' response
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Psychological explanations of phobic disorders

Evaluation

Cognitive 

Dysfunctional assumptions

  • there is support for the veiw that phobics have dysfunctional assumptions
  • Gournay (1989) found that phobics were more likely than normal people to overestimate risks
  • might mean they are generally ore fearful
  • results in them being more predisposed to develop phobias 

Success of CBT

  • CBT as a treatment for phobias can be seen as support for the explanation
  • can be argued that, if a therapy changes the dysfunctional assumptions a preson has and this leads to a reduction in their phobia, then the dysfunctional assumptions may originally have caused the disorder
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Biological explanations of phobic disorders

Chemotherapy

Anti-anxiety drugs

  • BZs are commonly used to reduce anxiety
  • work by slowing down activity of the central nervous system by enhancing the activiy of GABA
  • does this by reacting with special sites (GABA receptors) on the outside of the receiving neurons
  • when GABA locks into these receptors, opens a channel which increases the flow of chloride ions into the neuron
  • chloride ions make it harder for the neuron to be stimulated by other neurotransmitters
  • slows down its activity and makes the person feel more relaxed

Beta-blockers

  • used to reduce anxiety
  • work by reducing the activity of adrenaline and noradrenaline which are part of the sympathmedullary response to stress
  • beta-blockers bind to receptors on cells of the heart and other parts of the body that are usually stimulated during arousal
  • by blocking these receptors, is harder to stimulate cells in these parts of the body
  • heart beats slower and with less force
  • blood vessels do not contract so easily
  • results in fall in blood pressure and less stress on the heart
  • person taking medication will feel calmer and less anxious
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Biological explanations of phobic disorders

Chemotherapy

Antidepressants

  • also used to reduce anxiety
  • SSRIs are currently the preferred drug for treating anxiety disorders
  • SSRIs such as Prozac increase levels of neurotransmitter serotonin which regulates mood and anxiety
  • another antidepressant, MAOI, has been used for anxiety disorders
  • they are an older class of antidepressants and are rarely used now
  • however, some patients respond better to them than the newer ones
  • Monoamine oxidase is the enzyme responsible for breaking down monoamine neutransmitters (such as serotonin, noradrenaline, dopaine)
  • inhibitor prevents this happening leading to higher levels of monoamines
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Biological explanations of phobic disorders

Evaluation

Effectiveness of chemotherapy

Anti-anxiety drugs

  • Kahn et al (1986) found that BZs were more effective than a placebo treatment in reducing anxiety
  • Hildalgo et al (2001) that BZs were more effective than anti-depressants 
  • Research studies have also shown that the benefits may be largely explained in terms of placebo effects
  • Turner et al (1994) found no difference beween a beta-blocker and placebo group in terms of reduced hear rate, feelings of nervousness and so on

Antidepressants

  • by contrast, MAOIs have been found to be more effective than placebos and mre effective in the reduction of anxiety than beta-blockers (Liebowitz et al 1992)
  • further study compared the use of SSRIs and placebo treatment
  • study found improved level of self-rated anxiety (Katzelnick et al 1995)
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Biological explanations of phobic disorders

Evaluation

Appropriateness of chemotherapy

Not a cure

  • Generally drugs not considered to be the primary treatment for specific phobias
  • these phobias tend to interfere less with day to day life than social phobias
  • chemotherapy is appropriate when panic attacks accompany specific phobias and also social phobia
  • drugs cannot provide a complete treatment as they simply focus on symptoms 

Side effects

  • possible side effects of BZs include increased aggressiveness and long term impairment of memory
  • recent research has suggested negative effects might be turned to positive use 
  • Beta blockers have few, if any, side effects
  • there are many problems associated with anti-depressants
  • SSRIs have been linked to increased suicides and MAOIs have a list of related issues such as dizziness, insomnia, drowsiness, blurred vision

Addiction

  • can be a problem with BZs, even when only low doses are given 
  • for this reason the recommendation is that they should be used for a maximum of four weeks (Ashton 1997)
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Psychological therapies for phobic disorders

Psychological therapies

Behavioural therapy: systematic desensitisation (SD)

Counterconditioning

  • process begins with learning relaxation techniques
  • eventual aim is to acquire a new stimulus-response link
  • move from responding to a stimulus with fear to responding to the feared stimulus with relaxation
  • this is called counterconditioning because the patient is taught a new association that runs counter to the original association
  • Wolpe also called this 'reciprocal inhibition' because the relaxation inhibits the anxiey

Cognitive theory: REBT

  • Rational Emotive Behaviour Therapy was developed by Albert Ellis in the 1950s
  • was a cognitive approach because psychological problems are seen as the result of irrational thinking
  • phobia aims to tackle irrational thoughts and turn them into 'rational' ones
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Psychological explanations of phobic disorders

Cognitive therapy: REBT

ABC Model

  • Ellis proposed that the way to deal with irrational thoughts was to identify them using the ABC model
  • 'A' stands for the activating event - a situation that results in feelings of frustration and anxiety
  • such events lead to irrational beliefs (B) and the beliefs lead to self defeating consequences (C)

Evaluation

Effectiveness of SD

  • research has found SD is successful for a range of phobic disorders
  • McGrath et al (1990) reported that about 75% of patients wih phobias respond to SD
  • Key to success appears to lie with actual contact with the feared stimulus
  • in vivo techniques are more successful than covert ones
  • ofen a number of different exposure techniques are involved
  • in vivo, cover and also modelling, where the patient watches someone else who is coping well with the feared stimulus (Comer 2002)
  • Ohman et al (1975) suggest that SD may not be as effective in treating phobias that have an underlying evolutionary survival component than in treating phobias that have been acquired as a result of personal experience
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Psychological explanations of phobic disorders

Appropriateness of SD

Strengths

  • Behavioural therapies for dealing with phobias are generally relatively fast and require less effort on the patient's part other than psychotherapies where patient must play a more active part in their treatment
  • further strength of SD is that it can be self adminstered 

Symptom substitution

  • SD may appear to resolve a problem but simply eliminating or suppressing symptoms can result in other symptoms appearing (symptom substitution)
  • Langevin claims that there is no evidence to support this objection

Effectiveness of REBT

  • has generally shown to be effective in outcome studies
  • in meta-analysis (Engels et al 1993), concluded REBT is an effective treatment for a number of different types of disorder including social phobia
  • Ellis (1957) claimed a 90% success rate, taking an average of 27 sessions
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Psychological explanations of phobic disorders

Appropriateness of REBT

Not suitable for all

  • REBT doesn't always work
  • Ellis (2001) believed sometimes people who claimed to be following REBT principles were not putting their revised beliefs into action
  • therapy was therefore not effective
  • Ellis also explained lack of success in terms of suitability
  • some people simply do not wan the direct sort of advice that REBT practitioners tend to dispense
  • prefer to share their worries with a therpist, without getting involved with the cognitive effort that is associated with recovery
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