Pyschopathology

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Phobic disorders

Almost everyone has aversions to certain things e.g. heights and spiders etc. When an aversion becomes an excessive and unreasonable fear then it's classified as a phobia. Although people with phobias usually acknowledge that their anxiety is out of all proportion to the actual danger posed by the stimulus, this does nothing to reduce their fear.

Diagnosis of phobias includes:

  • Persistant fear of a specific situation which is out of all proportion to the real danger.
  • They have a sense that something catastrophic will happen e.g. a panic attack
  • A compelling desire to avoid and escape the situation e.g. not going over bridges.
  • Recognition that the fear is unreasonably excessive. The person is consciously aware that they have a problem but feels unable to control their behaviour.

There are 3 catergories of phobia (DSM-IV):

  • Agoraphobia: A fear of open spaces, majority are women. They are anxious when they are away from home, in crowds.
  • Social phobia: An intense and excessive fear of being in a social situation. Occur in about 3-7% of population.
  • Specific phobia: Innapropriately anxious in the presence of a particular object or in a specific situation.
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The Symptoms of Fear

Cognitive:

  • There is an expectation of impending harm
  • We worry what will happen and often anticipate dire consequences

Behavioural:

  • Not being able to move (freezing) or running away (fleeing) or avoidance behaviour

Emotional:

  • Feelings of dread, terror, panic etc. If we experience these feelings over a long period of time we feel feel dranined and overwhelmed.

Physical

  • The bodys emergency reaction to danger. The sympathetic nervous system is activated (Fight or flight response).
  • We show involuntary physiological responses, such as a dry mouth, palpitationas, tensed muscles and sweating.
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Issues of classification and diagnosis of phobias

There is more than one classification system: There are currently two widely established systems for classifying mental disorders - ICD-10 produced by the World Health Organisation and the DSM-IV produced by the American Psychiatric Assosiation. The DSM and ICD differ in some respects so diagnoses depend on which system you use. There is reasonably good agreement between between the DSM and ICD

The myth of mental illness: Thomas Szasz would argue that md's such as phobias are a myth - phobias are simply problems of living - a fear of something is in most cases something we should fear. Over medicalising the problem makes it worse and takes power away from the person to deal with the issues themselves. Szasz believes that because diagnostic systems are based on the medical model it leads to the pathologising of mental disorders. In other words we see mental disorders such as phobias as mental illnesses such as phobias as mental illnesses when they are actually just symptoms of the problems of living.

Stigmitizing: Diagnosis can produce benefits in terms of rapid and effective treatment but it can also have negative effects in terms of labelling. Once labelled, someone with a phobia may suffer adverse consequences and be treated differently by society. Doctors may interpret all medical things which happen to them in terms of their phobia.

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The rationale for classifying and diagnosing

A diagnosis of a mental disorder is also not as straightforward as the as the diagnosis of physiological conditions. This is because although there have been huge improvements in the classification system there is still room for subjective interpretation on the part of the psychiatrist. For example the first diagnostic criteria for specific phobias states:

'Marked and persistent fear that is excessive or unreasonable....'

Clearly a subjective judgement needs to be made with regards to what constitutes 'marked and persistant'. Given the problems with classification and diagnosis it is perhaps worth considering why professionals believe it is worth classifying and diagnosing mental disorders. The major reason to classify a mental disorder is so that we can provide individuals with a diagnosis so that we can target appropriate treatments towards them,

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Issues in the diagnosis of phobias

Phobias have a distinct set of easily observable symptoms so we would expect their diagnosis to have good reliability. With regards to phobias, this is in fact largely the case at least in comparison with other mental disorders particularly depression when it is often difficult to distinguish clinical depression from ordinary variations in mood.

Smoller (2007) has discussed the construct validity of phobias.  For example social phobia and avoidant personality disorder  overlap considerably. This calls into question the existence of social phobia as a distinct disorder. Many people diagnosed with one anxiety disorder also show signs of another anxiety disorder. Many people diagnosed with one anxiety disorder also show signs of another anxiety disorder and this raises issues about the validity of some of the categories as distinct symptoms.

Categories of mental disorders should not overlap and an ideal diagnostic system should not allow 2 categories of mental disorders to contain the same signs and symptoms. Social phobias are particularly hard to diagnose as some people are extremely shy and this is hard to distinguish from a true social phobia. Phobias can co-occur making it difficult to identify which should be treated. This is important as establishing the primary disorder influences the treatment offered.

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Issues with classification

To a large extent the most recent DSM achieves this aim. For example:

  • There are some similarities between people with specific ilness phobias and people with hyponchrondria. However someone with SIP fears they might contract a particular illness e.g. AID's or cancer even thogu hthey recognise that their fears are irrational
  • People with social phobias can often sugger from agoraphobia or panic disorder. Both diagnoses can be made but most clinicians prefer to identify one as the primary disorder because this has implications for treatment. Some mental disorders precede others.

However in the DSM, there are many similarites beteen social phobia and avoidant personality disorder. In theory, social phobia has a recognisable onset and a shorter duration but in practice it can be difficult to differentiate. Many people demonstrate characteristics that meet the criteria for both diagnoses which again threatens the validity of the DSM

The implication of this assumption of seperate categories is that a person is either 'normal' or abnormal. While this is often the case there are many people who are for example apprehensice in particular social situations. In reality there is a continum of behaviour from slightly apprehensive to out right crippling social phobia. The issue is when the boundary is crossed from normal wariness of spiders for example to abnormality in the form of arachnophobia.

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Explanations/Causes of phobias

Biological explanations - genes

  • Psychological disorders are caused by the same biological factors as physiological disorders. The medical model of abnormal behaviours is that mental disorders are illnesses caused by something 'going wrong' with normal bodily functions.
  • We have an evolutionary predisposition to fear what posed a danger to our ancestors
  • Some of us inherit a genetic predisposition to fear what posed a danger a danger to our ancestors
  • Anxiety is caused by disrupted biochemisry or other abnormal brain activity

Genes may be one possible for some anxiety disorders such as phobias. There are 3 main ways of investigating genes:

  • Family history
  • Twin studies
  • Adoption studies
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Family History studies

Solyom et al (1974) - a study of 47 phobic patients found a family history of phobic disorders in 45% of the cases in contrast to only 19% in families of a non-phobic control group of patients.

Noyes et al (1986) - Found a higher than normal rate of agoraphobia (12%) and panic disorders (17%) in first degree relatives using the family interview method compared to other types of disorder.

Last et al (1991) - The researchers found that a significantly higher proportion (35%) of first degree relatives of people with an anxiety disorder also had an anxiety disorder to only 25% of relatives of people with a non-anxiety disorder (e.g. depression)

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Twin studies

Togerson (1983) - found a 31% concordance rate in 13 MZ twins for panic disorder and agoraphobia compared to a zero concordance in 16 DZ pairs. However, none of the MZ twins shared the same phobia.

Kendler et al (1992) - interviewed 722 female twins with a lifetime history of phobias. They that MZ twins had a significantly lower concordance rate for agoraphobia that DZ twins, with runs counter to the genetic hypothesis. The researcher suggested that this finding might reflect a protective effect of the close emotional bond of MZ twins.

Temperament - Another genetic feature in the development of anxiety disorders has to do with the fundamental temperant a person was born with. Studies has suggested that some children are born with the trait of nervousness, Kagan et al (1988) found that some children were socially inhibited even in the first 2 years and that this trait remained consistant until the age of 7. It is therefore possile that some people are born with anxiety-related temperaments.

Biological preparedness - Rosenhan and Seligman (1984) proposed that there is an interaction between genes and conditioning that biologically predisopses us to phobias towards certain stimuli. According to this idea, we are genetically prepared to fear things which, in evolutionary past, were a source of danger to us. In support of this, there is less phobias of guns and knives, even those they are potentially just as harmful as snake and spiders. Seligmen (1971) argues that humans are 'prepared' by the process of natural selection to fear certain thing (mostly creature).

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Evaluation of biological preparedness

Cook and Mineka (1989) studied monkeys and found that they quickly learnt a phobia for snakes by watching other monkeys show a fear of snakes. However, the monkeys did not become fearful of artifical flowers when doing the same thing. Although this study shows that phobias can be learnt through observation, it also seems to suggest that there is a genetic tendency to develop certain types of phobias over others.

The fact that there is a greater incidence of phobias of 'creepy-crawlies' compared to non-natural stimuli, does not necessarily imply a genetic predisposistion to fear certain objects based on our evolutionary past. Because we live in a society in which many people react negatively to certain animals, learning processes rather than genetic elements may account for such fears.

This theory can account for individual differences. Seligmans theory of biological preparedness cannot explain why some people have extreme and seemingly bizarre phobias of harmless stimuli such as shirt buttons, water or even oneself. Likewise, this theory cannot explain why some people have no fear of potentially harmful objects to the extent they even enjoy close encouters with poisonous snakes or jumping out of planes etc.

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Biochemical explanations of phobias

GABA - a neurotransmitter that is automatically released, binds to receptors and inhibits neurone activity, therefore reducing arousal levels and decreasing anxiety.

The effect of benzodiazines studies of people treated with benzodiazines such as valium. There work like GABA by binding to neuroreceptors and decreasing arousal and anxiety.

The amygdala is a part of the brain activated in response to a threat. PET scan evidence shows that people with phobias have an increased blood flow in the the amygdala.

When people with a specific phobia were exposed to the phobic stimulus they had a startled response. This increased activity in the amygdala.

Evalutation

  • Successful treatment using the drug citopram or cognitive behaviour therapy has been shown to increase blood flow in the amygdala.
  • Not all people with phobias show blood flow abnormalities and it is not clear whether they are not a casual factor or result of a phobic disorder.
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Biological therapies for phobias

The medical model of abnormal behaviours that mental disorders are illnesses caused by abnormality in normal bodily functions for example an imbalance of neurotransmitters. Biological treatments are designed to correct this imbalance through the administration of drug treatments or ECT.

  • Anti-anxiety drugs (Benzodiazepines) - commonly used to reduce anxiety. They slow down the activity of the CNS by enhancing the activity of GABA, which is a neurotransmitter that has a quieting effect on many of the neurones in the brain.
  • Beta blockers - also used to reduce anxiety. They work by reducing the activity of adrenaline and noradrenaline which are part of the response to stress. This results in a fall in BP, and so less stress of the heart. The person taking the medication will feel calmer and less anxious.
  • Anti-depressants (SSRIs) - increase levels of serotonin which is a neurotransmitter that regulates mood and anxiety.
  • Psychosurgery - Capsulotomy and Cingulotomy. Functionally remove the connection either above or below the organ. They are part of the limbic system which is the region of the brain associated with emotion. Such operations are irreversible and only performed at a last resort.
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Evaluation of biological explanations

​Kindt et al (2009) conditioned people to have a fear of spiders using electric shock and then giving half a Beta-blocker and half a placebo. 24hrs later those who had had the Beta-blocker showed a reduced fear response whereas those given the placebos did not. This supports the use of BB's as a treatment for Phobic disorders as it did reduce the fear response the participants.

​There are some ethical issues involved in Kindt’s study as there is an issue of informed consent as most participants were not informed of the comparative success of the Beta-blockers verses placebos and therefore expose themselves to possible side effects unknowingly.

​Ruck et al (2003) gave psychosurgery to 26 people who had been suffering from non-obsessive anxiety disorders for more than 5 years and who had tried various other treatments. A year later 25 out of 26 of the people had dropped from an average of 22.0 to an average of 4.6 on the brief anxiety scale. This would support psychosurgery as a treatment for phobic disorders as it worked as a last resort for 95% of the participants.

However although it seems to support psychosurgery one year after treatment 7 of the participants had tried to commit suicide and 2 had epileptic fits. This suggests that although PS may be a working treatment it also carries lots of risks, especially of side effects that must be thought about before taking part in the procedure.

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Psychological Explanations

Behavioural causes

Underlying assumptions - the behavioural approach views abnormal behaviour as having developed in the same way as all other behaviour, i.e. as the result of learning processes. This approach states that psychological disorders arise because an individual has learned self-defeating or ineffective ways of behaving.

The 3 main types of learning within this approach

  • Classical conditioning - Pavlov's dogs, Little Albert
  • SLT - Bandura (Bobo Doll)
  • Operant conditioning - Skinner (Avoiding the stimulus)

Based of the works of Pavlov, Skinner, Watson and others, behavioural research and therapies suggest that these type of learning can lead to learned anxieties such as phobias.

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Learned behavior in phobias

  • A person may become trapped in a lift and unfortunately experience a panic attack. An association is now established between the feeling of anxiety and the lift. This is generalised to all lifts and small spaces (stimulus generalisation). Classical conditioning has now taken place.
  • Avoiding something unpleasant can be a reward (negative reinforcement). By avoiding lifts and small spaces the preson is rewarded by the reduction or absence of anxiety. Operant conditioning has taken place.
  • Through classical and operant conditioning the person has now developed claustrophobia.

Little Albert - Watson and Rayner (1920) ~ Before the start of the study  Albert had no fear of any fluffy objects or animals. They then smashed a metal pole together when he was a rat over 6 sessions. After the sessions, they put Albert with the rat and he cried and tried to get away. The researchers took this as he was now conditioned to be fearful of rats. They then put him near other fluffy animals such as rabbits, dogs etc. and also fluffy teddy bears and found he had the same fear. So this supports the behaviourist explanation of classical conditioning.

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Behavioural treatments

A modified version of systematic desensitisation, anmed the 'in vivo' version, use the actual stimulus, e.g. a real spider, again in a hierarchical way. Craske et al (1992), amongst others, believes this is a much more effective method than simply imagining the feared stimulus.

An alternative to systematic desensitisation is flooding and modelling:

  • Flooding - when the patient is exposed to the most intense feared stimulus without being taught relaxation. The idea is that the patient wll calm down when a catastrophe doesn't happen.
  • Modelling - this is based on social learning theory. The researcher handles the object the patient has a phobia about by demonstrating that there is nothing to fear.
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Evaluation of behavioural explanations for phobias

Strengths

  • The behavioural explanation for phobias has face validity and the effectiveness of the treatments derived from this explanation support the view that phobias are learned patterns of maladaptive behaviour.
  • Agoraphobia is one of the most difficult phobias to treat yet systematic desensitisation has helped to improve 60-80% of cases (Caske et al, 1993)
  • Mcgrath et al (1990) found that systematic desensitisation was effective for around 75% of clients with a specific phobia.
  • Behavioural therapies can offer treatments that work very quietly. Ost et al (1990) conducted a study where the whole hierachy of feared stimuli were presented in a single session over a few hours. The study found that 90% of patients improved by the end of the session. There are few other therapies which work so quickly.
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Evaluation of behavioural explanations for phobias

Weaknesses

  • Some studies have failed to support behavioural explanations e.g. Munjack (1984) studied a group of people with driving phobia and found that only 50% of them had a frightening experience in a car.
  • The behavioural approach and ensuing therapies only focus on observable apsects of a disorder. It is argued that such therapies fail to identify the underlying causes of a disorder. Failing to address the underlying cause may lead to symptomsubstitution where removing one symptom simply leads to the occurance of another symptom.
  • Some argue that behavioural therapies are unethical, especially behaviour modification therapies which are based on reward and punishment. A counter argument to this claim is that patients fully consent to their treatment.
  • The learning approach underestimates the complexity of humans and see them as being entirely at the mercy of environmental influences (although SLT does take other factors into account.
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Psychodynamic approach to phobias

Phobias are associated with unconcious sexual fears (id impulses) and that they operate through the ego defence mechanisms of repression and displacement

Neurotic anxiety is associated with unconcious fears or urges which are controlled or kept at bay through the defence mechanisms. The original source of the fear is repressed into the unconcious and the fear is then displaced onto some other person, object or situation. Thus the fear seems to be irrational as there is no concious explanation for it. 

Freud's neurotic anxiety is the type of anxiety mostly associated with anxiety disorders.

An example of neurotic anxiety is shown in the case of 'Little Hans'. Little Hans had a fear of horses. Freud interpreted this in terms of a displaced fear. He said that Hans wanted his mother to himself and therefore, unconciously, hated his father. Hans also feared he would castrated. Such fear would be unnacceptable ot the child on a concious level so he displaced the fear to horses.

Evaluation: Case studies, such as this provide rich and detail info. However, they are open to interpretation and cannot be generalised. This could make the approach invalid.

A good scientific theory is parsomonias. This explanation lacks this as it is far fetched.

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Psychodynamic Therapy

Pyschoanalyis aims to uncover hidden sources of conflict and thereby gain insight. There are several techniques by which this can be done:

  • Free association: The client is asked to allow the free flow of feelings, thoughts or images and the to express them in words, without censorship. The reasoning is that associations shuld arise from, and therefore reflect, internal dynamic conflict.
  • Word association: The client has to respond to particular words with whatever comes instantly to mind.
  • Dream analysis: Freud believed that are unconcious drives our expressed uncersored in dreams, although they are disguised in symbolic form in order to protect the conscious mind. He used the term manifest content to describe the content of the dreams and latent content to refer to to the dreams hidden content. The role of the analyst is to help the client interpret the signifiance of their dream
  • Transference: As the therapy progresses, the analysand redirects the feelings they had for their parents onto the analyst, there-by reenacting early conflicts. In a sense, what is happening is that the analysand is recreating an earlier neurosis that can be resolved.
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Evaluation of psychodynamic therapies

  • Critics suggest that psychodynamic therapies may lead to psychological harm by uncovering unconcious emotions. The treatment may make the client feel even worse. Eysenck (1952) suggests that psychodynamic therapies dont word. He conducted a meta-analysis and found 66% of patients improved while on waiting lists whereas 44% improved with this therapy.
  • The idea of neurotic anxiety is supported by the case of 'Little Hans'.This is an impressive amount of evidence provided that the horse did symbolise the father. This study provides a detailed description of the events in childhood that might result in the development of a phobia.
  • Psychodynamic therapies such as Insight therapy, works on the idea that if a client can gain an insight or understanding of their underlying problem then they can work towards reducing their anxiety. In a review of 19 studies of short-term psychodynamic therapies, Svartberg & Stiles (1991) found that psychotherapy was good for those people described as 'neurotic'.
  • There is little emperical evidence to support the idea of repression. Evidence that the cause of Hans' phobia was his relationship with his father is limited. There are alternative explanations, for example, beahvioural psychologists would argue that his fear is due to a horse had reared up in from of him, causing him to become classically conditioned to fear horse.
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Evaluation of psychodynamic therapies

  • The case of Little Hans was a single case study so the results do not necessarily generalise to the target population.
  • Other types of therapies (e.g. drug therapies) aside from insight therapies can also be effective treatments for a variety of anxiety disorders, suggesting that there must be alternative causes of phobias.
  • Psychodynamic therapes are very time consuming lasting up to 2 years. As a result drop out rates are very high. Secondly phobias can be distressing and a therapy that takes 2yrs to work is a significant disadvantage.
  • Psychodynamic therapy addresses the complexity of human psychology and treats people as individuals. This therapy addresses underlying psychological causes of phobias unlike behaviourism. Psychodynamic approaches and therapies lack the problem of reductionism as they suggest that the causes of phobias vary for each individual.
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The cognitive approach to phobias

Assumptions

  • Cognitive therapy is based on the assumption that certain attitudes and beliefs create and compound psychological disorders.
  • When thoughts are persistently negative and irrational they can result in maladaptive behaviour. 
  • It is necessary for patients to undergo cognitive restructuring, i.e. changing irrational self-defeating thoughts and attitudes for more realistic ones.

Cognitive explanation for phobias: Previous negative beliefs and expectations about particular stimulus can influence the reaction to a traumatic event involving that stimulus make it more likely that a phobia will develop. Once aquired, it is maintained through cognitive rehearsal of fear. Many people with phobias think about the possible dreadful outcomes that will occur if they encounter the actual stimulus.

According to Beck people with phobias know at a rational level that danger is minimal yet they also truly believe that their feared object will cause them physical or psychological harm. Beck et al (1985) found that 'danger beliefs' were activated when the person was in close proximity to the phobic stimulus.

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Cognitive behaviour therapy (Beck, 1976)

Stage 1: Clients are encouraged to draw up a schedule of activities in the presence of the phobic stimulus.

Stage 2: They are encouraged to recognise their automatic, negative thoughts (e.g. if I see a button I will die) and record them and bring them to the weekly sessions. The therapist then helps them to test the treality of their thoughts.

Stage 3: The therapist helps clients to recognise the underlying illogical thinking processes that produce negative thinking.

Stage 4: The therapist helps clients to change their maladaptive attitudes, often by asking them to test them out in real-life situations. They are also encouraged to keep actively engaged in pleasurable activities.

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Evaluation of cognitive behavioral therapies

Strengths

  • This approach offers patients a greater degree of control over their own behaviour. By following the instructions provided by the therapist, patients feel empowered to help themselves to deal with their phovia.
  • These therapies also result in a reduction in self criticism, an increase in self-esteem and a more positive approach to life in general. This can be used in day-to-day situations after therapy has ended.
  • CBT's are structured with clear goals and measurable outcomes. They are also short term and economic. 
  • Barlow and Lehman (1996) found CBT to be the more effective for generalised anxiety disorder and social phobia, but behaioural therapy was found to be more effective for specific phobias and OCD.
  • Burke et al hypothesised that graded exposure would be more effective if the rationale was presented in cognitive terms (i,e. as an oppurtunity to challenge negative thoughts) rather than in strictly behavioural terms
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Evaluation of cognitive behavioral therapies

Weaknesses

  • These therapies are limited; although useful for depression and phobias they are not appropriate for psychotic conditions in which it is not possible for the patient to gain an insight into the unrealistic nature of their thoughts.
  • Because they require the analysis of life situations it is generally assumed that they are best suited to fairly intelligent individuals (not suitable for children)
  • Negative thoughts maybe the consequences of phobias and not the cause of it
  • Some psychologists disagree with the use of the term 'faulty thinking' as they believe it is unethical to tell people that their thoughts are faulty. Mental illnesses may be a natural reaction to adverse life events

The stress-diathesis model

The stress-diathesis model suggests that no single factor is seen as entirely responsible for causing a disorder, but is a combination of social, psychological and biological factors. It proposes that different people have different stress thresholds, and that social factors, such as adverse life events, simply act as an additional factor for those who are vulnerable. This theory helps to explain individual differences.

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