Social Anxiety Disorder and Specific Phobia

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What are phobias?

  • Phobias relate to anxiety towards events, situations and objects
  • Social Anxiety Disorder - apprehension towards social events and interaction.
  • Specific Phobias - Anxiety directed to towards single (mostly) objects or activities. 
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DSM-5 diagnostic of SAD

  1. A marked fear and anxiety about one or more social situations in which the person is exposed to possible scrutiny by others. Examples include social interactions, being observed, and performing in front of others.
  2. The individual fears that he/she will act in a way (or show anxiety symptoms) that will be negatively evaluated
  3. The social situations almost always provoke fear or anxiety
  4. The social situations are avoided or endured with intense fear or anxiety
  5. The fear or anxiety is out of proportion to the actual threat posed by social situation and to the sociocultural context
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DSM-5 diagnostic of SAD

  1. The fear, anxiety or avoidance is persistent, typically lasting for 6 months or more (NEW)
  2. The fear, anxiety or avoidance causes clinical distress or impairment in social, occupational or other important areas of functioning.
  3. The disturbance is not due to the direct physiological effects of substance abuse or a general medical condition
  4. The disturbance is not better explained by another mental disorder (e.g. ASD's)
  5. If another medical condition is present, the fear, anxiety, or avoidance is clearly unrelated or excessive.
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What is the prevalence of SAD?

SAD is a common anxiety disorder.

  • Furmark et al (1999): Examined the prevelance of SAD in the Swedish general popn, and demographic characteristics associated with this anxiety disorder. 2000 adults were given a posted survey. Point prevelance of SAD estimated at 15.6% but rates varied between 1.9/20.4% across the different levels of distress and impairment used to define cases. Public speaking was shown to be the most common fear, and higher prevelance rates were associated with the female gender, low educational attainment, psychiatric medication use and a lack of social support.
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What are the behaviours in SAD?

SAD is quite distinct from being shy (shyness is a relatively stable temperamental trait - an aspect of personality). Exposure to a social situation provokes anxiety, which may take the form of an anxiety attack. There are a range of symptoms associated with SAD, which take on different forms:

  • Physical symptoms: Sweating, blushing, dizziness, trembling. Heart palpitations which can lead to a full blown anxiety attack. 
  • Cognitive symptoms: Become convinced that others will notice their nervousness, and will be judged as weak, inarticulate, stupid. 
  • Emotional symptoms: Feel fearful and panicky. 
  • Behavioural symptoms: Engage in 'safety behaviours' - avoid eye contact and stand away from people (Overt symptoms)
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What is the biological aetiology of SAD?

Biological factors: 

  • Brain structure and function > Etkin and Wagner (2007) - hyperactivity in the amygdala and insula. Unclear whether this is a cause or correlate.
  • Genetic factors: Moderate explanation from genetic and family factors. 
  • Hettema et al (2001): Odds ratio for family studies showed homogeneity in the predicting the association of illness in first-degree relatives. Ranged from 4-6 depending on the disorder. Heritabilities in twin studies were 0.43 for panic disorder and 0.32 for generalized panic disorder. Variance could be attributed to a non-shared environment.
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Pharmacological treatments of SAD

  • Beta blockers: Reduce the effect of adrenaline in activating symptoms.
  • Benzodiazepines: Show rapid effects upon anxiety symptoms. However, SP requires long-term treatment and there are dependency issues. 
  • Monoamine oxidase inhibitors (MAOI's): Can be effective but unpopular due to dietary restrictions. Many MAOI's not tolerated due to physical side effects.
  • Tricyclic Antidepressants (TCA): Not generally used in social phobia. 
  • Selective Serotonin Reputake Inhibitors (SSRI): Paraoxetine commonly used SSRI in social phobia. Trials show significant improvement vs placebo. Reduced fear, anticipatory anxiety, and disability. Improved social life and work. 
  • Serotonin - norepineephrine reputake inhibitors (SNRI): Venlafaxine also performs well in trials. 
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Cognitive and Behavioural Aetiology of SAD

Behavioural theories fairly strong as explanations for SAD. It sees SAD as a learned behaviour.

  • Arises from classical conditioning. Subject to prior perceived social defeat (being a target of anger or criticism). 
  • Generalized to all social situations. 
  • Maintained by operant conditioning - negative reinforcemnet through avoidance of the feared social situation. 
  • However, not all people with phobias can identify a prior traumatic or avervise experience.

Cognitive theories strongly supported.

  • Socially phobic people expect others to negatively evaluate them. Feel vulnerable around people that are percieved as a threat.
  • Hypervigilant to body sensations in social situations, which interferes with social interaction. Cognitive factors make social phobia very pervasive.
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SAD aetiology and maintenance

Clark and Wells (1995) proposed a cognitive model of the maintenance of social phobia. The four maintenance processes are:

  1. Increased self-focused attention and a linked decrease in observation of other people and their responses
  2. Use of misleading internal information (feelings and images) to make excessively negative inferences about how one appears to others.
  3. Extensive use of over and covert safety behaviours
  4. Problematic pre- and post-event processing.
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Psychological treatments of SAD

  • Behavioural treatments focus on prolonged and graduated exposure to social situations. They help to evoke fear and learn that you can deal with it. Therapy may include role-play in small groups to rehearse social encounters. Purely behavioural interventions are used more with specific phobias than SAD.
  • Cognitive behavioural therapies: Also use group sessions. Practice feared social situations in front of other patients. Block safety behaviours. Also cognitively reppraise faulty thinking - challenge catatrophisising thoughts and negative appraisals, or self, appearance and performance.
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Evaluating treatments for SAD

CBT vs Behavioural

  • Unclear if adding cognitive aspect to exposure enhances outcome or not - Acarturk et al (2008)
  • Clark et al (2006): CT outperforms exposure and relaxation 

CBT in groups

  • Good evidence of success demonstrated empirically: CBT vs phenelzine, placebo, group info and support. After 12 weeks - Group CBT and phenelzine = significant improvement. Both better than group info/support and placebo. No diff between CBT and phenelzine. But group CBT showed significantly fewer relapses at 1yr. 

CBT vs pharmacological treatments: CBT better than SSRI's.

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Specific Phobias

Main types of specific phobia:

  1. Animal type: Spiders, snakes, dogs, cats, bees/wasps, rats/mice.
  2. Natural environment type: Heights, storms, water
  3. Situational types: Airplanes, lifts, bridges

Specific phobias are said to be very common - Kessler et al (2005): Lifetime prevelance of 12.5%

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Physical symptoms of specific phobia

Physical symptoms (during encounter with feared object or situation)

  • Increased heart beat
  • Increased blood pressure
  • Shortness of breath

However, blood, injections and injury phobia are exempt from this

  • Blood pressure decreases, potentially leading to fainting.
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Phobic behaviours

  • Exposure for feared stimulus produces panic-like symptoms. 
  • Go to great lengths to avoid stimulus and even avoid representation of stimulus.
  • Thought of facing the feared stimulus can be terrifying.

Irrationality

  • Sufferer may know that the fear is irrational, but cannot do anything about it no matter how hard they try to face the fear. This is reinforced by avoidance behaviour which confirms the feeling of safety.
  • Only clinically noteworthy if the phobia significantly interferes with life.

Disgust

  • Often fear of object is associated with disgust, especially with animal phobias. Olatunji and Deacon (2008) - those with specific phobia report elevated fear and disgust when viewing pictures of spiders when compared to those without phobia.
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Psychodynamic explanations of SP

Freud

  • Phobias = anxiety displaced onto 'neutral' object. People do not fear the object itself, but have displaced anxiety over the other issue onto it. 
  • Original conflict resides with Oedipus complex - too unbearable, so transferred onto neutral object. Avoiding neutral object = avoiding original conflict.

Arieti

  • Interpersonal childhood problem is repressed.
  • Children originally trust those around them - to protect them from danger. They then fear that adults/parents cannot be trusted. 
  • To deal with mistrust they displace fear onto other objects to enable them to trust people again.
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Behavioural theories of SP

Behavioural theories commonly incorporate the idea that phobias are learned through classical conditioning and maintained by operant conditioning through negative reinforcement.

Mowrer's two-factor theory

  • Phobias acquired through classical conditioning. E.g. get stung by bee. Phobia develops for future contact with bees. This is maintained by operant conditioning (avoidance). Avoidance relieves anxiety.

Eysenck's Incubation theory

  • Phobia started with reinforced stimulus (CS). E.g such as bee sting > phobia > avoidance
  • Eysenck argued that phobia is maintained even with non-reinforced CS. This may be due to high trait anxiety overriding extinction. 
  • This leads to a predisposition to attend to fear and aversion.
  • Overly ruminate on original conditioning event, also reffered to as 'paradoxical enhancement'

Evolutionary theories

  • Prepared learning - fear of dangerous animals (such as snakes and bees) may be due to ancestors unpleasant encounters, which are rapidly conditioned to be avoided. 

Vicarious learning

  • Observing a phobic person's fear of object, which can lead someone to fear the object themselves.
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Biological aetiology of SP

  • Genetics: Little evidence to support that specific phibia is genetic. But propensity to anxiety is moderately heritable.
  • Autonomic lability: ANS controls arousal - some people more labile (jumpy) than others. ANS involved in phobic behaviour. This propensity could be genetic. 
  • Hyperactivity in the amygdala and insula - Etkin and Wagner (2007)
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Specific phobia treatment

Fewer than 1 in 5 seek any form of treatment - Wong et al (2002).

Pharmacological treatments

  • People with phobias often self-medicate to relieve anxiety. E.g. alcohol, valium. Short-term relief but phobia remains. Pharmacological treatment is rare with phobias.

Psychological treatments

  • Behavioural: Exposure therapy. In-vivo vs imaginal vs virtual reality. Gradual vs flooding. With vs without relaxation (systematic desensitisation). External vs internal (interoceptive exposure).
  • Modelling: Therapist engages with feared object. Client watches this before being asked to directly confront fear. Calmness of the therapist helps to reduce the clients own fears about the feared object. Works on principles of social learning theory.
  • Flooding: Client is exposed to intensive dose of feared object. Therapist prepares client with relaxation techniques to reduce fear during flooding. It is an effective and quick therapy but compliance is difficult. Only used if other techniques fail.
  • Operant conditioning: Therapists focus on avoidance rather than fear. Aim to shape behaviour. Client is rewarded for each step towards exposure. Many therapists address both fear and avoidance - desensitisation for the fear, operant conditioning for the avoidance. Relaxation training and graduated exposure popular techniques.
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