CBT Models of Phobias

CBT
Conceptualization
of Phobia
Dr. Preeti Singh
Assistant Professor of Clinical Psychology
Institute of Mental Health and Hospital, Agra©Dr. Preeti Singh, Asst. Prof of Clinical
Psychology, IMHH, Agra

Points to be covered
• Fear and phobia
• Phobic reactions
• When peoples comes for
therapy
• Origin of phobia
• Significance of age and
gender of phobic reaction
• Types of phobia
• Cognitive and behavioural
model of specific phobia
a. Cognitive model of phobia
b. Behavioural model of phobia
c. A vicious circle model of
phobia
d. A cognitive-behavioural
model for the maintenance of
specific phobias
e. A model of the development
and maintenance of specific
phobias
• CBT model of Social Phobia
• CBT model of Claustrophobia
• CBT model of Agoraphobia
©Dr. Preeti Singh, Asst. Prof of Clinical

Normal fear and Phobia
• Fear is a rational emotional response (Real Snake)
towards any threatening stimuli or situation and on
the other side phobic reaction is an irrational,
extreme fearful response towards little or no
threatening stimuli or situation (Snake Picture).

Phobic Reactions
• Physical
• Pounding or racing heart
• Shortness of breath
• Rapid speech or inability to speak
• Dry mouth
• Upset stomach or nausea
• Elevated blood pressure
• Trembling or shaking
• Chest pain or tightness
• Choking sensation
• Dizziness or light headedness
• Profuse sweating
• Hot flushes or chills
• A sensation of butterflies in the
stomach
• Numbness
• A need to go to the toilet
• Psychological
• Fear of losing control
• Fear of fainting
• Fear of dying
• Confusion or disorientation
• Sense of impending doom

No fear
Opportunity to learn coping
skill and identify the real level
of danger
Fear
Unable to learn coping
ability and exacerbated
level of danger

10 9 8 7 6 5 4 3 2 1
Flight
Preventive measures
(Safety Behaviour)
Itself becomes problem and leads therapeutic consultation©Dr. Preeti Singh, Asst. Prof of Clinical

Origin of phobia
• Real traumatic exposure or experience
• Observation of others going through traumatic event
(real, TV, magazine, newspaper)
• Information transmission (sociocultural background)

Phobia in children
• Type of phobia - natural environment, animal, or blood-injection-
injury
• Symptomatic presentation - young children may express their fear
and anxiety by crying, tantrums, freezing, or clinging, neediness,
and unexplained pain, such as stomach or head pain.
• Less avoidance (behavioural response without cognitive
formulation of fear) - young children typically are not able to
understand the concept of avoidance. Therefore, additional
information should be gathered from parents, teachers, or others
who know the child well.
• Excessive fears are quite common in young children but are usually
transitory and only mildly impairing and thus considered
developmentally appropriate.

Phobia in Adolescence
• Type of phobia - Situational and Social phobia
• Symptomatic presentation - usually hides their
symptoms due to embrace feeling and if required to face
it then brings close assistance and help of closed ones.
• Complete avoidance
• Functional Consequences - elevated rates of school
dropout and with decreased well-being, employment,
workplace productivity, socioeconomic status, and
quality of life, difficulty to establish love relationship,
being single, impede leisure activities and rarely comes
for the therapy by-self . Less disabling therefore low
frequency to seek treatment.

Phobia in adulthood
• Type of phobia – Agoraphobia
• Symptomatic Presentation – housebound, if going outside then
must be with someone and with complete safety measures
(medical kit or near to hospital etc.), at home also someone must
be present, medical facilities should be also available at home as a
preventive measure, full details should be available at home of all
nursing homes and hospitals nearby or with special facilities.
• Avoidance – in absence of medical care facility or person to help.
• Functional consequences - totally housebound and delimited all
personal, social, occupational and other activities. If male then
significant economical crisis situation for the family.

Phobia in Old age
• Type of phobia - natural environment specific phobias
and phobias of falling.
• In old age specific phobia tends to co-occur with medical
concerns like coronary heart disease and chronic
obstructive pulmonary disease.
• Older individuals attributed their symptoms of fear more
likely due to medical conditions.
• The presence of specific phobia in older adults is
associated with decreased quality of life and may serve
as a risk factor for major neurocognitive disorder.
• Comorbid depression is very common in old age

Gender and phobia
• Agoraphobia, social anxiety disorder, animal, natural
environment, and situational specific phobias are
predominantly experienced by females.
• Blood-injection-injury phobia is experienced nearly
equally by both genders.
• Younger age more in females but older age equal
prevalence in both gender.

Types of Phobia
Phobia
Animal
Natural
environment
Blood -injection
-injury
Situational Other
Social Agoraphobia
Specific
Spider, insects,
dog, lizard etc.
Height, storm,
Water, etc.
Airplane, elevator,
enclosed spaces etc.
Blood, needles or
invasive medical
procedure
Loud sound,
costumed
characters etc.

Blood-injection-injury
Blood-injection-injury specific phobia often
demonstrate a vasovagal fainting or near-fainting
response that is marked by initial brief acceleration of
heart rate and elevation of blood pressure followed by
a deceleration of heart rate and a drop in blood
pressure.

Social Phobia
• Marked fear or anxiety about one or more social situations in which the individual
is exposed to possible scrutiny by others. E.g. social interactions, being observed
and performing in front of others .
• The individual fears that he or she will act in a way or show anxiety symptoms that
will be negatively evaluated.
• The social situations almost always provoke fear or anxiety.
• The social situations are avoided or endured with intense fear or anxiety.
• The fear or anxiety is out of proportion to the actual threat posed by the social
situation and to the sociocultural context.
Performance only: If the fear is restricted to speaking or performing in public.
In children, the anxiety must occur in peer settings and not just during interactions with adults
and fear or anxiety may be expressed by crying, tantrums, freezing, clinging, shrinking, or
failing to speak in social situations.©Dr. Preeti Singh, Asst. Prof of Clinical

Other specific characteristics
Individuals with social anxiety disorder may be inadequately assertive
or excessively submissive or, less commonly, highly controlling of the
conversation. They may show overly rigid body posture or inadequate
eye contact, or speak with an overly soft voice. These individuals may
be shy or withdrawn, and they may be less open in conversations and
disclose little about themselves. They may seek employment in jobs
that do not require social contact. They may live at home longer. Men
may be delayed in marrying and having a family, whereas women who
would want to work outside the home may live a life as homemaker
and mother. Self-medication with substances is common (e.g., drinking
before going to a party). Blushing is a hallmark physical response of
social anxiety disorder.

Claustrophobia
• Claustrophobia is the fear of being enclosed in
a small space or room and having no escape. It
can be triggered by many situations or stimuli,
including elevators crowded to capacity,
windowless rooms, small cars and even tight-
necked clothing.
1. fear of restriction
2. fear of suffocation.
(e.g. small rooms, locked rooms, cars, airplanes, trains,
tunnels, underwater caves, cellars, elevators, caves.)

Childhood conditioning of claustrophobia
• A child (or, less commonly, an adult) is shut into a black room and cannot
find the door or the light-switch.
• A child gets shut into a box.
• A child is locked in a closet.
• A child falls into a deep pool and cannot swim.
• A child gets separated from their parents in a large crowd and gets lost.
• A child sticks their head between the bars of a fence and then cannot get
back out.
• A child crawls into a hole and gets stuck, or cannot find their way back.
• A child is left in their parent's car, truck, or van.
• A child is in a crowded area with no windows (a classroom, basement,
etc.) or is put there as a means of punishment.

Agoraphobia
Marked fear or anxiety about two (or more) of the following
five situations:
1. Using public transportation (e.g., automobiles, buses,
trains, ships, planes).
2. Being in open spaces (e.g., parking lots, marketplaces,
bridges).
3. Being in enclosed places (e.g., shops, theatres, cinemas).
4. Standing in line or being in a crowd.
5. Being outside of the home alone.©Dr. Preeti Singh, Asst. Prof of Clinical

• The individual fears or avoids these situations because of
thoughts that escape might be difficult or help might not be
available in the event of developing panic-like symptoms or
other incapacitating or embarrassing symptoms (e.g., fear of
falling in the elderly; fear of incontinence).
• The agoraphobic situations almost always provoke fear or
anxiety and are actively avoided, require the presence of a
companion, or are endured with intense fear or anxiety.
• Highly disabling - More than one-third of individuals with
agoraphobia are completely homebound and unable to work.
• Highest Heritability for agoraphobia is 61%.

COGNITIVE MODEL OF
PHOBIA

Situational Trigger
Physiological
Heart thumping
Sweating
Trembling etc.
Behavioural
Running away
“freezing”
Shouting for help etc.
Subjective
“I might fall”
“This is terrible”
Fear etc.
Symptoms
Relevant Childhood Data
(Information processed by parents - snake)
Core belief
(snake bite can lead death)
Assumptions/Beliefs/Rules
(1. Exposure of snake means death
2. Should avoid those places wherever possibility of snake
3. I am incapable to fight with snake, so should run away to see snake)

BEHAVIOURAL MODEL OF
PHOBIA

Classical Conditioning
Stimulus
UCS
Real exposure of snake bite
CS
Snake pic, hearing about snake,
situation where snake bite happen,
time when snake bite happen, probable
places of snake presence etc.
Response
UCR
Runs away, Faint
CR
Avoidance, runs away, faint

OPERANT CONDITIONING

ACQUISITION OF PHOBIA
Real snake
Flight
Relived from
distress and
fear
Positive
reinforcement

MAINTENANCE OF PHOBIA
Negative
reinforcement
Probable
places of
snake
presence
Avoidance
Relieved
from
distress
and fear

Social Learning

CBT MODELS OF PHOBIA

A vicious circle model of Phobia
Situational Trigger
Physiological
Heart thumping
Sweating
Trembling etc.
Behavioural
Running away
“freezing”
Shouting for help etc.
Subjective
“I might fall”
“This is terrible”
Fear, etc.
Symptoms
Reactions
Physiological
Heart thumping
etc.
Fatigue
Behavioural
Avoidance, withdrawing
from demanding or
pleasurable activities
Subjective
“I can’t cope”
“I must get out”
Lowered confidence worry,
frustration, fear

A cognitive-behavioural model for the maintenance of specific phobias
Various objects / situations are perceived as
potentially harmful
Avoidance
Encountering the phobic object / situation
Catastrophic
beliefs
Autonomic
arousal
Pre-attentive
activation
High
degree of
conviction Escape or safety behaviour
The catastrophe does not occur and anxiety
reactions dissipate
Conclusion drawn: The escape / safety
behaviour prevent the catastrophe
The catastrophic belief is confirmed
The phobia remains unchanged

A model of the development and maintenance of specific phobias
Development
Biological preparedness, temperament, developmental stage, culture, experience
(classical conditioning, vicarious learning), memories/images, beliefs
Assumptions
With increased vulnerability to
Trigger
Frightening object or situation
Anxious Cognitions
(thoughts and images concerning stimulus)
Overestimating Threat And Consequences/ Underestimating Coping And Rescue
Anxious mood
Increasingly anxious cognitions about
external triggers
Safety behaviours
(related to anxious thoughts about
Physiological symptoms
Anxious cognitions about symptoms
(fear of fear)
Safety behaviours
(related to fear of fear)
Hyper
vigilance
about
physical
symptoms

CBT MODEL OF SOCIAL
PHOBIA

Activates assumptions
1. I will perform very poor
2. I am incompetent to present such topic
Perceived social danger
(everybody laugh on me, teacher and
other students will think that I am
stupid)
Processing of Self as a Social
Object (everybody watching
me/ my symptoms and my
single mistake will ruined my
and my families reputation)Safety behaviours
(Avoid going school or
tried to bung the class)
a
Somatic & cognitive
symptoms
(heart beat, respiration,
palpitation mind goes blank,
unable to concentrate, )
Cognitive Behaviour model of social phobia
[Clarks and Wells (1995) and Wells and Clark (1997)]
Social Situation
Presentation in class

CBT MODEL OF
CLAUSTROPHOBIA

Cognition
(perceived threat)
Physiological reaction
(ANS arousal)
Psychological reaction
(fear, anxiety)
Avoidance
(safety behaviour)
Triggering Stimuli or
situation

CBT MODEL OF
AGORAPHOBIA

Perceived
threat
Apprehension
Bodily
sensation
Interpretation
of sensations
as catastrophic
Triggering situation or stimulus
internal or external)

?

CBT Models of Phobias

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